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Objective To assess the impact of hospital affiliation, centralization, and managed care plan ownership on inpatient cost and quality. Data Sources Inpatient discharges from 3,957 community hospitals in 44 states and American Hospital Association Annual Survey data from 2010 to 2012. Study Design We conducted a retrospective longitudinal regression analysis using hierarchical modeling of discharges clustered within hospitals. Data Collection Detailed discharge data including costs, length of stay, and patient characteristics from the Healthcare Cost and Utilization Project State Inpatient Databases were merged with hospital survey data from the American Hospital Association. Principal Findings Hospitals affiliated with health systems had a higher cost per discharge and better quality of care compared with independent hospitals. Centralized systems in particular had the highest cost per discharge and longest stays. Independent hospitals with managed care plans had a higher cost per discharge and better quality of care compared with other independent hospitals. Conclusions Increasing prevalence of health systems and hospital managed care ownership may lead to higher quality but are unlikely to reduce hospital discharge costs. Encouraging participation in innovative payment and delivery reform models, such as accountable care organizations, may be more powerful options.

Objectives: To compare outcomes and measures of efficiency for hospitalized elderly adults managed by geriatricians with those managed by other physicians. Design: Secondary data analysis using a system that integrates clinical and financial information for inpatient and outpatient services delivered throughout the University of Pittsburgh Medical Center (UPMC). Propensity scores were developed based on participant sociodemographic and clinical characteristics and used to match participants based on the attending physician's specialty (geriatrician, n = 701; nongeriatrician, n = 11,549). Multivariate analyses using generalized estimating equations methods were performed. Setting: Two UPMC hospitals in Pittsburgh, Pennsylvania. Participants: Patients aged 65 and older admitted in 2002 in a medical diagnosis-related group (DRG). Measurements: Outcomes (inpatient mortality, 30-day mortality, readmission) and efficiency measures (length of stay, total costs, and surplus, which is the difference between hospital costs and payment received for an admission). Results: Elderly adults managed by geriatricians were significantly older (P < .001) and more likely to be male (P < .001) and had more diagnoses (P < .001). Propensity scores successfully balanced characteristics managed by the two groups. Patients of geriatricians had shorter length of stay (P < .001), lower costs per admission (P < .001), and greater surplus (P < .001) with no differences in outcomes. In multivariate analyses, there were not significant differences in outcomes, but patients of geriatricians had significantly shorter length of stay and lower costs per admission and generated more surplus for the hospitals. Conclusion: Geriatricians were more efficient than other physicians in managing hospitalized elderly adults with medical DRGs frequently managed by geriatricians. This efficiency did not compromise patient outcomes.

To examine whether low-income parents of children enrolled in the New York State Children's Health Insurance Program (SCHIP) choose managed care plans with better quality of care.2001 New York SCHIP evaluation data; 2001 New York State Managed Care Plan Performance Report; 2000 New York State Managed Care Enrollment Report.Each market was defined as a county. A final sample of 2,325 new enrollees was analyzed after excluding those in markets with only one SCHIP plan. Plan quality was measured using seven Consumer Assessment of Health Plans Survey (CAHPS) and three Health Plan Employer Data and Information Set (HEDIS) scores. A conditional logit model was applied with plan and individual/family characteristics as covariates.There were 30 plans in the 45 defined markets. The choice probability increased 2.5 percentage points for each unit increase in the average CAHPS score, and the association was significantly larger in children with special health care needs. However, HEDIS did not show any statistically significant association with plan choice.Low-income parents do choose managed care plans with higher CAHPS scores for their newly enrolled children, suggesting that overall quality could improve over time because of the dynamics of enrollment.

The U.S. government is deeply involved in the health care market, and in the price control settings, one of the government's concerns is quality of care. Since managed care started expanding throughout the country in the 1980s, government and private organizations have been trying to develop quality measurement tools and monitor the quality of care. For example, the Consumer Assessment of Health Plans Survey (CAHPS®) and the Health Plan Employer Data and Information Set (HEDIS®) were developed to assess the quality of managed care plans in the 1990s. Starting in 1999, Congress has required the Agency of Healthcare Research and Quality (AHRQ) to produce an annual National Health Quality Report (AHRQ 2003). In recent years, an increasing number of states have switched their Medicaid or State Children's Health Insurance Program (SCHIP) from fee-for-service to managed care (Kaiser Family Foundation 2001). For example, New York State and the State of Florida rely on managed care plans to provide health care for SCHIP enrollees. In New York State, mandatory Medicaid managed care has been implemented in about 30 counties (NYSDOH 2005). The New York State government sets the monthly capitation rate for participating managed care plans and releases an annual quality report of all the managed care plans operating in the state. The relationship between quality of care and competition has been one of the focuses of researchers for the last several decades. Most prior studies are about hospital competition, which is subject to price control under the Medicare Prospective Payment System (PPS). Based on the data before 1983 when the PPS was implemented, many studies show a positive association between competition and quality or cost (e.g., Joskow 1980; Robinson and Luft 1985, 1987; Noether 1988). Those studies analyzing the data after 1983, however, provide mixed evidence on the relationship between competition and quality or cost because there are two forces at play: the PPS and the penetration of managed care. The PPS actually acts as a price control mechanism, and higher price is associated with higher quality if assuming the same market competition level, as shown in the study by Cutler (1995). Alternatively, if the price is held constant, increasing market competition would result in higher quality and higher cost. Theoretically, managed care penetration would lower the cost of care, but the PPS would lead to higher costs in more competitive markets. Not surprisingly, the evidence about cost or quality is mixed (e.g., Shortell and Hughes 1988; Zwanziger and Melnick 1988; Dranove, Shanley, and Simon 1992; Manheim, Bazzoli, and Sohn 1994; Kessler and McClellan 2000; Mukamel, Zwanziger, and Tomaszewski 2001; Gowrisankaran and Town 2003). Because managed care plans have financial incentives to reduce cost at the expense of quality of care, the effect of managed care competition on quality is worthy of investigation. However, only a few studies have been conducted in this area. Using a national representative sample from the Community Tracking Study, Sommers and Wholey (2003) regress evaluation of physician thoroughness on health maintenance organization (HMO) competition and other control variables, and conclude that HMO competition increases the evaluation of physician thoroughness among HMO enrollees. Scanlon et al. (2005) assess the association between HMO competition and plan performance as measured by CAHPS and HEDIS, and find that competition is negatively correlated with three out of six quality domains. Another study using longitudinal data by Scanlon et al. (2006), however, shows that more HMO competition is associated with better overall ratings of health plans, but is not consistently correlated with HEDIS measures. Despite the states' increasing dependence on managed care to provide comprehensive coverage for the low-income population, few studies have been conducted to examine the effect of nonprice competition on the quality of care. Nonprice competition means a situation where price does not play a role in market competition. Using the 2002 New York State Managed Care Plan Performance Report and 2001 Annual Managed Care Enrollment Report, we are able to assess the effect of nonprice competition on quality of care within the New York SCHIP market,1 which is subject to the price control from the state government.

Study Purpose Administrative databases are commonly used to examine use of healthcare service, with researchers relying on diagnostic codes to identify medical conditions. This study evaluates the accuracy of administrative claims in identifying Parkinsonism cases compared to the self-reported Parkinson's disease (PD). Methods The reference cases were identified based on the self-reported PD status and the use of PD drugs collected by the 1992–2000 Medicare Current Beneficiary Survey that contained 72,922 observations from 30,469 individuals. Using ICD-9 CM, cases with PD were extracted from the corresponding Medicare claims. We compared prevalence of PD obtained using different types of claims. Results The sensitivities were the highest when all claims were used (66%). All the specificities were greater than 99%. When drug use information was included in the gold standard, the sensitivities became lower, while the specificities and positive predictive values (PPVs) increased. Using more diagnostic codes improved the sensitivity of the identification process but reduced PPVs. Conclusions Administrative claims can provide fairly accurate and practical approach to “rule in” patients with PD. Depending on the purpose of evaluation, researchers may consider using more categories of claims to improve the sensitivity of the identification algorithm or use fewer diagnoses to minimize number of false positive cases. © 2006 Movement Disorder Society

We evaluated medical utilization and economic burden of self-reported Parkinson's disease (PD) on patients and society. Using the 1992–2000 Medicare Current Beneficiary Survey, we compared health care utilization and expenditures (in 2002 U.S. dollars) of Medicare subscribers with and without PD, adjusting for sociodemographic characteristics and comorbidities. PD patients used significantly more health care services of all categories and paid significantly more out of pocket for their medical services than other elderly (mean ± SE, $5,532 ± $329 vs. $2,187 ± $38; P < 0.001). After adjusting for other factors, PD patients had higher annual health care expenses than beneficiaries without PD ($18,528 vs. $10,818; P < 0.001). PD patients were more likely to use medical care (OR = 3.77; 95% CI = 1.44–9.88), in particular for long-term care (OR = 3.80; 95% CI = 3.02–4.79) and home health care (OR = 2.08; 95% CI = 1.76–2.46). PD is associated with a significant economic burden to patients and society. Although more research is needed to understand the relationship between PD and medical expenditures and utilization, these findings have important implications for health care providers and payers that serve PD populations. © 2005 Movement Disorder Society