Sherry Glied

Importance  Given higher reimbursement rates, hospitals primarily serving privately insured patients may invest more in intensive coding than hospitals serving publicly insured patients. This may lead these hospitals to code more diagnoses for all patients.

Objective  To estimate whether, for the same Medicaid enrollee with multiple hospitalizations, a hospital’s share of privately insured patients is associated with the number of diagnoses on claims.

Design, Setting, and Participants  This cross-sectional study used patient-level fixed effects regression models on inpatient Medicaid claims from Medicaid enrollees with at least 2 admissions in at least 2 different hospitals in New York State between 2010 and 2017. Analyses were conducted from 2019 to 2021.

Exposures  The annual share of privately insured patients at the admitting hospital.

Main Outcomes and Measures  Number of diagnostic codes per admission. Probability of diagnoses being from a list of conditions shown to be intensely coded in response to payment incentives.

Results  This analysis included 1 614 630 hospitalizations for Medicaid-insured patients (mean [SD] age, 48.2 [20.1] years; 829 684 [51.4%] women and 784 946 [48.6%] men). Overall, 74 998 were Asian (4.6%), 462 259 Black (28.6%), 375 591 Hispanic (23.3%), 486 313 White (30.1%), 128 896 unknown (8.0%), and 86 573 other (5.4%). When the same patient was seen in a hospital with a higher share of privately insured patients, more diagnoses were recorded (0.03 diagnoses per percentage point [pp] increase in share of privately insured; 95% CI, 0.02-0.05; P < .001). Patients discharged from hospitals in the bottom quartile of privately insured patient share received 1.37 more diagnoses when they were subsequently discharged from hospitals in the top quartile, relative to patients whose admissions were both in the bottom quartile (95% CI, 1.21-1.53; P < .001). Those going from hospitals in the top quartile to the bottom had 1.67 fewer diagnoses (95% CI, −1.84 to −1.50; P < .001). Diagnoses in hospitals with a higher private payer share were more likely to be for conditions sensitive to payment incentives (0.08 pp increase for each pp increase in private share; 95% CI, 0.06-0.10; P < .001). These findings were replicated in 2016 to 2017 data.

Conclusions and Relevance  In this cross-sectional study of Medicaid enrollees, admission to a hospital with a higher private payer share was associated with more diagnoses on Medicaid claims. This suggests payment policy may drive differential investments in infrastructure to document diagnoses. This may create a feedback loop that exacerbates resource inequity.

Research Objective

People with a history of incarceration have high rates of physical and behavioral health conditions as well as increased hospitalizations and emergency department visits. This research extends the existing literature about the health profile of individuals with a history of justice involvement by examining patterns of Medicaid utilization and costs.

Study Design

We linked New York State Medicaid and New York City Department of Correction Data from 2012–2016 and examined patterns of jail utilization, health care utilization (including inpatient, emergency department, and outpatient use) and health care cost by categories of service, as well as the prevalence of chronic physical and mental health disorders. We selected two sets of comparisons, any jail contact vs. no jail contact and high jail contact vs. low jail contact.

Population Studied

Individuals with at least one jail admission in 2012 were defined as having any jail contact. Individuals with only one jail admission between 2012–2016 are defined as having low jail contact. Those who were in the top 10 percentile of number of jail admissions are defined as having high jail contact. The no jail contact group is defined as Medicaid recipients matched with individuals with any jail contact on age, sex, race/ethnicity, Medicare status and number of Medicaid enrollment months.

Principal Findings

Comparing to individuals with no jail contact, any jail contact was associated with a higher prevalence of both chronic physical and mental health conditions; those with any jail contact had a doubling in the risks of mortality and of health care resource use; the average number of hospitalizations was 4 times higher among people with any jail contact; people with jail contact had Medicaid costs that were 3 to 7 times greater, with inpatient costs largely driving these differences for people with the most frequent jail contact. Compared to individuals with low jail contact, individuals with high jail contact had drastically higher prevalence of both chronic physical and mental health conditions, triple the number of hospitalizations, and quadruple the number of emergency department visits. The annual inpatient expenditure of an individual with high jail contact is $12 k higher than that of an individual with low jail contact; total Medicaid expenditures of high contact individuals averages over $33 k per year and are twice as high as those of low contact individuals.

Conclusions

The prevalence of physical and mental health conditions was very high among individuals with high jail contact, as were their health care costs. Only a small fraction of costs for this group were for outpatient primary care, behavioral health treatment, and case management that could help to address these needs and prevent hospitalization.

Implications for Policy or Practice

These findings highlight the need for more effective health care engagement strategies for people with a history of incarceration. Specifically, preventative, primary care and behavioral health care services — particularly outpatient substance use services — that are tailored to the needs of this population could lead to more effective health care engagement, reduced health care costs, and improved health and well-being for individuals who have had some contact with NYC jails.

Primary Funding Source

The Robert Wood Johnson Foundation.

One important concern around the spread of respiratory infectious diseases has been the contribution of public transportation, a space where people are in close contact with one another and with high-use surfaces. While disease clearly spreads along transportation routes, there is limited evidence about whether public transportation use itself is associated with the overall prevalence of contagious respiratory illnesses at the local level. We examine the extent of the association between public transportation and influenza mortality, a proxy for disease prevalence, using city-level data on influenza and pneumonia mortality and public transit use from 121 large cities in the United States (US) between 2006 and 2015. We find no evidence of a positive relationship between city-level transit ridership and influenza/pneumonia mortality rates, suggesting that population level rates of transit use are not a singularly important factor in the transmission of influenza.

Although the pace of gentrification has accelerated in cities across the US, little is known about the health consequences of growing up in gentrifying neighborhoods. We used New York State Medicaid claims data to track a cohort of low-income children born in the period 2006–08 for the nine years between January 2009 and December 2017. We compared the 2017 health outcomes of children who started out in low-income neighborhoods that gentrified in the period 2009–15 with those of children who started out in other low-income neighborhoods, controlling for individual child demographic characteristics, baseline neighborhood characteristics, and preexisting trends in neighborhood socioeconomic status. Our findings suggest that the experience of gentrification has no effects on children’s health system use or diagnoses of asthma or obesity, when children are assessed at ages 9–11, but that it is associated with moderate increases in diagnoses of anxiety or depression—which are concentrated among children living in market-rate housing.

The pace of gentrification has accelerated in cities across the country since 2000, and many observers fear it is displacing low-income populations from their homes and communities. We offer new evidence about the consequences of gentrification on mobility, building and neighborhood conditions, using longitudinal New York City Medicaid records from January 2009 to December 2015 to track the movement of a cohort of low-income children over seven years, during a period of rapid gentrification in the city. We leverage building-level data to examine children in market rate housing separately from those in subsidized housing. We find no evidence that gentrification is associated with meaningful changes in mobility rates over the seven-year period. It is associated with slightly longer distance moves. As for changes in neighborhood conditions, we find that children who start out in a gentrifying area experience larger improvements in some aspects of their residential environment than their counterparts who start out in persistently low-socioeconomic status areas. This effect is driven by families who stay in neighborhoods as they gentrify; we observe few differences in the characteristics of destination neighborhoods among families who move, though we find modest evidence that children moving from gentrifying areas move to lower-quality buildings.

The Congressional Budget Office (CBO), a nonpartisan agency of Congress, made official projections of the Affordable Care Act’s impact on insurance coverage rates and the costs of providing subsidies to consumers purchasing health plans in the insurance marketplaces. This analysis finds that the CBO overestimated marketplace enrollment by 30 percent and marketplace costs by 28 percent, while it underestimated Medicaid enrollment by about 14 percent. Nonetheless, the CBO’s projections were closer to realized experience than were those of many other prominent forecasters. Moreover, had the CBO correctly anticipated income levels and health care prices in 2014, its estimate of marketplace enrollment would have been within 18 percent of actual experience. Given the likelihood of additional reforms to national health policy in future years, it is reassuring that, despite the many unforeseen factors surrounding the law’s rollout and participation in its reforms, the CBO’s forecast was reasonably accurate.

In theory, improving low-income families’ housing and neighborhoods could also improve their children’s health, through any number of mechanisms. For example, less exposure to environmental toxins could prevent diseases such as asthma; a safer, less violent neighborhood could improve health by reducing the chances of injury and death, and by easing the burden of stress; and a more walkable neighborhood with better playgrounds could encourage children to exercise, making them less likely to become obese.

Yet although neighborhood improvement policies generally achieve their immediate goals— investments in playgrounds create playgrounds, for example—Ingrid Gould Ellen and Sherry Glied find that many of these policies don’t show a strong effect on poor children’s health. One problem is that neighborhood improvements may price low-income families out of the very neighborhoods that have been improved, as new amenities draw more affluent families, causing rents and home prices to rise. Policy makers, say Ellen and Glied, should carefully consider how neighborhood improvements may affect affordability, a calculus that is likely to favor policies with clear and substantial benefits for low-income children, such as those that reduce neighborhood violence.

Housing subsidies can help families either cope with rising costs or move to more affluent neighborhoods. Unfortunately, demonstration programs that help families move to better neighborhoods have had only limited effects on children’s health, possibly because such transi- tions can be stressful. And because subsidies go to relatively few low-income families, the presence of subsidies may itself drive up housing costs, placing an extra burden on the majority of families that don’t receive them. Ellen and Glied suggest that policy makers consider whether granting smaller subsidies to more families would be a more effective way to use these funds.

 

About half of the $2.1 trillion of US health services spending constitutes compensation to employees. We examined how the wages paid to health-sector employees compared to those paid to workers with similar qualifications in other sectors. Overall, we found that health care workers are paid only slightly more than workers elsewhere in the US economy, but the patterns are starkly different for nonprofessional and professional employees. Nonprofessional health care workers earn slightly less than their counterparts elsewhere in the economy. By contrast, the average nurse earns about 40 percent more than the median comparable worker in a different sector. The average physician earns about 50 percent more than a comparable worker in another sector of the economy, and this differential has increased sharply since 1993. Cost containment is likely to lead to reductions in the earnings of health care professionals, but it will also require using fewer or less skilled employees to produce a given service.

Thousands of measures are in use today to assess health and health care in the United States. Although many of these measures provide useful information, their sheer number, as well as their lack of focus, consistency, and organization, limits their overall effectiveness in improving performance of the health system. To achieve better health at lower cost, all stakeholders—including health profes­sionals, payers, policy makers, and members of the public—must be alert to the measures that matter most. What are the core measures that will yield the clearest understanding and focus on better health and well-being for Americans?

With support from the Blue Shield of California Foundation, the California Healthcare Foundation, and the Robert Wood Johnson Foundation, the Institute of Medicine (IOM) convened a committee to identify core measures for health and health care. In VITAL SIGNS: Core Metrics for Health and Health Care Progress, the committee proposes a streamlined set of 15 standardized mea­sures, with recommendations for their application at every level and across sec­tors. Ultimately, the committee concludes that this streamlined set of measures could provide consistent benchmarks for health progress across the nation and improve system performance in the highest-priority areas.

This is a commentary to an article in Public Administration Review about Danish public service employee motivation. The piece that we commented on noted that there are two dimensions for how Danish public service employees can choose to do their work, and that these motivations can shift over time: the author identified public service work being done either through direct service production/delivery or through service regulation/policy. Almost all possible public service jobs in Denmark are in governmental agencies.

Following the Supreme Court's decision in 2012, state officials are now deciding whether to expand their Medicaid programs under the Affordable Care Act. While the states' costs of participating in the Medicaid expansion have been at the forefront of this discussion, the expansion has much larger implications for the flow of federal funds going to the states. This issue brief examines how participating in the Medicaid expansion will affect the movement of federal funds to each state. States that choose to participate in the expansion will experience a more positive net flow of federal funds than will states that choose not to participate. In addition to providing valuable health insurance benefits to low-income state residents, and steady sources of financing to state health care providers, the Medicaid expansion will be an important source of new federal funds for states.

The opportunities for researchers to improve health and health care by contributing to the formulation and implementation of policy are almost unlimited. Indeed, the availability of these opportunities is a tribute to a generation of health services researchers questioning existing policies or studying essential "Why?" and “What if?” questions using rigorous analysis. Moreover, the steady albeit uneven transition of health care delivery from a paper-based cottage industry toward an enterprise that provides transparent information to clinicians, patients, policy makers and the public, and potentially vast amounts of data to policy researchers, combined with the expectations of an increasingly information-savvy public, have increased the focus on health care quality, access, and costs.

Our health care system, like those in other countries, confronts continued pressures from increasing costs; inconsistent quality; avoidable patient harms; pervasive disparities in health and health care associated with individual characteristics such as race, ethnicity, income, education and geography; and poor population health outcomes. The persistence of many of these challenges reflects, in part, a failure of science alone to improve heath. Strategies to address many of these challenges exist in the laboratory, but the contribution of this science to the health of the public is limited by a research enterprise that values discovery of new knowledge far more than its successful application.

Despite a push to create electronic health records and a plethora of healthcare data from disparate sources, there are no data from a single electronic source that provide a full picture of a patient’s hospital course. This paper describes a process to utilize electronically available inpatient hospital data for research. We linked several different sources of extracted data, including clinical, procedural, administrative, and accounting data, using patients’ medical record numbers to compile a cohesive, comprehensive account of patient encounters. Challenges encountered included (1) interacting with distinct administrative units to locate data elements; (2) finding a secure, central location to house the data; (3) appropriately defining health measures of interest; (4) obtaining and linking these data to create a usable format for conducting research; and (5) dealing with missing data. Although the resulting data set is incredibly rich and likely to prove useful for a wide range of clinical and comparative effectiveness research questions, there are multiple challenges associated with linking hospital data to improve the quality of patient care. Clin Trans Sci 2011; Volume 4: 338–345

The Department of Health and Human Services (HHS) recently unveiled the most comprehensive federal commitment yet to reducing racial and ethnic health disparities. The 2011 HHS Action Plan to Reduce Racial and Ethnic Health Disparities not only responds to advice previously offered by stakeholders around the nation, but it also capitalizes on new and unprecedented opportunities in the Affordable Care Act of 2010 to benefit diverse communities. The Action Plan advances five major goals: transforming health care; strengthening the infrastructure and workforce of the nation’s health and human services; advancing Americans’ health and well-being; promoting scientific knowledge and innovation; and upholding the accountability of HHS for making demonstrable progress. By mobilizing HHS around these goals, the Action Plan moves the country closer to realizing the vision of a nation free of disparities in health and health care.

Patient-centered outcomes research, which aims to assist clinicians and patients in making informed decisions regarding prevention, diagnosis, and treatment, is essential for improving the delivery of quality health care. Much of patient-centered outcomes research relies on observational and quasi-experimental methods applied to data generated as a byproduct of providing care. While existing data sources have improved, there remain important data-related barriers to rapid, efficient research. Recent changes in the policy environment, coupled with significant technological progress, provide an opportunity to surmount some of these obstacles.

Higher health care prices in the United States are a key reason that the nation’s health spending is so much higher than that of other countries. Our study compared physicians’ fees paid by public and private payers for primary care office visits and hip replacements in Australia, Canada, France, Germany, the United Kingdom, and the United States. We also compared physicians’ incomes net of practice expenses, differences in financing the cost of medical education, and the relative contribution of payments per physician and of physician supply in the countries’ national spending on physician services. Public and private payers paid somewhat higher fees to US primary care physicians for office visits (27 percent more for public, 70 percent more for private) and much higher fees to orthopedic physicians for hip replacements (70 percent more for public, 120 percent more for private) than public and private payers paid these physicians’ counterparts in other countries. US primary care and orthopedic physicians also earned higher incomes ($186,582 and $442,450, respectively) than their foreign counterparts. We conclude that the higher fees, rather than factors such as higher practice costs, volume of services, or tuition expenses, were the main drivers of higher US spending, particularly in orthopedics.

The 2010 Patient Protection and Affordable Care Act (P.L. 111-148), or ACA, requires that U.S. citizens either purchase health insurance or pay a fine. To offset the financial burden for lower-income households, it also provides subsidies to ensure that health insurance premiums are affordable. However, relatively little work has been done on how such affordability standards should be set. The existing literature on affordability is not grounded in social norms and has methodological and theoretical flaws. To address these issues, we developed a series of hypothetical vignettes in which individual and household sociodemographic characteristics were varied. We then convened a panel of eighteen experts with extensive experience in affordability standards to evaluate the extent to which each vignette character could afford to pay for one of two health insurance plans. The panel varied with respect to political ideology and discipline. We find that there was considerable disagreement about how affordability is defined. There was also disagreement about what might be included in an affordability standard, with substantive debate surrounding whether savings, debt, education, or single parenthood is relevant. There was also substantial variation in experts' assessed affordability scores. Nevertheless, median expert affordability assessments were not far from those of ACA.

The Oxford Handbook of Health Economics provides an accessible and authoritative guide to health economics, intended for scholars and students in the field, as well as those in adjacent disciplines including health policy and clinical medicine. The chapters stress the direct impact of health economics reasoning on policy and practice, offering readers an introduction to the potential reach of the discipline. Contributions come from internationally-recognized leaders in health economics and reflect the worldwide reach of the discipline. Authoritative, but non-technical, the chapters place great emphasis on the connections between theory and policy-making, and develop the contributions of health economics to problems arising in a variety of institutional contexts, from primary care to the operations of health insurers. The volume addresses policy concerns relevant to health systems in both developed and developing countries. It takes a broad perspective, with relevance to systems with single or multi-payer health insurance arrangements, and to those relying predominantly on user charges; contributions are also included that focus both on medical care and on non-medical factors that affect health. Each chapter provides a succinct summary of the current state of economic thinking in a given area, as well as the author's unique perspective on issues that remain open to debate. The volume presents a view of health economics as a vibrant and continually advancing field, highlighting ongoing challenges and pointing to new directions for further progress.

How effective was organizational reform implemented inside one critical New York City health agency? Specifically, we examine the extent to which the reorganization of the HIV/AIDS Services Administration (HASA) into the Medical Insurance Services Administration (MICSA) achieved three goals: (1) realizing synergies among the component MICSA programs; (2) cross-fertilizing ideas among MICSA agencies; and (3) facilitating HASA operations through the lens of organization change theory. Qualitative methods including interviews, site visits, and document analysis triangulate the effects of the reorganization. Implications for organization change literature are explored, especially highlighting where more theoretical and empirical studies are needed.

The private psychiatric hospital market has exhibited great volatility over time. From 1976 to 1992, the number of hospitals more than doubled, while in the decade following, the number of facilities dropped by half. Recently, however, the industry has begun to grow again. The evolution of this market reflects the response of a private industry with access to capital markets to changes in both the supply of substitutes and the demand for services. Most recently, the limited supply of facilities and expanded demand for psychiatric services have spurred renewed growth. The two leading firms today, Universal Health Services, Inc., which rode the market crest and downturn since the 1980s, and Psychiatric Solutions, Inc., a newer entrant, have employed different strategies to take advantage of these opportunities. The rapid responsiveness of the private psychiatric hospital market, as exemplified by these two firms, presents significant potential for shaping future mental health policy.

Depression is often diagnosed and treated in primary care settings. Organizational and systems interventions that restructure primary care practices and train staff have been shown to be cost-effective strategies for treating depression. Funders are increasingly calling for a cost–benefit assessment of such programs. In this study, the authors review existing cost-effectiveness studies of primary care depression treatments, classify them into categories, translate the results into net benefit terms, and assess whether more costly programs generate greater net benefit. The authors find that interventions that provide training to primary care teams in how to manage depression most consistently produce net benefits, with more costly interventions of this type generating larger net benefits than less costly interventions. Collaborative care interventions, which add specialized staff to primary care practices, and therapy interventions, in which clinicians are trained to provide therapy, also generate net social benefits at conventional valuations of quality-adjusted life years.

The past half-century has been marked by major changes in the treatment of mental illness: important advances in understanding mental illnesses, increases in spending on mental health care and support of people with mental illnesses, and the availability of new medications that are easier for the patient to tolerate. Although these changes have made things better for those who have mental illness, they are not quite enough.

In Better But Not Well, Richard G. Frank and Sherry A. Glied examine the well-being of people with mental illness in the United States over the past fifty years, addressing issues such as economics, treatment, standards of living, rights, and stigma. Marshaling a range of new empirical evidence, they first argue that people with mental illness—severe and persistent disorders as well as less serious mental health conditions—are faring better today than in the past. Improvements have come about for unheralded and unexpected reasons. Rather than being a result of more effective mental health treatments, progress has come from the growth of private health insurance and of mainstream social programs—such as Medicaid, Supplemental Security Income, housing vouchers, and food stamps—and the development of new treatments that are easier for patients to tolerate and for physicians to manage.

The authors remind us that, despite the progress that has been made, this disadvantaged group remains worse off than most others in society. The "mainstreaming" of persons with mental illness has left a policy void, where governmental institutions responsible for meeting the needs of mental health patients lack resources and programmatic authority. To fill this void, Frank and Glied suggest that institutional resources be applied systematically and routinely to examine and address how federal and state programs affect the well-being of people with mental illness.

Chronic Condition provides a compelling analysis of the causes of the current health care crisis and of the shortcomings of reform proposals. It also offers an ingenious new framework for reform that, while minimizing government interference, would provide a means for financing care for the less affluent.

Sherry Glied shows that rising health care spending is consistent with a rising standard of living. Since we can, as a nation, afford more health care, reform must address not the overall level of health care costs but the distribution of health care spending.

Prior reform proposals, Glied argues, have failed to account for the tension between the clearly manifested desire for improving the quality of health care and the equally widespread interest in assuring that the less fortunate share in these improvements. After careful analysis of the ill-fated Clinton plan, Glied proposes a new solution that would make the willingness to pay for innovation the means of financing health care improvements for the less affluent. While rejecting the idea that the distribution of health care should be perfectly equal, Glied's proposal would enable all Americans to benefit from the dynamics of the free market.