Jonathan D. Ketcham

Hospital-Physician Gainsharing In Cardiology

The Health and Human Services Office of Inspector General has approved a handful of gainsharing arrangements in which physicians receive cash payments for reducing hospital spending. Gainsharing might reduce costs by aligning hospital and physician incentives, but concerns remain about quality and access. We examine the effects of thirteen gainsharing programs on coronary stent patients. Compared to other hospitals, gainsharing hospitals reduced costs by 7.4 percent per patient, with 91 percent of the savings from lower prices and 9 percent from lower utilization. The available measures of access and quality suggest that neither was reduced, nor was access to drug-eluting stents before 2006.

Economic Voting in U.S. Presidential Elections: Who Blames Whom for What

Abstract In United States presidential elections, the incumbent party’s fortunes depend significantly on recent economic conditions, as numerous studies have shown. Many details of how economic voting takes place, however, are still not well understood. Here we present evidence on four issues. 1) Which is more important for determining people’s votes, national or local economic conditions? 2) What time frame do people consider in economic voting? 3) Which demographic groups are most sensitive to the economy in their voting behavior? 4) How does economic voting depend on the political context—in particular, whether a candidate is running for re-election, and whether the incumbent party also controls Congress? Our study includes the first county-level analysis of economic voting in presidential elections. We find the answers to our four questions are: 1) national conditions, by far; 2) the most recent year; 3) blacks, females, and the non-elderly; and 4) no.

Physician Practice Revenues and Use of Information Technology in Patient Care

Objectives:Although information technology (IT) may improve efficiency and quality of patient care, the adoption of clinical IT by physicians has been limited. This study investigates the relationships between physician practice revenue and use of clinical IT. Research Design:We undertook a cross-sectional analysis of data on 6849 U.S. physicians in physician-owned practices who responded to the 2000–2001 Community Tracking Study Physician Survey. Physician practice revenues, measured as the percentage of total revenues, is defined along 2 dimensions: type (capitation, noncapitated managed care, or fee-for-service) and source (Medicare, Medicaid, or private/other). Analyses were adjusted for physician and practice characteristics and geographic location. Measures:The proportion of physicians using IT for 5 functions of patient care: treatment guidelines, formularies, patient notes or lists, electronic prescriptions, and data exchange with other physicians. Results:Practice revenues are associated with differences in physicians’ use of IT in patient care. Above-average Medicaid revenue was associated with 20% higher use of IT overall (incidence density ratio = 1.20, 95% confidence interval [CI] = 1.12–1.30). Above-average capitation revenue corresponds to higher use of IT overall (incidence density ratio = 1.10, 95% CI = 1.02–1.19) and greater odds of using IT for guidelines (odds ratio = 1.26, 95% CI = 1.05–1.53). Above-average noncapitated managed care revenue, however, has no apparent relationship with IT use. Conclusions:Differences in the type and source of physician revenues were associated with differences in the use of IT in patient care in 2000–2001. The relationships between practice revenues and IT use varied across clinical IT functions.

Variations in the use of an innovative technology by payer: the case of drug-eluting stents.

Background:Despite receiving identical reimbursement for treating heart disease patients with bare metal stents (BMS) or drug-eluting coronary stents (DES), cardiologists’ use of the new technology (DES) may have varied by patient payer type as DES diffused. Payer-related factors that differ between hospitals and/or differential treatment inside hospitals might explain any overall differences by payer type. Objectives:To assess the association between payer and DES use and to examine between-hospital and within-hospital variation in DES use over time. Methods:We conducted a retrospective analysis of 4.1 million hospitalizations involving DES or BMS from 2003 to 2008 Nationwide Inpatient Sample. We estimated hybrid-fixed effects logit models and calculated the adjusted within-quarter, cross-payer differences in DES use. Results:Coronary stent patients with Medicaid or without insurance were significantly less likely to receive DES than were patients with private insurance throughout the study period. The differences fluctuated over time as the popularity of DES relative to BMS increased and decreased. The within-hospital gaps paralleled the overall differences, and were largest in Q3 2003 (Medicaid: 11.9, uninsured: 10.9% points) and Q4 2008 (Medicaid: 12.8, uninsured: 20.7% points), and smallest in Q4 2004 (Medicaid: 1.4, uninsured: 1.1% points). The between-hospital adjusted differences in DES use by payer were small and rarely significant. Conclusions:We found substantial differences in DES use by payer within hospitals, suggesting physicians selected the new technology for patients in a manner associated with patients’ payer type.

Physician clinical information technology and health care disparities

The authors develop a conceptual framework regarding how information technology (IT) can alter within-physician disparities, and they empirically test some of its implications in the context of coronary heart disease. Using a random experiment on 256 primary care physicians, the authors analyze the relationships between three IT functions (feedback and two types of clinical decision support) and five process-of-care measures. Endogeneity is addressed by eliminating unobserved patient characteristics with vignettes and by proxying for omitted physician characteristics. The results indicate that IT has no effects on physicians’ diagnostic certainty and treatment of vignette patients overall. The authors find that treatment and certainty differ by patient age, gender, and race. Consistent with the framework, IT’s effects on these disparities are complex. Feedback eliminated the gender disparities, but the relationships differed for other IT functions and process measures. Current policies to reduce disparities and increase IT adoption may be in discord.

Which Physicians are Affected Most by Medicaid Preferred Drug Lists for Statins and Antihypertensives

AbstractBackground: To limit quickly rising prescription drug expenditures, many state Medicaid programmes have implemented preferred drug lists (PDLs) and prior authorisation (PA). Lessons from Medicaid efforts may be informative for Medicare, which started covering outpatient prescription drugs recently. Objectives: To examine how the cost of compliance with Medicaid PDLs for antihypertensives and statins varied across physicians, and to assess the effects of PDLs on physician prescribing patterns and access for Medicaid patients. Data and methods: An anonymous survey of primary care physicians and cardiologists in nine states with PDLs was conducted in December 2005 and January 2006. Survey responses were augmented with physician prescribing data, practice location characteristics, and publicly available information about state PDLs. We analysed six physician-level outcome measures: annual PDL-related costs; the proportion of Medicaid prescriptions covered by the PDL; the proportion of Medicaid prescriptions written for an alternative to a physician’s most preferred drug because of PDLs; the proportion of times no drug was prescribed to a Medicaid patient because of PDLs; whether they restricted their new Medicaid patient caseload because of PDLs; and whether they decreased the proportion of prescriptions not covered by the Medicaid PDL for non-Medicaid patients. We assessed how these outcomes varied with Medicaid caseload, physician practice size, and socioeconomic characteristics of the practice’s ZIP Code. Results: Costs from complying with Medicaid PDLs for statins and antihypertensives were greatest for physicians in solo practices with high Medicaid caseloads located in poor areas. Although all physicians’ prescribing patterns were influenced to some extent by PDLs, those with high volumes of Medicaid prescriptions were affected more. They more frequently prescribed Medicaid patients a less-preferred medication or nothing at all, and were more likely to alter their prescribing to non-Medicaid patients. Physicians with low Medicaid prescription volumes in areas with fewer minorities were more likely to limit their willingness to treat new Medicaid patients. Conclusion: The burden of Medicaid PDLs fell greatest on physicians in disadvantaged areas and their patients.

Influence of Patient Race on Physician Prescribing Decisions: A Randomized On-Line Experiment

ABSTRACTBACKGROUNDPrior research reports black patients have lower medication use for hypercholesterolemia, hypertension, and diabetes.OBJECTIVETo assess whether patient race influences physicians’ prescribing.DESIGNWeb-based survey including three clinical vignettes (hypercholesterolemia, hypertension, diabetes), with patient race (black, white) randomized across vignettes.SUBJECTSA total of 716 respondents from 5,141 eligible sampled primary care physicians (14% response rate).INTERVENTIONSNoneMEASUREMENTSMedication recommendation (any medication vs none, on-patent branded vs generic, and therapeutic class) and physicians’ treatment adherence forecast (10-point Likert scale, 1—definitely not adhere, 10—definitely adhere).RESULTSRespondents randomized to view black patients (n = 371) and white patients (n = 345) recommend any medications at comparable rates for hypercholesterolemia (100.0% white vs 99.5% black, P = 0.50), hypertension (99.7% white vs 99.5% black, P = 1.00), and diabetes (99.7% white vs 99.7% black, P = 1.00). Patient race influenced medication class chosen in the hypertension vignette; respondents randomized to view black patients recommended calcium channel blockers more often (20.8% black vs 3.2% white) and angiotensin-converting enzyme inhibitors less often (47.4% black vs 62.6% white) (P < 0.001). Patient race did not influence medication class for hypercholesterolemia or diabetes. Respondents randomized to view black patients reported lower forecasted patient adherence for hypertension (P < 0.001, mean: 7.3 black vs 7.7 white) and diabetes (P = 0.05 mean: 7.4 black vs 7.6 white), but race had no meaningful influence on forecasted adherence for hypercholesterolemia (P = 0.15, mean: 7.2 black vs 7.3 white).CONCLUSIONRacial differences in outpatient prescribing patterns for hypertension, hypercholesterolemia, and diabetes are likely attributable to factors other than prescribing decisions based on patient race.

Medicaid preferred drug lists' costs to physicians

Background:Medicaid preferred drug lists (PDLs) might reduce costs for Medicaid programs while creating costs to physicians. Objectives:To measure the costs from complying with Medicaid PDLs for primary care physicians and cardiologists, and to quantify the costs of a hypothetical PDL for Medicare Part D. Research Design:We analyzed cardiologists’ and primary care physicians’ experiences with Medicaid PDLs for antihypertensives and statins in 9 states. Physicians’ prescribing volumes and PDL compliance were generated by combining pharmacy claims data from Wolters Kluwer Health with the state PDLs. These data were augmented with a survey of physicians. A Monte Carlo simulation was used to randomly assign each relevant physician in the state to a survey response. Estimates of the cost of a potential Part D PDL relied on the volume of Part D claims reported by Centers for Medicare and Medicaid Services (CMS) through May 2006. Results:Physicians’ PDL-related costs averaged

Have HMOs broadened their hospital networks?: Changes in HMO hospital networks in California, 1999-2003.

8.02 [95% confidence interval (CI):

Reference Pricing of Pharmaceuticals for Medicare: Evidence from Germany, the Netherlands and New Zealand

7.25–