Browsing by Author "Short, Marah Noel"
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Item Annual Spending per Patient and Quality in Hospital-Owned Versus Physician-Owned Organizations: an Observational Study(2019) Ho, Vivian; Metcalfe, Leanne; Vu, Lan; Short, Marah Noel; Morrow, Robert; James A. Baker III Institute for Public PolicyBackground: Recent studies that compared patient spending in hospital-owned physician practices versus physician-owned groups did not compare quality of care. Past studies had incomplete measures of physician-hospital integration, or lacked patient-level data. Objective: To measure the association between physician-hospital integration and both spending and quality using patient-level data and explicit physician-hospital contracting information. Design: Retrospective review of claims data from 2014 through 2016. Adjustments were made for patient, physician, and regional characteristics. Patients: Patients aged 19 to 64 enrolled in a Blue Cross Blue Shield Texas Preferred Provider Organization in the four largest metropolitan areas in Texas who could be attributed to a physician practice based on claims. Main Outcomes and Measures: Annual spending per patient was compared for patients treated by a physician practice that is billing through a hospital, versus billing through an independent physician practice; spending was also subdivided by BETOS category, by site and type of care, and percent of patients with positive spending by subcategory. Quality measures included readmission within 30 days of discharge for hospitalized patients, appropriate care for diabetic patients, and screening mammography for women ages 50–64. Results: Estimates suggest that patients in a preferred provider organization incur spending which is 5.8 percentage points higher when treated by doctors in hospital-owned versus physician-owned practices (95% CI 1.7 to 9.9; p = 0.006). Spending is significantly higher for durable medical equipment, imaging, unclassified services, and outpatient care. The spending difference appears attributable to greater service utilization rather than higher prices. There was no consistent difference in care quality for hospital-owned versus physician-owned practices. Conclusions and Relevance: We find that financial integration between physicians and hospitals raises patient spending, but not care quality. Given that higher spending raises the price of health insurance, policy makers should carefully consider policies that limit consolidation of hospitals and physicians.Item Are Texas Hospitals Practicing Price Transparency?(2022) Ho, Vivian; Solcher, Patrick; Ye, Vivian; Short, Marah Noel; James A. Baker III Institute for Public PolicyItem CDC Case Report Data for COVID-19: Characterizing the Pandemic with Limited Information(James A. Baker III Institute for Public Policy, 2021) Ho, Vivian; Short, Marah Noel; Tapaneeyakul, Sasathorn; James A. Baker III Institute for Public PolicyNationwide standardized surveillance of COVID-19 using the U.S. Center for Disease Control (CDC)'s COVID-19 case report forms could yield invaluable information on disease burden and the nature of virus transmission. If respondents provided comprehensive responses to the form’s queries, public health officials, policymakers, and business leaders would have a wealth of data when making critical decisions on where to direct testing and treatment resources, and how to conduct safe reopenings. We obtained CDC case reports through July 19, 2020 through an expedited Freedom of Information Act request. We examined data from May 5 through July 19 to determine completeness of CDC case counts relative to more accurate counts reported by the New York Times (NYT). We found that the CDC’s case reports contained surprisingly incomplete information relative to the amount that the agency’s official form was intended to collect. Only seven states had sufficient data to characterize cases by ethnicity or race, or exposure type. People age 20 to 39 accounted for more COVID-19 cases than their share of the population. The most infections for all ages tended to occur during the third time period (June 24 through July 19) in our sample. White people were infected in proportion to their share of the population, while Hispanic cases were overrepresented. The most common sources of exposure were workplaces and households.Item Certificate of Need Regulations and the Availability and Use of Cancer Resections(2008) Short, Marah Noel; Aloia, Thomas A.; Ho, Vivian; James A. Baker III Institute for Public PolicyBackground: Several states use certificate of need regulations (CON) to control the growth of acute-care services, but the possible association between these restrictions and the provision of cancer surgery has not been assessed. This study examines the association between acute-care CON, the availability of cancer surgery hospitals, and provision of six cancer operations. Methods: Medicare data were collected for beneficiaries treated with one of six cancer resections and an associated cancer diagnosis from 1989 to 2002. Hospital, procedure, and incidence rates for each cancer diagnosis were stratified by state and year. The number of hospitals performing each operation per cancer incident, the number of procedures performed per cancer incident, and hospital volume were compared between states with and without CON, and those that discontinued CON during the sample period were noted. Results: The number of hospitals per cancer incident was lower in CON states versus non-CON states for colectomy (P = .022), rectal resection (P = .026), and pulmonary lobectomy (P = .032). Hospital volume was significantly higher in CON states versus non-CON states for colectomy (P = .006) and pulmonary lobectomy (P = .043). There were no differences between states with and without CON in the number of procedures per cancer incident. Conclusion: Although use of cancer procedures was similar in CON and non-CON states, those with acute-care CON had fewer facilities performing oncologic resections per cancer patient. Correspondingly, average hospital procedure volume tended to be higher in CON states. These differences may have important implications for patient outcomes and costs.Item Community Benefit Spending and the Tax-Exempt Status of Nonprofit Hospitals(James A. Baker III Institute for Public Policy, 2018) Alexander, Alex; Short, Marah Noel; Ho, Vivian; James A. Baker III Institute for Public PolicyItem Comparing Prices and Price Transparency Among Top-Ranked Hospitals and Close Competitors(2022) Ho, Vivian; Lara, Alan Beltran; Ruiz, David; Cram, Peter; Short, Marah Noel; James A. Baker III Institute for Public PolicyA regulation from the Centers for Medicare and Medicaid Services (CMS) required that, starting January 1, 2021, all U.S. hospitals publicly display the cash price as well as the minimum and maximum negotiated charge for 300 “shoppable services.” During July and August 2021 we evaluated compliance with these requirements among the U.S. News & World Report’s 20 honor roll hospitals in 2020-21 and 41 high-quality hospitals in the same cities. We compared prices for three imaging studies (brain MRI, abdominal ultrasound, and chest x-ray) and three hospital services (basic metabolic panel, electrocardiogram [ECG], and lower joint replacement). Within each of the studied procedures, at most 7 of the 14 cities with top-20 hospitals had minimum negotiated prices that were reported by at least one top-20 hospital and a competitor that was comparable in quality. The top-20 hospital was the highest priced for 5 of 7 cities for ECGs. Yet a top-20 hospital was the highest priced facility in only 1 of 5 cities for both MRIs and joint replacements. For a handful of cities and procedures, the top-20 hospital was priced much lower than its competitor(s), or there was wide price disparity between top-20 hospitals in the same city. Top-20 hospitals were more likely to report cash prices, but they were orders of magnitude higher than their minimum negotiated price. Many highly respected U.S. hospitals are not in compliance with new price transparency legislation, even though the prices of reporting top-20 hospitals are not systematically higher than competitors with comparable quality. Full price transparency by all hospitals would aid patients and payers in identifying price outliers and choosing the most cost-effective providers.Item Could substantial health care savings be achieved by reducing complications from cancer surgery?(2014) Short, Marah Noel; Ho, Vivian; Aloia, Thomas A.; James A. Baker III Institute for Public PolicyItem Health Reform Monitoring Survey-Texas, Issue Brief #10: Marketplace Plans: Premiums, Network Size and Market Competition(James A. Baker III Institute for Public Policy;Episcopal Health Foundation, 2014) Kim, Woohyeon; Marks, Elena M.; Short, Marah Noel; Crowe, Hannah; Ho, Vivian; James A. Baker III Institute for Public PolicySince late 2013, individuals have been able to shop for and purchase private health insurance through the Marketplace via Healthcare.gov. Through the Marketplace, Texans can learn what plans are available to them, examine the features of the plans, determine whether they qualify for tax credits to lower their premiums, and purchase the plan that is best suited to their needs. During the first year of the Affordable Care Act’s Health Insurance Marketplace, consumers learned that many plans offered limited provider networks. This issue brief examines the availability of Marketplace plans in Texas, the number of in-network hospitals in the plans, and other plan characteristics influencing premiums. Our analysis focuses on Marketplace Silver plans, because they provide the benchmark by which premium-reducing tax credits are determined and because the majority of Texans who purchased Marketplace plans chose a Silver plan.Item Impact of processes of care aimed at complication reduction on the cost of complex cancer surgery(2015) Short, Marah Noel; Ho, Vivian; Aloia, Thomas A.; National Cancer Institute, National Institutes of Health; Cancer Prevention and Research Institute of Texas; James A. Baker III Institute for Public PolicyBackground and Objectives: Health care providers add multiple processes to the care of complex cancer patients, believing they prevent and/or ameliorate complications. However, the relationship between these processes, complication remediation, and expenditures is unknown. Methods: Data for patients with cancer diagnoses undergoing colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection were obtained from hospital and inpatient physician Medicare claims for the years 2005 to 2009. Risk-adjusted regression analyses measured the association between hospitalization costs and processes presumed to prevent and/or remedy complications common to high-risk procedures. Results: After controlling for comorbidities, analysis identified associations between increased costs and the use of multiple processes, including arterial lines (4-12% higher; p<0.001), central venous catheters (11-22% higher; p<0.001) and pulmonary artery catheters (23-33% higher; p<0.001). Epidural analgesia was not associated with higher costs. Consultations were associated with 24-44% (p<0.001) higher costs, and total parenteral nutrition was associated with 13-31% higher costs for multiple procedures (p<0.001) Conclusions: Many frequently utilized processes and services presumed to avoid and/or ameliorate complications are associated with increased surgical oncology costs. This suggests that the patient-centered value of each process should be measured on a procedure-specific basis. Likewise, further attention should be focused on defining the efficacy of each of these costly, but frequently unproven, additions to perioperative care.Item The Influence of Complications on the Costs of Complex Cancer Surgery(Wiley, 2013) Short, Marah Noel; Aloia, Thomas A.; Ho, Vivian; James A. Baker III Institute for Public PolicyIt is widely known that outcomes after cancer surgery vary widely, depending on interactions between patient, tumor, neoadjuvant therapy, and provider factors. Within this complex milieu, the influence of complications on the cost of surgical oncology care remains unknown. The authors examined rates of Patient Safety Indicator (PSI) occurrence for 6 cancer operations and their association with costs of care. The Agency for Healthcare Research and Quality (AHRQ) PSI definitions were used to identify patient safety-related complications in Medicare claims data. Hospital and inpatient physician claims for the years 2005 through 2009 were analyzed for 6 cancer resections: colectomy, rectal resection, pulmonary lobectomy, pneumonectomy, esophagectomy, and pancreatic resection. Risk-adjusted regression analyses were used to measure the association between each PSI and hospitalization costs. Overall PSI rates ranged from a low of 0.01% for postoperative hip fracture to a high of 2.58% for respiratory failure. Death among inpatients with serious treatable complications, postoperative respiratory failure, postoperative thromboembolism, and accidental puncture/laceration were >1% for all 6 cancer operations. Several PSIs?including decubitus ulcer, death among surgical inpatients with serious treatable complications, and postoperative thromboembolism?raised hospitalization costs by ? 20% for most cancer surgery types. Postoperative respiratory failure resulted in a cost increase >50% for all cancer resections. The consistently higher costs associated with cancer surgery PSIs indicate that substantial health care savings could be achieved by targeting these indicators for quality improvement.Item The Economic Impact of Uninsured Children on America(James A. Baker III Institute for Public Policy, 2009) Ho, Vivian; Short, Marah Noel; James A. Baker III Institute for Public PolicyItem The Integration and De-integration of Physicians and Hospitals Over Time(James A. Baker III Institute for Public Policy, 2017) Short, Marah Noel; Ho, Vivian; McCracken, Ayse; James A. Baker III Institute for Public PolicyThe Affordable Care Act and changing economic conditions have encouraged an increase in the integration of physicians with hospitals. Current research has focused on the overall trend of tighter integration, but it has not examined the more granular level of how hospitals transition between integration levels. The objective of the study is to examine trends in physician-hospital integration over time. We used the 2008-2013 American Hospital Association annual survey data to designate four forms of integration based on the type of contractual relationship a hospital has with physicians. We examined overall changes in the number and percentage of hospitals engaged in varying forms of physician-hospital integration and the transitions between these integration levels by hospitals over time. Between 2008 and 2013, the share of hospitals with physicians on salary rose from 44 to 55 percent of all facilities. Looser forms of physician-hospital integration, such as joint contractual networks with managed care organizations, decreased in prominence. However, the aggregate shift toward tighter vertical integration masks the fact that many hospitals de-integrated or shifted to less tightly integrated physician-hospital relationships during this time period. The shift to tighter physician-hospital integration is more complex than previously expected. Future studies that distinguish between integration types are essential for setting policies that foster integrated care to improve quality and lower costs, instead of raising prices and harming patient welfare.Item The Integration and De-Integration of Physicians and Hospitals Over Time(2017) Short, Marah Noel; Ho, Vivian; McCracken, Ayse; James A. Baker III Institute for Public PolicyThe Affordable Care Act and changing economic conditions have encouraged an increase in the integration of physicians with hospitals. Current research has focused on the overall trend of tighter integration, but it has not examined the more granular level of how hospitals transition between integration levels. The objective of the study is to examine trends in physician-hospital integration over time. We used the 2008-2013 American Hospital Association annual survey data to designate four forms of integration based on the type of contractual relationship a hospital has with physicians. We examined overall changes in the number and percentage of hospitals engaged in varying forms of physician-hospital integration and the transitions between these integration levels by hospitals over time. Between 2008 and 2013, the share of hospitals with physicians on salary rose from 44 to 55 percent of all facilities. Looser forms of physician-hospital integration, such as joint contractual networks with managed care organizations, decreased in prominence. However, the aggregate shift toward tighter vertical integration masks the fact that many hospitals de-integrated or shifted to less tightly integrated physician-hospital relationships during this time period. The shift to tighter physician-hospital integration is more complex than previously expected. Future studies that distinguish between integration types are essential for setting policies that foster integrated care to improve quality and lower costs, instead of raising prices and harming patient welfare.Item Using Medicare data to measure vertical integration of hospitals and physicians(Springer Nature, 2020) Ho, Vivian; Tapaneeyakul, Sasathorn; Metcalfe, Leanne; Vu, Lan; Short, Marah Noel; James A. Baker III Institute for Public PolicyResearchers, healthcare providers, and policy makers have become increasingly interested in the cost and quality effects of vertical integration (VI) between hospitals and physicians. However, tracking VI is often financially costly. Because the Medicare Data on Provider Practice and Specialty (MD-PPAS) annual dataset may be more cost-effective for researchers to access than private data sources, we examine the accuracy of MD-PPAS in identifying VI by comparing it to physician and hospital affiliations reported in Blue Cross Blue Shield Texas (BCBSTX) PPO claims data for 2014–2016. The BCBSTX data serve as a gold standard, because physician–hospital affiliations are based on the insurer’s provider contract information. We merged the two datasets using the physician National Provider Identifier (NPI), then determined what percentage of physicians had the same Tax Identification Number (TIN) in both sources, and whether the TIN implied the physician belonged to a physician- or hospital-owned practice. We found that 71.3% of successfully matched NPIs reported the same TIN, and 95.1% of patient-level observations were attributed to organizations with the same ownership type in both datasets, regardless of TIN. We compared regression estimates of patient-level annual spending on an indicator variable for physician versus hospital ownership for the primary attributed physician and found that estimates were within one percentage point whether one determined VI based on the BCBSTX or the MD-PPAS data. The results suggest that MD-PPAS, which costs less to obtain than from a for-profit data source, can be used to reliably track VI between hospitals and physicians.Item Weighing the Effects of Vertical Integration Versus Market Concentration on Hospital Quality(2019) Short, Marah Noel; Ho, Vivian; James A. Baker III Institute for Public PolicyProvider organizations are increasing in complexity, as hospitals acquire physician practices and physician organizations grow in size. At the same time, hospitals are merging with each other to improve bargaining power with insurers. We analyze 29 quality measures reported to the Center for Medicare and Medicaid Services’ Hospital Compare database for 2008 to 2015 to test whether vertical integration between hospitals and physicians or increases in hospital market concentration influence patient outcomes. Vertical integration has a limited effect on a small subset of quality measures. Yet increased market concentration is strongly associated with reduced quality across all 10 patient satisfaction measures at the 95% confidence level (p < .05) and 6 of the 10 patient satisfaction measures remain statistically significant with a Bonferroni corrected p value (p < .005). Regulators should continue to focus scrutiny on proposed hospital mergers, take steps to maintain competition, and reduce counterproductive barriers to entry.