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Joseph P Newhouse

Publications and source records attributed to Joseph P Newhouse.

At least 19 recordsLinked to original sources
PubMed2006

Frequency and cost of chemotherapy-related serious adverse effects in a population sample of women with breast cancer.

BACKGROUND: The number, nature, and costs of serious adverse effects experienced by younger women receiving chemotherapy for breast cancer outside of clinical trials are unknown. METHODS: From a database of medical claims made by individuals with employer-provided health insurance between January 1998 and December 2002, we identified 12,239 women 63 years of age or younger with newly diagnosed breast cancer, of whom 4075 received chemotherapy during the 12 months after the initial breast cancer diagnosis and 8164 did not. Diagnostic codes for eight chemotherapy-related adverse effects were identified. Total hospitalizations for all causes, hospitalizations or emergency room visits for adverse effects that are typically related to chemotherapy, and health care expenditures were compared between the two groups of women. All statistical tests were two-sided. RESULTS: Women who received chemotherapy were more likely than those who did not to be hospitalized or to visit the emergency room for all causes (61% versus 42%; mean difference = 19%, 95% confidence interval [CI] = 16.7% to 21.3%, P<.001) and for chemotherapy-related serious adverse effects (16% versus 5%, mean difference = 11%, 95% CI = 9.6% to 12.4%, P<.001). The percentages of chemotherapy recipients who were hospitalized or visited the emergency room during the year after their breast cancer diagnosis were 8.4% for fever or infection; 5.5% for neutropenia or thrombocytopenia; 2.5% for dehydration or electrolyte disorders; 2.4% for nausea, emesis, or diarrhea; 2.2% for anemia; 2% for constitutional symptoms; 1.2% for deep venous thrombosis or pulmonary embolus; and 0.9% for malnutrition. Chemotherapy recipients incurred large incremental expenditures for chemotherapy-related serious adverse effects (1271 dollars per person per year) and ambulatory encounters (17,617 dollars per person per year). CONCLUSIONS: Chemotherapy-related serious adverse effects among younger, commercially insured women with breast cancer may be more common than reported by large clinical trials and lead to more patient suffering and health care expenditures than previously estimated.

Adult↗
PubMed2006

Reconsidering the moral hazard-risk avoidance tradeoff.

The received model for optimal demand-side cost sharing trades off moral hazard and risk avoidance. This model appears to lie behind recent increases in initial cost sharing, such as those embodied in Health Savings Accounts and Health Reimbursement Accounts. At the same time there is evidence that lower cost sharing for certain drugs can reduce future total health care costs and/or improve future health, and this may be true of other medical services as well. To the degree that individuals remain in the same common insurance pool, lower cost sharing that induces increases in certain services that reduce total costs, including future costs, represents a classic case for a subsidy and will minimize an employer's labor costs. Even if total costs increase, the value of a change in health could increase more. In that case such a subsidy is consistent with recent work in behavioral economics for those with self-control problems.

Cost Sharing↗
PubMed2006

Unintended consequences of caps on Medicare drug benefits.

BACKGROUND: Little information exists about the consequences of limits on prescription-drug benefits for Medicare beneficiaries. METHODS: We compared the clinical and economic outcomes in 2003 among 157,275 Medicare+Choice beneficiaries whose annual drug benefits were capped at 1,000 dollars and 41,904 beneficiaries whose drug benefits were unlimited because of employer supplements. RESULTS: After adjusting for individual characteristics, we found that subjects whose benefits were capped had pharmacy costs for drugs applicable to the cap that were lower by 31 percent than subjects whose benefits were not capped (95 percent confidence interval, 29 to 33 percent) but had total medical costs that were only 1 percent lower (95 percent confidence interval, -4 to 6 percent). Subjects whose benefits were capped had higher relative rates of visits to the emergency department (relative rate, 1.09 [95 percent confidence interval, 1.04 to 1.14]), nonelective hospitalizations (relative rate, 1.13 [1.05 to 1.21]), and death (relative rate, 1.22 [1.07 to 1.38]; difference, 0.68 per 100 person-years [0.30 to 1.07]). Among subjects who used drugs for hypertension, hyperlipidemia, or diabetes in 2002, those whose benefits were capped were more likely to be nonadherent to long-term drug therapy in 2003; the respective odds ratios were 1.30 (95 percent confidence interval, 1.23 to 1.38), 1.27 (1.19 to 1.34), and 1.33 (1.18 to 1.48) for subjects using drugs for hypertension, hyperlipidemia, and diabetes. In each subgroup, the physiological outcomes were worse for subjects whose drug benefits were capped than for those whose benefits were not capped; the odds ratios were 1.05 (95 percent confidence interval, 1.00 to 1.09), 1.13 (1.03 to 1.25), and 1.23 (1.03 to 1.46), respectively, for subjects with a systolic blood pressure of 140 mm Hg or more, a serum low-density-lipoprotein cholesterol level of 130 mg per deciliter or more, and a glycated hemoglobin level of 8 percent or more. CONCLUSIONS: A cap on drug benefits was associated with lower drug consumption and unfavorable clinical outcomes. In patients with chronic disease, the cap was associated with poorer adherence to drug therapy and poorer control of blood pressure, lipid levels, and glucose levels. The savings in drug costs from the cap were offset by increases in the costs of hospitalization and emergency department care.

Antihypertensive Agents↗
PubMed2006

Cost-sharing for emergency care and unfavorable clinical events: findings from the safety and financial ramifications of ED copayments study.

OBJECTIVE: To evaluate the effect of emergency department (ED) copayment levels on ED use and unfavorable clinical events. Data Source/Study Setting. Kaiser Permanente-Northern California (KPNC), a prepaid integrated delivery system. STUDY DESIGN: In a quasi-experimental longitudinal study with concurrent controls, we estimated rates of ED visits, hospitalizations, ICU admissions, and deaths associated with higher ED copayments relative to no copayment, using Poisson random effects and proportional hazard models, controlling for patient characteristics. The study period began in January 1999; more than half of the population experienced an employer-chosen increase in their ED copayment in January 2000. DATA COLLECTION/EXTRACTION METHODS: Using KPNC automated databases, the 2000 U.S. Census, and California state death certificates, we collected data on ED visits and unfavorable clinical events over a 36-month period (January 1999 through December 2001) among 2,257,445 commercially insured and 261,091 Medicare insured health system members. PRINCIPAL FINDINGS: Among commercially insured subjects, ED visits decreased 12 percent with the $20-35 copayment (95 percent confidence interval [CI]: 11-13 percent), and 23 percent with the $50-100 copayment (95 percent CI: 23-24 percent) compared with no copayment. Hospitalizations, ICU admissions, and deaths did not increase with copayments. Hospitalizations decreased 4 percent (95 percent CI: 2-6 percent) and 10 percent (95 percent CI: 7-13 percent) with ED copayments of $20-35 and $50-100, respectively, compared with no copayment. Among Medicare subjects, ED visits decreased by 4 percent (95 percent CI: 3-6 percent) with the $20-50 copayments compared with no copayment; unfavorable clinical events did not increase with copayments, e.g., hospitalizations were unchanged (95 percent CI: -3 percent to +2 percent) with $20-50 ED copayments compared with no copayment. CONCLUSIONS: Relatively modest levels of patient cost-sharing for ED care decreased ED visit rates without increasing the rate of unfavorable clinical events.

Cost Sharing↗
PubMed2006

Selection and plan switching behavior.

A majority of employees can choose among health insurance plans of varying generosity. They may switch plans if prices, information, or their health status change. This paper analyzes switching behavior presumptively caused by changes in health status. We show that people who move to a less generous plan have lower medical spending prior to the switch than the average for the generous plan in which they started, while those who move to a more generous plan appear to anticipate higher spending, which they delay until after the switch. This transfer of costs from a less to a more generous plan increases the burden of adverse selection. Our data suggest that switching may be more important to the level of premiums than previously documented.

Adult↗
PubMed2005

The costs of a national health information network.

BACKGROUND: The use of information technology may result in a safer and more efficient health care system. However, consensus does not exist about the structure or costs of a national health information network (NHIN). OBJECTIVES: To describe the potential structure and estimate the costs of an NHIN. DESIGN: Cost estimates of an NHIN model developed by an expert panel. SETTING: U.S. health care system. MEASUREMENTS: An expert panel estimated the existing and the expected prevalence in 5 years of critical information technology functionalities. They then developed a model of an achievable NHIN by defining key providers, functionalities, and interoperability functions. By using these data and published cost estimates, the authors determined the cost of achieving this model NHIN in 5 years given the current state of information technology infrastructure. RESULTS: To achieve an NHIN would cost 156 billion dollars in capital investment over 5 years and 48 billion dollars in annual operating costs. Approximately two thirds of the capital costs would be required for acquiring functionalities and one third for interoperability. Ongoing costs would be more evenly divided between functionality and interoperability. If the current trajectory continues, the health care system will spend 24 billion dollars on functionalities over the next 5 years or about one quarter of the cost for functionalities of a model NHIN. LIMITATIONS: Because of a lack of primary data, the authors relied on expert estimates. CONCLUSIONS: While an NHIN will be expensive, 156 billion dollars is equivalent to 2% of annual health care spending for 5 years. Assessments such as this one may assist policymakers in determining the level of investment that the United States should make in an NHIN.

Health Expenditures↗
PubMed2005

Care-seeking behavior in response to emergency department copayments.

BACKGROUND: Patients are increasingly paying for more of their medical care through cost-sharing, yet little is known about how patients change the ways that they seek care in response. OBJECTIVE: We sought to assess how patients change their care-seeking behavior in response to emergency department (ED) copayments. RESEARCH DESIGN: Telephone interviews with a stratified random sample of adult members of a large integrated delivery system. SUBJECTS: There were 932 respondents (72% response rate). MEASURES: We examined participants' knowledge of their copayment level for ED services, and measures of how the cost-sharing affected their decisions about where or when to seek care. RESULTS: Overall, 82% of participants faced a copayment for ED services (ranging between 5 US dollars and 100 US dollars), and 41% correctly reported the amount of this copayment. In response to the perceived copayment amount, 19% reported changing their care-seeking behavior within the previous 12 months: 12% sought care from an alternate delivery site, 12% contacted a provider by telephone or the Internet, 9% delayed going to the ED, and 2% avoided medical care altogether. In multivariate models, the ED cost-sharing amount was significantly associated with reporting changes in care-seeking behavior. CONCLUSIONS: When faced with an ED copayment, patients in the health system most commonly shifted toward seeking care from other available alternatives, and rarely avoid medical care altogether.

Adult↗
PubMed2005

The geographic distribution of physicians revisited.

CONTEXT: While there is debate over whether the U.S. is training too many physicians, many seem to agree that physicians are geographically maldistributed, with too few in rural areas. OBJECTIVE: Official definitions of shortage areas assume the market for physician services is based on county boundaries. We wished to ascertain how the picture of a possible shortage changes using alternative measures of geographic access. We measure geographic access by the number of full-time equivalent physicians serving a community divided by the expected number of patients (possibly both from within the community and outside) receiving care from those physicians. Moreover, we wished to determine how the geographic distribution of physicians had changed since previous studies, in light of the large increase in physician numbers. DESIGN: Cross-sectional data analyses of alternative measures of geographic access to physicians in 23 states with low physician-population ratios. RESULTS: Between 1979 and 1999, the number of physicians doubled in the sample states. Although most specialties experienced greater diffusion everywhere, smaller specialties had not yet diffused to the smallest towns. Multiple measures of geographic access, including physician-to-population ratios, average distance traveled to the nearest physician, and projected average caseload per physician, confirm that residents of metropolitan areas have better geographic access to physicians. Physician-to-population ratios exhibit the largest degree of geographic disparity, but ratios in rural counties adjacent to metropolitan areas are smaller than in those not adjacent to metropolitan areas. Distance-traveled and caseload models that allow patients to cross county lines show less disparity and indicate that residents of isolated rural counties have less access than those living in counties adjacent to metropolitan areas. CONCLUSION: Geographic access to physicians has continued to improve over the past two decades, although some smaller specialties have not diffused to the most rural areas. While substantial variation in the supply of physicians across communities remains, current measures of geographic access to physicians overstate the extent of maldistribution and yield an incorrect ranking of areas according to geographic accessibility of physicians.

Cross-Sectional Studies↗
PubMed2004

Cost-sharing: patient knowledge and effects on seeking emergency department care.

BACKGROUND: The use of cost-sharing to control healthcare expenditures is increasing, but there is scant information about patients' knowledge of cost-sharing or its influence on behavior. OBJECTIVE: The objective of this study was to evaluate what patients know about their individual levels of cost-sharing and how it influences decisions to seek care. STUDY DESIGN: We conducted a cross-sectional telephone survey with a 69% response rate. SUBJECTS: We studied a stratified random sample of 695 adult patients in an integrated delivery system: 266 subjects > or =65 years, 218 low-income subjects, and 211 subjects from the overall membership. MEASURES: We used perceived and actual levels of copayments for emergency department (ED) visits, office visits, and prescription drugs; and self-reports of copayment-related behavior changes. RESULTS: One third of subjects correctly reported their ED copayment, whereas three fourths correctly reported their prescription drug and office visit copayments. Over half of the subjects (57%) underestimated their ED copayment by $20 or more. Among patients who reported having any copayment, 11% described changing their behavior because of the copayment, ie, delayed or avoided emergency care. The perceived copayment level was strongly associated with behavior change (odds ratio, 3.9). Other significant factors included having more ED visits in the past 12 months and having a low health status. CONCLUSIONS: Patients have less knowledge of their ED cost-sharing levels than for other services. The perceived copayment amount was strongly associated with avoidance of or delays in emergency care. Further research is needed to determine whether these responses reflect greater efficiency or harmful decisions.

Adult↗
PubMed2004

The costs of decedents in the Medicare program: implications for payments to Medicare + Choice plans.

OBJECTIVE: To discuss and quantify the incentives that Medicare managed care plans have to avoid (through selective enrollment or disenrollment) people who are at risk for very high costs, focusing on Medicare beneficiaries in the last year of life-a group that accounts for more than one-quarter of Medicare's annual expenditures. DATA SOURCE: Medicare administrative claims for 1994 and 1995. STUDY DESIGN: We calculated the payment a plan would have received under three risk-adjustment systems for each beneficiary in our 1995 sample based on his or her age, gender, county of residence, original reason for Medicare entitlement, and principal inpatient diagnoses received during any hospital stays in 1994. We compared these amounts to the actual costs incurred by those beneficiaries. We then looked for clinical categories that were predictive of costs, including costs in a beneficiary's last year of life, not accounted for by the risk adjusters. DATA EXTRACTION METHODS: The analyses were conducted using claims for a 5 percent random sample of Medicare beneficiaries who died in 1995 and a matched group of survivors. PRINCIPAL FINDINGS: Medicare is currently implementing the Principal Inpatient Diagnostic Cost Groups (PIP-DCG) risk adjustment payment system to address the problem of risk selection in the Medicare+Choice program. We quantify the strong financial disincentives to enroll terminally ill beneficiaries that plans still have under this risk adjustment system. We also show that up to one-third of the selection observed between Medicare HMOs and the traditional fee-for-service system could be due to differential enrollment of decedents. A risk adjustment system that incorporated more of the available diagnostic information would attenuate this disincentive; however, plans could still use clinical information (not included in the risk adjustment scheme) to identify beneficiaries whose expected costs exceed expected payments. CONCLUSIONS: More disaggregated prospective risk adjustment methods and alternative payment systems that compensate plans for delivering care to certain classes of patients should be considered to ensure access to high-quality managed care for all beneficiaries.

Actuarial Analysis↗
PubMed2002

The economic impacts of the tobacco settlement.

Recent litigation against the major tobacco companies culminated in a master settlement agreement (MSA) under which the participating companies agreed to compensate most states for Medicaid expenses. Here the terms of the settlement are outlined and its economic implications analyzed using data from Massachusetts. The financial compensation to Massachusetts (and other states) under the MSA is substantial. However, this compensation is dwarfed by the value of the health impacts induced by the settlement. Specifically, Medicaid spending will fall, but only by a modest amount. More importantly, the value of health benefits ($65 billion through 2025 in 1999 dollars) from increased longevity is an order of magnitude greater than any other impacts or payments. The net efficiency implications of the settlement turn mainly on a comparison of the value of these health benefits relative to a valuation of the foregone pleasure of smoking. To the extent that the value of the health benefits is not offset by the value of the pleasure foregone, the economic impacts of the MSA will include a share of these health benefits.

Advertising↗
PubMed2002

Managed care and efficient rationing.

Widespread dissatisfaction with managed care has led to calls for major reform and consumer protection. Although some have concluded that managed care backlash is simply a result of too much rationing, we propose an alternative view that focuses on the nature of services eliminated by managed care. In particular, we point out that managed care rations services largely without regard to consumer preferences. We question whether managed care's emphasis on supply-side control of moral hazard is consistent with the principles of efficient rationing. Further research on the nature of provider and consumer rationing decisions is needed to inform the design of supply-side and demand-side incentives that will lead to an efficient allocation of services.

Consumer Behavior↗
PubMedDate not supplied

Why is there a quality chasm?

Medical care seems to obtain less value from the resources it uses than other industries do, a phenomenon not limited to the United States. I explore several reasons for this, including consumers' ignorance, the rate of technological change, the widespread use of administered pricing, the difficulty of appraising a given provider's quality, and the role of the public sector with objectives other than efficiency. Although these causes suggest that the performance of medical care may always lag behind that of other industries, greater use of information technology and improved financial incentives will help to reduce the size of the quality chasm.

Biomedical Technology↗
PubMedDate not supplied

Accounting for teaching hospitals' higher costs and what to do about them.

Academic health centers (AHCs) have higher costs per case and also lower margins than either other teaching hospitals or community hospitals. The differences in margins stem mostly from differences in the intensity with which similar patients are treated, as well as hospitals' ability to generate revenue to cover the costs of that greater intensity, rather than graduate medical education per se. How much patient care capacity should be supported in AHCs and who should be treated with the greater intensity they offer are open questions. If there is to be a public trust fund to subsidize AHCs, it should be financed from general revenues.

Academic Medical Centers↗
PubMedDate not supplied

How much should Medicare pay for drugs?

Discussions of the Medicare drug benefit have focused more on what beneficiaries will pay than what pharmaceutical manufacturers will receive. A key choice is the degree to which Medicare must become involved in setting manufacturers' prices. If prices must be set, Medicare could do so using average wholesale price, comparison with prices in other markets, cost, or rate-of-return regulation. Because all four methods have substantial drawbacks, Medicare should not initially attempt to set prices, but to prevent abuses in pricing, Congress should allow cost to be considered in coverage decisions.

Decision Making, Organizational↗
PubMedDate not supplied

Consumer-directed health plans and the RAND Health Insurance Experiment.

Today's consumer-directed health plans, with their high deductibles, bear a strong resemblance to the high-deductible plan of the RAND Health Insurance Experiment (HIE), although they come into a post-managed-care world. The high deductibles and the tools of managed care should complement each other, the former directed primarily at the initiation of care for an episode of illness and the latter at the costliness of episodes, especially ongoing chronic disease episodes. Although the RAND experiment established the effects of varying prices to patients, future experiments with how physicians respond to the various tools of managed care may be useful.

Community Participation↗
PubMedDate not supplied

Does reimbursement influence chemotherapy treatment for cancer patients?

Before the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, Medicare reimbursed physicians for chemotherapy drugs at rates that greatly exceeded physicians' costs for those drugs. We examined the effect of physician reimbursement on chemotherapy treatment of Medicare beneficiaries older than age sixty-five with metastatic lung, breast, colorectal, or other gastrointestinal cancers between 1995 and 1998 (9,357 patients). A physician's decision to administer chemotherapy to metastatic cancer patients was not measurably affected by higher reimbursement. Providers who were more generously reimbursed, however, prescribed more-costly chemotherapy regimens to metastatic breast, colorectal, and lung cancer patients.

Aged↗