Michael D. Finch

The Demand for Employment-Based Health Insurance Plans

We estimate the demand for health plans by employees in 17 Minneapolis firms. The data set has approximately 900 employees who chose a single-coverage health plan and 2,100 employees who chose family coverage. A nested logit model is empirically shown to be the right approach for modeling health plan choice, with freedom to choose your own doctor being the variable that distinguishes health plan nests. Our estimates show that employees are very sensitive to the out-of-pocket premium for each plan, controlling for other plan characteristics. These results are important both for public policy and for employers who offer multiple health plans.

Bouncing Back: Patterns and Predictors of Complicated Transitions 30 Days After Hospitalization for Acute Ischemic Stroke

OBJECTIVES: To identify predictors of complicated transitions within 30 days after discharge from hospitalization for acute stroke.

Rehospitalization and survival for stroke patients in managed care and traditional Medicare plans.

Background:Stroke affects more than 500,000 older persons each year in the United States, but no studies have compared older stroke patients in Medicare health maintenance organizations (HMOs) and fee-for-service (FFS) after recent changes in FFS reimbursement. Objectives:We sought to compare utilization and outcomes after stroke in Medicare HMO and FFS. Design:We reviewed administrative data in 11 regions from Medicare and a large national health plan. Subjects:We studied Medicare beneficiaries 65 years and older discharged with ischemic stroke during 1998–2000, ie, 4816 HMO patients and a random sample of 4187 FFS patients from 422 hospitals. Measures:We measured survival, rehospitalization, length of stay, discharge destination, and warfarin use. Results:Overall, HMO patients were younger, male, non-Caucasian, and had fewer comorbid conditions. When compared with FFS patients, HMO patients were more likely to be rehospitalized within 30 days for a primary diagnosis of ischemic stroke (Adjusted Hazard Ratio = 1.45, 95% Confidence Interval [CI] 1.14–1.83) or ill-defined conditions (eg, rehabilitation services) (2.87, 95% CI 1.85–4.46) and less likely to be rehospitalized for fluid and electrolyte disorders (0.54, 95% CI 0.34–0.87) or circulatory/respiratory problems (0.77, 95% CI 0.60–0.98). There were no consistent differences in 30-day mortality or in 1-year rehospitalization or mortality for 30-day survivors. HMO patients also were much less likely to be discharged to rehabilitation facilities, slightly less likely to be discharged to skilled nursing facilities and to have a shorter length of stay, and did not differ in the use of home care services or warfarin use when compared with FFS patients. Conclusions:Traditional measures of quality such as 30-day rehospitalization may not be valid when comparing HMO and FFS patients if differences might reflect an alternative service mix. Utilization of postacute care for FFS patients appears similar to HMO patients except for discharge to rehabilitation facilities.

Socioeconomic Status and Health over the Life Course

On average, individuals of lower socioeconomic status (SES)—based on education, income, or occupation—have worse health than their higher SES counterparts (Adler, Boyce, Chesney, Folkman, & Syme, 1993; Antonovsky, 1967; Feinstein, 1993; Feldman, Makuc, Kleinman, & Cornoni-Huntley, 1989; House, Kessler, & Herzog, 1990; Kitagawa & Hauser, 1973; Marmot, Shipley, & Rose, 1984; Pappas, Queen, Hadden, & Fisher, 1993; Preston & Taubman, 1994; Townsend & Davidson, 1982). This relationship is best depicted as a gradient in health with a fairly linear trend in better health associated with increasing levels of SES, rather than a threshold effect. Furthermore, this relationship is stratified by age; lower SES individuals begin to experience health problems shortly after adolescence, while higher SES individuals experience little health decline until around retirement age (House et al, 1990, 1994). This life course patterning of SES and health is intriguing since it suggests substantial variation in the ability of each group to sustain good health over the life course.

30-day survival and rehospitalization for stroke patients according to physician specialty.

Background and Purpose: Stroke patients appear to have improved outcomes when cared for by neurologists, but the mechanism by which improved outcome is achieved is unclear. This study compares 30-day cause-specif ic rehospitalization, 30-day mortality, and specific processes of care for patients treated by a neurologist only, a generalist only, a neurologist and a generalist (i.e., collaborative care), or by another specialist during the index hospitalization.Methods: This study uses Cox regression to analyze claims and enrollment data from 44,099 Medicare beneficiaries 65 years of age and older and discharged with acute ischemic stroke from 1998 to 2000 in 11 US metropolitan regions. Results: Patients seen by neurologists had more severe strokes than patients seen by generalists, though patients seen by generalists had more comorbidities. Patients seen by neurologists (alone or collaboratively) had a 10 and 16% lower risk of 30-day mortality, respectively. Patients seen by a neurologist only had a 12% lower risk of rehospitalization for infections and aspiration pneumonitis. In contrast, patients seen by neurologists had a higher risk of rehospitalization for atherosclerotic (cardiovascular and non-acute cerebrovascular) disease. Patients seen by neurologists were more likely to be discharged to inpatient rehabilitation, had longer lengths of stay, and were more likely to receive warfarin after discharge. Conclusions: Results support the hypothesis that neurologists improve outcomes specifically by reducing the potential for aspiration (through increased swallowing evaluations) or by improving functioning (through use of rehabilitation therapy). Future studies should continue to examine the mechanisms by which neurologists may achieve better outcomes in stroke care.

The price of bouncing back: one-year mortality and payments for acute stroke patients with 30-day bounce-backs.

OBJECTIVES: To examine 1‐year mortality and healthcare payments of stroke patients experiencing zero, one and two or more bounce‐backs within 30 days of discharge.

Bouncing-Back: Rehospitalization in Patients with Complicated Transitions in the First Thirty Days After Hospital Discharge for Acute Stroke

SUMMARY Background: “Bounce-backs” (movements from a less intensive to a more intensive care setting) soon after hospital discharge are common, but reasons for bouncing-back remain unknown. Objective: To examine how the primary diagnosis for first rehospitalization relates to thirty-day bounce-back number and initial discharge destination in acute stroke. Population: Administrative data from 5,250 Medicare beneficiaries > 65 years discharged with acute ischemic stroke in 1998–2000 to a rehabilitation center, skilled nursing facility or home with home health care and with at least one thirty day rehospitalization. Analysis: Probability of thirty-day bounce-back was calculated using multivariate models. Results: Infections and aspiration pneumonitis were the most common reasons for rehospitalization, regardless of initial discharge site. Conclusions: Efforts addressing aspirations and infections, the preventable complications of immobility, will be critical in decreasing acute stroke bounce-backs.

The complexity of medication regimens and test ordering for patients with diabetes from 1995 to 2003

ABSTRACT Objective: Diabetes care has become increasingly complex. We set out to quantify recent trends in the complexity of medication regimens and test ordering for diabetes patients continuously enrolled in health plans affiliated with a large, regional US health maintenance organization, with representation in the South and Midwest. Research design and methods: We provide descriptive trends analysis of overall diabetes care complexity (number of components [i.e., glucose, blood pressure, cholesterol control], number of medications/tests) from 1995 to 2003 for adults with diabetes (N = 304 233). Main outcome measures: The main outcomes were (1) the proportion of patients receiving diabetes-related medications (blood glucose, blood pressure, and cholesterol control agents), (2) the average number of medications, (3) the proportion of patients receiving diabetes-related tests (glycosylated hemoglobin [HbA1c], urine microalbumin, and serum cholesterol),(4) and the average number of tests ordered within the first year that a patient had any indication of diabetes. Results: The proportion of patients on cholesterol lowering drugs (18% → 39%, p < 0.01) and blood pressure lowering drugs (51% → 62%, p = 0.04) rose significantly, while the proportion on glucose lowering drugs fell (76% → 47%, p < 0.01). Among patients prescribed medications, the average total number of diabetes-related medications rose from 2.96 to 3.70 medications ( p < 0.01) with smaller increases seen for glucose lowering (1.45 → 1.65, p < 0.01) and blood pressure lowering regimens (2.14 → 2.51, p < 0.01), and no change for cholesterol lowering drugs (1.23 → 1.19, p = 0.19). For laboratory tests, the proportion receiving cholesterol (40% → 58%), and urine microalbumin (4% → 18%) (all ps < 0.01) rose significantly, while the testing rates for HbA1c remained unchanged. The average total number of tests ordered per year increased significantly from 3.34 to 4.10 ( p < 0.01) with more modest increases observed for individual tests. Limitation: Trends analyses are unadjusted for many clinical characteristics that might influence the complexity of diabetes care. Conclusions: Diabetes care grew more complex with the largest change in the number of patients receiving multi-component diabetes care. While the use of blood pressure and cholesterol lowering drugs rose overall, the proportion of patients using glucose lowering drugs declined and the average number of prescribed glucose lowering drugs did not increase in a clinically significant manner.

Predictors of Hospice Utilization among Acute Stroke Patients who Died within Thirty Days

BACKGROUND Hospice is considered to be underutilized, particularly among patients with noncancer diagnoses such as stroke. The highest mortality among stroke patients occurs within the first 30 days; however, we know little about the hospice enrollment decision for this population during this critical time frame. OBJECTIVES To determine hospice enrollment rates and to describe sociodemographic and clinical predictors of hospice utilization among patients who die within 30 days of their stroke. DESIGN Retrospective analysis of administrative data. SUBJECTS Medicare beneficiaries 65 years and older discharged with ischemic stroke from 422 hospitals and 11 metropolitan regions during the year 2000 who died within 30 days of their stroke. MEASURES Hospice utilization within 30 days. RESULTS The overall hospice enrollment rate in our study was 23%. Using multivariable logistic regression, factors predicting increased hospice enrollment included older age, female gender, health management organization (HMO) membership, length of stay more than 3 days, and dementia. Factors predicting decreased enrollment included African American race, mechanical ventilation, gastrostomy tube placement, uncomplicated diabetes mellitus, and valvular disease. When in-hospital deaths were excluded, overall enrollment increased to 44%, and mechanical ventilation and dementia ceased to predict enrollment. CONCLUSIONS Hospice enrollment rates among patients who die within the first 30 days of their stroke, particularly among those who survive to discharge, are much higher than prior estimates suggest. Although overall enrollment rates were higher than anticipated, there remain important sociodemographic and clinical characteristics unique to this population that predict low hospice utilization that should serve as targets for further research and intervention.

Discharge Destination's Effect on Bounce-Back Risk in Black, White, and Hispanic Acute Ischemic Stroke Patients

OBJECTIVE To determine whether racial and ethnic effects on bounce-back risk (ie, movement to settings of higher care intensity within 30 d of hospital discharge) in acute stroke patients vary depending on initial posthospital discharge destination. DESIGN Retrospective analysis of administrative data. SETTING Four hundred twenty-two hospitals, southern/eastern United States. PARTICIPANTS All Medicare beneficiaries 65 years or more with hospitalization for acute ischemic stroke within one of the 422 target hospitals during the years 1999 or 2000 (N=63,679). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Adjusted predicted probabilities for discharge to and for bouncing back from each initial discharge site (ie, home, home with home health care, skilled nursing facility [SNF], or rehabilitation center) by race (ie, black, white, and Hispanic). Models included sociodemographics, comorbidities, stroke severity, and length of stay. RESULTS Blacks and Hispanics were significantly more likely to be discharged to home health care (blacks=21% [95% confidence interval (CI), 19.9-22.8], Hispanic=19% [17.1-21.7] vs whites=16% [15.5-16.8]) and less likely to be discharged to SNFs (blacks=26% [95% CI, 23.6-29.3], Hispanics=28% [25.4-31.6] vs whites=33% [31.8-35.1]) than whites. However, blacks and Hispanics were significantly more likely to bounce back when discharged to SNFs than whites (blacks=26% [95% CI, 24.2-28.6], Hispanics=28% [24-32.6] vs whites=21% [20.3-21.9]). Hispanics had a lower risk of bouncing back when discharged home than either blacks or whites (Hispanics=14% [95% CI, 11.3-17] vs blacks=20% [18.4-22.2], whites=18% [16.8-18.3]). Patients discharged to home health care or rehabilitation centers demonstrated no significant differences in bounce-back risk. CONCLUSIONS Racial/ethnic bounce-back risk differs depending on initial discharge destination. Additional research is needed to fully understand this variation in effect.