Medical Care Research and Review

Multiprofessional primary care models promise to deliver better care and reduce waste. This study evaluates the impact of such a model, the primary care unit (PCU), on three outcomes. A multilevel analysis within a “pre- and post-PCU” study design and a cross-sectional analysis were conducted on 215 PCUs located in the Emilia-Romagna region in Italy. Seven dimensions captured a set of processes and services characterizing a well-functioning PCU, or its degree of vitality. The impact of each dimension on outcomes was evaluated. The analyses show that certain dimensions of PCU vitality (i.e., the possibility for general practitioners to meet and share patients) can lead to better outcomes. However, dimensions related to the interaction and the joint works of general practitioners with other professionals tend not to have a significant or positive impact. This suggests that more effort needs to be invested to realize all the potential benefits of the PCU’s multiprofessional approach to care.

What are the barriers to voluntary take-up of high-deductible plans? We address this question using a large-scale employer survey conducted after an open-enrollment period in which a new high-deductible plan was first introduced. Only 3% of the employees chose this plan, despite the respondents’ recognition of its financial advantages. Employees who believed that the high-deductible plan provided access to top physicians in the area were three times more likely to choose it than employees who did not share this belief. A framed field experiment using a similar choice menu showed that displaying additional financial information did not increase high-deductible plan take-up. However, when plans were presented as identical except for the deductible, respondents were highly likely to choose the high-deductible plan, especially in a two-way choice. These results suggest that informing plan choosers about high-deductible plans’ health access provisions may affect choice more strongly than focusing on their financial advantages.

Research on hospitalist programs has primarily focused on large, urban facilities. To fill a gap in the literature on hospitalist use in rural hospitals, the authors conducted a national survey of 402 rural hospitals with 100 or fewer beds that had reported having hospitalists. The survey examined reasons for using hospitalists, characteristics of hospitalist practices, and the impacts of hospitalist use in rural settings. Rural hospitals most commonly establish a hospitalist program to address medical staff requests, call coverage, and quality issues. Respondents report positive impacts of hospitalist programs on quality of care and primary care physician recruitment and retention, but mixed financial impacts. Assessments of the impact of hospitalists in rural hospitals need to take into account the variety of practitioner specialties functioning as hospitalists, the amount of time they spend as hospitalists, and the multiple roles they play in the rural hospital and community.

Literature indicates favorable selection among Medicare Advantage (MA) enrollees compared with fee-for-service (FFS) enrollees. This study examined whether favorable selection into MA affected readmission rates among Medicare-eligible veterans following hospitalization for congestive heart failure in the Veterans Affairs Health System (VA). We measured total (VA + Medicare FFS) 30-day all-cause readmission rates across hospitals and all of VA. We used Heckman’s correction to adjust readmission rates to be representative of all Medicare-eligible veterans, not just FFS-enrolled veterans. The adjusted all-cause readmission rate among FFS veterans was 27.1% (95% confidence interval [CI] = 26.5% to 27.7%), while the adjusted readmission rate among Medicare-eligible veterans was 25.3% (95% CI = 23.6% to 27.1%) after correcting for favorable selection. Readmission rate estimates among FFS veterans generalize to all Medicare-eligible veterans only after accounting for favorable selection into MA. Estimation of quality metrics should carefully consider sample selection to produce valid policy inferences.

Medicare and Medicaid dual-eligible beneficiaries use more medical care and experience worse health outcomes than Medicare-only beneficiaries. This article points to a possible inefficiency in the skilled nursing facility (SNF) admission process, specifically that patients and SNFs are partially matched based on dual-eligibility status, and investigates its influence on patients’ SNF length of stay. Using a set of fee-for-service beneficiaries newly admitted for Medicare-paid SNF care, we document two findings: (1) compared with Medicare-only patients, dual-eligibles are more likely to be discharged to SNFs with low nurse-to-patient ratios and (2) dual-eligibles are more likely to become long-stay nursing home residents than Medicare-only beneficiaries if treated in SNFs with low nurse-to-patient ratios. We conclude that changes in the current SNF care referral process have the potential to reduce excess SNF utilization by dual-eligible beneficiaries and could help reduce spending by both Medicare and Medicaid.

In September 2009, federal funding for health care–associated infection (HAI) program development was dispersed through a cooperative agreement to 51 state and territorial health departments. From July to September 2011, 69 stakeholders from six states—including state health department employees, representatives from partner organizations, and health care facility employees—were interviewed to assess state HAI program achievements, implementation barriers, and strategies for sustainability. Respondents most frequently cited enhanced HAI surveillance as a program achievement and resource constraints as an implementation barrier. To sustain programs, respondents recommended ongoing support for HAI prevention activities, improved surveillance processes, and maintenance of partnerships. Findings suggest that state-level HAI program growth was achieved during the cooperative agreement but that maintenance of programs faces challenges.

Over the past decade, prescription drug expenditures grew faster than any other service category and comprised an increasing share of per capita health spending. Using the 2005 and 2009 Medical Expenditure Panel Surveys, this analysis identifies the sources of spending growth for prescription drugs among the nonelderly population. We find that prescription drug expenditures among the nonelderly increased by $14.9 billion (9.2%) from 2005 to 2009 and expenditures increased in 12 out of the 16 therapeutic classes. Changes in the number of users and expenditures per fill were the drivers of spending fluctuations in these categories. The main results also provide insight into generic entry, the price gap between brand and generic drugs, and from a health reform evaluation perspective, the importance of separating prepolicy secular trends in expenditures from changes attributable to specific forces, such as shifts toward generic versions of blockbuster drugs.