TAG: "Health policy"

Study: Hospital mergers, acquisitions leading to increased patient costs


Counterintuitive findings published in Journal of the American Medical Association.

The trend of hospitals consolidating medical groups and physician practices in an effort to improve the coordination of patient care is backfiring and increasing the cost of patient care, according to a new study led by a UC Berkeley health policy expert.

The counterintuitive findings, published today (Oct. 21) in the Journal of the American Medical Association, come as a growing number of local hospitals and large, multi-hospital systems in this country are acquiring physician groups and medical practices.

“This consolidation is meant to better coordinate care and to have a stronger bargaining position with insurance plans,” said study lead author James Robinson, professor and head of health policy and management at UC Berkeley’s School of Public Health. “The movement also aligns with the goals of the Affordable Care Act, since physicians and hospitals working together in ‘accountable care organizations’ can provide care better than the traditional fee-for-service and solo practice models. The intent of consolidation is to reduce costs and improve quality, but the problem with all this is that hospitals are very expensive and complex organizations, and they are not known for their efficiency and low prices.”

Robinson teamed up with study co-author Kelly Miller, program analyst at Integrated Healthcare Association, a nonprofit organization that promotes health care quality improvement, accountability and affordability in California.

The researchers analyzed four years of data, from 2009 to 2012, on 158 major medical groups and 4.5 million patients in California. Groups were put into three categories: owned by physicians, owned by a local hospital or hospital system, or owned by a large hospital system that spans multiple geographic markets in the state.

The measure of costs included physician visits, inpatient hospital admissions, outpatient surgery and diagnostic procedures, drugs, and all other forms of medical care except for mental health services. (The researchers did not have data on mental health services since they are paid for separately.)

After controlling for such factors as the mix of severely ill patients and geographic differences in cost, the researchers found that per patient expenditures were 19.8 percent higher for physician groups in multi-hospital systems compared with physician-owned organizations. Groups owned by local hospitals were better, but per patient costs still ran 10.3 percent higher compared with physician-owned groups.

Why would consolidation lead to increased costs? It could be that once a medical group has been acquired, physicians in those groups are expected to admit their patients to the high-priced hospital, Robinson said.

“Hospital-owned medical groups usually are expected to conduct ambulatory surgery and diagnostic procedures in the outpatient departments of their parent hospital, but hospital outpatient departments are much more costly and charge much higher prices than freestanding, non-hospital ambulatory centers,” he said.

Robinson said that public policy should not encourage mergers and acquisitions as a means of promoting collaboration. Instead, he said, policymakers should consider supporting the use of bundled payments for hospitals and physicians to improve coordination of care.

“Hospitals are an essential part of the health care system, but they should not be the center of the delivery system,” said Robinson. “Rather, physician-led organizations based in ambulatory and community settings are likely to be more efficient and provide cheaper care.”

The study authors noted that their findings are limited to California, and that further studies should be done using data from other states.

“Nevertheless, these findings are important since California is the nation’s leader in terms of having physicians participate in large medical groups that already perform the functions ascribed to ‘accountable care organizations’ by the Obama administration,” said Robinson.

The Robert Wood Johnson Foundation provided support for this research.

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Increased hospital use after Medicaid expansion is mostly temporary


UCLA study finds pent-up demand for health care will decline after first year of enrollment.

The expansion of Medicaid to millions of uninsured people should not have the catastrophic impact some predicted for state budgets because the increases in hospital and emergency room usage are only temporary, according to a new study by the UCLA Center for Health Policy Research.

“We found that the surge doesn’t last long once people get coverage,” said Nigel Lo, a research analyst at the UCLA Center for Health Policy Research and the study’s lead author. “Our findings suggest that early and significant investments in infrastructure and in improving the process of care delivery can effectively address the pent-up demand for health care services of previously uninsured people. Fears that these new enrollees will overuse health care services are just not true.”

Using two years of claims data from 182,000 low-income, uninsured people enrolled in California’s state-run health insurance programs, the UCLA researchers found that people who previously had had the least medical care used hospital emergency rooms at a high rate of 600 visits per 1,000 people. But usage declined sharply in the first quarter to 424 visits (a 29 percent drop), followed by another 25 percent decline the following quarter. Between 2011 and 2013, the overall decline was 69.5 percent (183 ER visits). The report also shows that their hospital admissions declined sharply, from 194 to 42, a decline of 78.5 percent.

“California’s success should set an example for states that are on the fence about expanding Medicaid,” said co-author Gerald Kominski, professor of health policy and management and director of the Center for Health Policy Research. “It’s an investment: Build more infrastructure and care delivery early on, and you can manage chronic care, address unmet health care needs, and keep cost increases to a manageable level.”

The Affordable Care Act has extended Medicaid eligibility in 27 states, but many other states have refused coverage in part because of predictions that state budgets would be overwhelmed by the demands of the previously uninsured, particularly once federal subsidies stop covering the full expansion cost in 2017. Three states — Indiana, Missouri and Utah — are considering expansion, and other state legislatures will soon debate the issue.

The Obama administration is pushing states to expand Medicaid, arguing that they are not only leaving millions of their residents uninsured, but are also forcing their hospitals to absorb billions of dollars in uncompensated costs for treating people without insurance.

The UCLA study looked at data from two programs in California — the Health Care Coverage Initiative, which ran from 2007 to 2010, and the Low Income Health Program, which ran from 2011 to 2013. On Jan. 1, 2014, these enrollees became part of the 1.5 million Californians who were able to transition under the Affordable Care Act into Medi-Cal, California’s Medicaid program that provides health insurance to low-income people.

The authors said that because California’s Low Income Health Program had provided preventative medical care and regular treatment for chronic diseases, the newly insured were no longer dependent on emergency room treatment and hospitalization. Improving care delivery through the use of an assigned source of primary care, care coordination and health risk assessments, as well as greater availability of specialty services and culturally competent self-care also potentially helped manage pent-up demand, they said.

The UCLA results provide new insights into previously published findings that costly emergency room visits in Oregon increased by 40 percent during the year after the state expanded Medicaid eligibility. By examining data over a longer period of time, the UCLA study was able to determine that such spikes in usage were only temporary.

The study was funded by the California Department of Health Care Services and the Blue Shield of California Foundation.

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Sesame Street helps teach physicians a lesson


Incarceration plays major role in health disparities in U.S., says UC Riverside professor.

UC Riverside’s Scott Allen (left) is seen here with Sesame Street’s Alex, a blue-haired, green-nosed Muppet who has a father in jail, and Brown University’s Josiah Rich (right). (Photo courtesy of Pam Hacker, Sesame Street)

More than two million people are incarcerated in the United States, the highest incarceration rate in the world. So perhaps it comes as no surprise that last year the popular children’s television series Sesame Street introduced a character that has an incarcerated father.

With incarceration having found a home even on Sesame Street, public health practitioners, policymakers and health care providers ought to pay closer attention to incarceration’s impact on health inequality in the country, argue a team of two physicians and a medical researcher in an article published today (Oct. 6) in Annals of Internal Medicine.

Scott A. Allen, M.D., a professor of medicine in the School of Medicine at the University of California, Riverside, and his colleagues report that while many people need to be in prison for the safety of society, a majority are incarcerated due to behaviors linked to treatable diseases such as mental illness and addiction.

“In such cases, incarceration will improve neither the imprisoned person nor the social problem without medical intervention,” Allen writes, along with co-authors Dora M. Dumont, Ph.D., M.P.H., at the Rhode Island Department of Health and Josiah D. Rich, M.D., M.P.H., at Brown University.

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Higher nurse-to-patient standard enhances staff safety


Study finds drop in occupational injuries to nurses after mandated staffing ratios in California.

J. Paul Leigh, UC Davis

A 2004 California law mandating specific nurse-to-patient staffing standards in acute care hospitals significantly lowered job-related injuries and illnesses for both registered nurses and licensed practical nurses, according to a UC Davis study published online in the International Archives of Occupational and Environmental Health. The study is believed to be the first to evaluate the effect of the law on occupational health.

“We were surprised to discover such a large reduction in injuries as a result of the California law,” said study lead author J. Paul Leigh, a professor of public health sciences and investigator with the Center for Healthcare Policy and Research at UC Davis. “These findings should contribute to the national debate about enacting similar laws in other states.”

California is the only state in the country with mandated minimum nurse-to-patient staffing ratios. They are established based on type of service (such as pediatrics, surgery, or labor and delivery) and allow for flexibility in cases of health care emergencies. (The ratios are available on the California Department of Public Health website.)

According to Leigh, some hospitals have argued against extending the law to other states because of the increased costs of additional nursing staff. There is also no consensus that the law has improved patient outcomes, which was its primary intent. Some studies show improvement, while others do not.

“Our study links the ratios to something just as important — the lower workers’ compensation costs, improved job satisfaction and increased safety that comes with linking essential nursing staff levels to patient volumes,” Leigh said.

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Taking preventive health care into community spaces


Bringing health care to non-traditional locations increases use of preventive services.

Janet Frank, UCLA

A church. A city park. An office. These are not the typical settings for a medical checkup. But a new nationwide study by the UCLA Center for Health Policy Research shows that providing health services in unorthodox settings helps underserved adults get preventive care.

With support from the Centers for Disease Control and Prevention, the study’s authors reviewed 142 outreach programs nationwide and identified 20 that successfully used non-traditional settings, such as churches and parks, to promote or deliver preventive services (such as bone density and cancer screenings) to older underserved populations.

“The research shows that health providers might need to think outside the box on how and where to deliver health services,” said Janet Frank, lead author of the study and an adjunct associate professor at the UCLA Fielding School of Public Health. “The programs that fared the best did not wait for patients to come to them — they went to where the patients were.”

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Providing futile treatment prevents others from getting critical care they need


UCLA findings have implications for fairness of American health care system.

Providing futile treatment in the intensive care unit sets off a chain reaction that causes other ill patients who need medical attention to wait for critical care beds, according to a study by UCLA and RAND Health.

The research is the first to show that when non-beneficial medical care is provided, others who might be able to benefit from treatment are harmed, said Dr. Thanh Huynh, the study’s lead author and an assistant professor of medicine in the division of pulmonary and critical care medicine at the David Geffen School of Medicine at UCLA.

The findings also have implications for the fairness of the American health care system, and they point toward policy improvements that would guide more efficient use of our limited health care resources, said senior author Dr. Neil Wenger, a UCLA professor of medicine and RAND Health scientist.

“Many people do not realize that there is a tension between what medicine is able to do and what medicine should do,” said Wenger, who also is director of the UCLA Health Ethics Center at the Geffen School of Medicine. “Even fewer realize that medicine is commonly used to achieve goals that most people, and perhaps most of society, would not value — such as prolonging the dying process in the intensive care unit when a patient cannot improve.

“But almost no one recognizes that these actions affect other patients, who might receive delayed care or, worse, not receive needed care at all because futile medical treatment was provided to someone else.”

The study appears in the August issue of the peer-reviewed journal Critical Care Medicine.

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Hospital charges for blood tests vary widely across California


UCSF study highlights difficulty of knowing health care prices.

Renee Hsia, UC San Francisco

New UC San Francisco research shows significant price differences for 10 common blood tests in California hospitals, with some patients charged as little as $10 for one test while others were charged $10,169 for the identical test.

The analysis of charges at more than 150 California hospitals looked at blood tests that are often required of patients, such as lipid panel, basic metabolic panel, and complete blood cell count with differential white cell count.

Hospital ownership and teaching status help explain a portion of the variation – prices generally were lower at government and teaching hospitals. Factors such as location, labor costs, patient capacity and percentage of uninsured population generally did not account for the price differences, the authors said, making it difficult for patients to know their costs in advance and to “act as rational consumers.”

The report was published in BMJ Open today (Aug. 15).

Charges for a basic metabolic test ranged from $35 to $7,303, depending on the hospital; the median charge was $214. The most extreme price difference was found in charges for a lipid panel: the median charge was $220, but overall charges ranged from $10 to as much as $10,169.

The results are of particular concern, said the authors, since there isn’t much room for variability in blood tests. Moreover, because the tests are identical across providers, consumers might be expected to think that hospital charges would be similar.

“You may hear people say that, ‘Charges don’t matter’ or that ‘No one pays full charges,’” said senior author Renee Y. Hsia, M.D., an associate professor of emergency medicine at UCSF and director of health policy studies in the Department of Emergency Medicine. She is also an attending physician in the emergency department at San Francisco General Hospital and Trauma Center.

“However, uninsured patients certainly face the full brunt of raw charges, especially if they don’t qualify for charity care discounts,” Hsia said. “And as employers are switching to more consumer-directed health plans with higher deductibles and co-pays, the out-of-pocket costs of even insured patients can be affected by these charges.”

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Medical schools urged to increase enrollment of undocumented immigrants


Accepting students eligible for federal DACA program could help address nation’s shortage of primary care physicians, UCLA center says.

Youhali Balderas-Medina Anaya, UCLA

A paper by researchers at the UCLA Center for the Study of Latino Health and Culture urges medical schools to do more to increase their enrollment of undocumented immigrants seeking access to the medical professions.

The authors of “Undocumented Students Pursuing Medical Education: The Implications of Deferred Action for Childhood Arrivals,” published in the current issue of the journal Academic Medicine, suggest that these students, who are often highly motivated and qualified, can help alleviate the nationwide shortage of primary care physicians, particularly in underserved, low-income areas.

“This country is in great need of primary care physicians to fill the ongoing shortage, yet qualified undocumented pre-medical students are still being denied access to medical schools because of concerns regarding their status,” said Dr. Yohualli Balderas-Medina Anaya, a resident physician in the department of family medicine at the David Geffen School of Medicine at UCLA and the paper’s lead author.

The authors suggest that Deferred Action for Childhood Arrivals (DACA), an initiative signed by the Obama administration in 2012 that allows certain young undocumented immigrants to work legally in the U.S. without fear of deportation, could help shore up the numbers.

“With DACA,” Anaya said, “undocumented pre-med students can help address this growing shortage. We are calling upon the medical and academic community to support undocumented students applying to medical school. We can all benefit from helping these students enter and successfully complete medical school.”

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Study finds health claims misleading for sports, energy drinks


‘Health halo’ around popular drinks obscures risks to children.

A new report by UC Berkeley researchers questions the health claims of popular energy, sports, tea and fruit drinks on the market.

In a report released today (Aug. 6), the authors evaluated 21 popular drinks with health claims — from immune boosters to energy enhancers — on their labels and in their marketing materials.

“We often see labels on energy and sports drinks that tout health benefits, but the sugar levels in these products rival that of sodas,” said lead author Patricia Crawford, director of the Atkins Center for Weight and Health and UC Berkeley adjunct professor of nutritional sciences and toxicology. “They are essentially sodas without the carbonation, but they give the misleading impression that they are healthy.”

The report, “Looking Beyond the Marketing Claims of New Beverages,” was commissioned by the California Center for Public Health Advocacy. Click here to access the full report, fact sheets and press release.

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Low-income diabetics up to 10 times likelier to lose a limb than wealthier patients


Most amputations preventable with earlier medical care, UCLA researchers say.

Carl Stevens, UCLA

It’s no secret that poverty is bad for your health. Now a new UCLA study demonstrates that California diabetics who live in low-income neighborhoods are up to 10 times more likely to lose a toe, foot or leg than patients residing in more affluent areas of the state. Earlier diagnosis and proper treatment could prevent many of these amputations, the researchers say.

The study authors hope their findings, published in the August issue of Health Affairs, will motivate public agencies and medical providers to reach out to patients at risk of late intervention and inspire policymakers to adopt legislation to reduce barriers to care.

“I’ve stood at the bedsides of diabetic patients and listened to the surgical residents say, ‘We have to cut your foot off to save your life,’” said lead author Dr. Carl Stevens, a clinical professor of medicine at the David Geffen School of Medicine at UCLA. “These patients are often the family breadwinners and parents of young children — people with many productive years ahead of them.

“When you have diabetes, where you live directly relates to whether you’ll lose a limb to the disease,” added Stevens, an emergency physician for 30 years at Harbor–UCLA Medical Center. ”Millions of Californians have undergone preventable amputations due to poorly managed diabetes. We hope our findings spur policymakers nationwide to improve access to treatment by expanding Medicaid and other programs targeting low-income residents, as we did in California in 2014.”

Dylan Roby, UCLA

The authors used data from the UCLA Center for Health Policy Research’s California Health Interview Survey, which estimated the prevalence of diabetes among low-income populations by ZIP code. They blended these statistics with household-income figures from the U.S. Census Bureau and hospital discharge data from the Office of Statewide Health Planning and Development that tracked diabetes-related amputations by ZIP code.

The result was a detailed set of maps showing diabetic amputation rates by neighborhood for patients 45 and older — the age range at greatest risk for amputation from disease complications.

“Neighborhoods with high amputation rates clustered geographically into hot spots with a greater concentration of households falling below the federal poverty level,” said co-author Dylan Roby, director of health economics at the UCLA Center for Health Policy Research and an assistant professor at the UCLA Fielding School of Public Health. “Amputation rates in California were 10 times higher in the poorest neighborhoods, like Compton and East Los Angeles, than in the richest neighborhoods, such as Malibu and Beverly Hills.”

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Odds of dying higher for hospital patients near closed emergency departments


UCSF study finds ED closures hurt surrounding communities as well as patients.

Renee Hsia, UC San Francisco

In the first analysis of its kind, UC San Francisco research shows that emergency department closures can have a ripple effect on patient outcomes at nearby hospitals.

In a study of more than 16 million emergency admissions to California hospitals between 1999 and 2010, researchers found that patients who were admitted to facilities located in the vicinity of an emergency department (ED) that had recently closed experienced 5 percent higher odds of dying than patients admitted to hospitals that were not near a recently closed ED.

The odds of dying were even higher for patients with certain time-sensitive conditions, especially heart attack (15 percent higher odds), stroke (10 percent) and sepsis (8 percent). The findings are of particular concern nationwide, said the authors, because the annual number of ED visits increased by 51 percent between 1996 and 2009, while the number of available emergency departments dropped by 6 percent.

The report will be published in the August issue of Health Affairs.

“Emergency department closures are affecting many more patients than previously thought,” said senior author Renee Y. Hsia, M.D., an associate professor of emergency medicine at UCSF and director of health policy studies in the department of emergency medicine. She is also an attending physician in the emergency department at San Francisco General Hospital and Trauma Center. “Most importantly, people who live in the area of nearby closures but whose own hospital did not close are still negatively affected by increased wait times and crowding in their own emergency department,” she said.

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3 of 4 California children with mental health needs don’t get treatment


Barriers to care persist, even though 95 percent have health insurance.

More than 300,000 California children between the ages 4 and 11 need mental health care, but only one in four is treated, according to a new policy brief from the UCLA Center for Health Policy Research — this, despite the Centers for Disease Control and Prevention recommending early-childhood intervention as a critical step in reducing the severity of mental health problems in adulthood.

“Without early assessment, you miss warning signs, as well as opportunities to intervene,” said D. Imelda Padilla-Frausto, a researcher at the center and lead author of the study. “Waiting can lead to more serious problems later.”

While about 8.5 percent of all California children in the 4-to-11 age group are identified as having mental health care issues — including conduct problems, emotional symptoms, hyperactivity and problems with peers — parents reported that 70.8 percent of these children went without emotional or psychological counseling over the previous year, according to the study, which used California Health Interview Survey (CHIS) data from 2007–09.

The study looked at a number of factors that contribute to mental health needs among children and obstacles that may contribute to a lack of treatment.

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