Roger Feldman

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.

The Effects of Market Concentration and Horizontal Mergers on Hospital Costs and Prices

Antitrust advocates believe that horizontal consolidation in hospital markets can reduce competition and increase prices while merger advocates believe it can benefit consumers by reducing service duplication. This study analyzed the market conditions, operating characteristics, and costs and prices of approximately 3500 short-term general hospitals (including 112 within-market-area mergers) from 1986 to 1994 to investigate the effects of market concentration, hospital mergers, and managed care penetration. The results show: a shift away from non-price competition toward price competition in health care markets; that this shift was fueled by increased market penetration by price-sensitive buyers; that horizontal hospital mergers produced average cost savings of approximately 5%, which were generally passed on to consumers as lower prices; that cost savings were generally greater for mergers of similar-size hospitals, with a higher degree of duplicative services, and with lower pre-merger occupancy rates; and some evidence that post-merger price reductions were smaller in less-competitive markets.

Effects of teaching on hospital costs

This study estimates effects of undergraduate and graduate medical education on hospital costs, using a national sample of 367 U.S. community hospitals observed in 1974 and 1977. Data on other cost determinants, such as casemix, allow us to isolate the influence of teaching with greater precision than most previous studies. Non-physician expense in major teaching hospitals is at most 20 percent higher than in non-teaching hospitals; the teaching effect is about half this for hospitals with more limited teaching programs. Results for ancillary service departments are consistent with those for the hospital as a whole.

Geographic Variation in Device Use for Intertrochanteric Hip Fractures

BACKGROUND Hip fractures in the elderly are a common and costly problem, with intertrochanteric fractures accounting for almost half of these fractures. Most intertrochanteric fractures are treated with either a plate-and-screw device or an intramedullary nail device. We assessed the degree of geographic variation in use of intramedullary nailing for intertrochanteric femoral fractures among Medicare beneficiaries between 2000 and 2002. METHODS Medicare 100% files (hospital and physician claims, and enrollment) for 2000 through 2002 were used to identify beneficiaries, sixty-five years of age or older, who had undergone inpatient surgery for the treatment of an intertrochanteric femoral fracture with a plate-and-screw device or an intramedullary nail. We used multiple logistic regression analysis to model the use of an intramedullary nail (as opposed to a plate-and-screw device) by state and year, after adjusting for patient age, sex, race, subtrochanteric fracture, comorbidities, and Medicaid-administered assistance. The odds ratios of receiving an intramedullary nail device are reported. The adjusted state rates of intramedullary nailing per 100 Medicare patients with an intertrochanteric fracture are reported for 2000 through 2002. RESULTS In this study, 212,821 claims for operations to treat patients with an intertrochanteric fracture from 2000 through 2002 met the inclusion criteria. There was considerable geographic variation in intramedullary nail use by state across all years. The mean adjusted intramedullary nailing rate per 100 Medicare patients with an intertrochanteric fracture increased nationally from 7.84 in 2000 to 16.98 in 2002. In 2000, surgeons in sixteen states used an intramedullary nail in fewer than one of every twenty Medicare patients with an intertrochanteric fracture. By 2002, surgeons in only two states used an intramedullary nail in fewer than one of every twenty patients with an intertrochanteric fracture, and in eight states they used an intramedullary nail in more than one of every four patients with an intertrochanteric fracture. CONCLUSIONS There was substantial geographic variation in the use of intramedullary nailing by state from 2000 through 2002 that was largely not explained by patient-related factors.

A Matter Of Race: Early-Versus Late-Stage Cancer Diagnosis

We compared the stage at which cancer is diagnosed and survival rates between African Americans and whites, for thirty-four solid tumors, using the population-based Surveillance Epidemiology and End Results (SEER) database. Whites were diagnosed at earlier stages than African Americans for thirty-one of the thirty-four tumor sites. Whites were significantly more likely than blacks to survive five years for twenty-six tumor sites; no cancer site had significantly superior survival among African Americans. These differences cannot be explained by screening behavior or risk factors; they point instead to the need for broad-based strategies to remedy racial inequality in cancer survival.

Ninety-Day Mortality After Intertrochanteric Hip Fracture: Does Provider Volume Matter?

BACKGROUND Research on the relationship between orthopaedic volume and outcomes has focused almost exclusively on elective arthroplasty procedures. Geriatric patients who have sustained an intertrochanteric hip fracture are older and have a heavier comorbidity burden in comparison with patients undergoing elective arthroplasty; therefore, any advantage of provider volume in terms of mortality could be overwhelmed by the severity of the hip fracture condition itself. This study examined the association between surgeon and hospital volumes of procedures performed for the treatment of intertrochanteric hip fractures in Medicare beneficiaries and inpatient through ninety-day postoperative mortality. METHODS The Medicare 100% files of hospital and physician claims plus the beneficiary enrollment files for 2000 through 2002 identified beneficiaries who were sixty-five years of age or older and who underwent inpatient surgery for the treatment of an intertrochanteric hip fracture with internal fixation. Provider volumes of intertrochanteric hip fracture cases were calculated with use of unique surgeon and hospital provider numbers in the claims. Fixed effects regression analysis using generalized estimating equations was used to model the association between hospital and surgeon intertrochanteric hip fracture volume and inpatient through ninety-day mortality, controlling for age, sex, race, Charlson comorbidity score, subtrochanteric fracture, prefracture nursing home residence, Medicaid-administered assistance, surgical device, and year. The unadjusted inpatient, thirty, sixty, and ninety-day mortality rates and adjusted relative risks are reported. RESULTS Between March 1, 2000, and December 31, 2002, 192,365 claims met inclusion criteria and matched with provider information. The unadjusted inpatient, thirty-day, sixty-day, and ninety-day mortality rates were 2.91%, 7.92%, 12.34%, and 15.19%, respectively. Patients managed at lower-volume hospitals had significantly higher (10% to 20%) adjusted risks of inpatient mortality than those managed at the highest-volume hospitals. By sixty days postoperatively, the increased mortality risk persisted only among patients managed at the lowest-volume hospitals (six cases per year or fewer). Patients who were managed by surgeons who treated an average of two or three cases per year had the highest mortality risks when compared with patients managed by the highest-volume surgeons. CONCLUSIONS Only the highest-volume hospitals showed an inpatient mortality benefit for Medicare patients with intertrochanteric hip fractures. Unlike the situation with elective arthroplasty procedures, our findings do not indicate a need to direct patients with routine hip fractures exclusively to high-volume centers, although the higher mortality rates found in the lowest-volume hospitals warrant further investigation.

Effects of HMOs on the creation of competitive markets for hospital services

Why do health maintenance organizations (HMOs) use particular hospitals, and do they concentrate patients in hospitals where they obtain low prices? We answered these questions with a study of six HMOs in four large metropolitan areas in 1986. A two-part model was estimated for the probability that a hospital would be used and the demand for general inpatient admissions at hospitals that were used. Four staff-network plans in our study do shop for hospital services on the basis of price more than was generally believed. However, two independent practice association (IPAs) plans use more hospitals in the community and do not concentrate patients effectively at hospitals that offer the lowest prices.

The effects of advertising--lessons from optometry.

We examine the effect of advertising bans on the price of optometric examinations. Advertising is viewed as an information medium which enables consumers to search for lower prices, to the relative disadvantage of high-cost, low-volume sellers. Self-interest leads these sellers to support bans on advertising. An empirical section shows that price is 16 percent higher in states that ban optometric and optician price advertising, when examination length, procedures, and office equipment are held constant. The two advertising bans work by interaction--both must be present to raise significantly the price of eye examinations.

Cost-effectiveness of HPV vaccination compared with Pap smear screening on a national scale: a literature review.

Recommendations for worldwide use of human papillomavirus (HPV) vaccine are increasing. This study conducted a systematic review of articles related to cost-effectiveness analysis of wide-range HPV vaccination programs compared with Pap smear screening published before August 2007. Eight articles were identified using predefined inclusion and exclusion criteria. After excluding two outliers, the range of incremental cost-effectiveness ratios (ICERs) from six articles is between

Provider Factors Associated with Intramedullary Nail Use for Intertrochanteric Hip Fractures

16,600 and