Dispelling An Urban Legend: Frequent Emergency Department Users Have Substantial Burden Of Disease
Health Affairs, 32, no.12 (2013):2099-2108
Billings, John and Maria C. Raven
Urban legend has often characterized frequent emergency department (ED) patients as mentally ill substance users who are a costly drain on the health care system and who contribute to ED overcrowding because of unnecessary visits for conditions that could be treated more efficiently elsewhere. This study of Medicaid ED users in New York City shows that behavioral health conditions are responsible for a small share of ED visits by frequent users, and that ED use accounts for a small portion of these patients’ total Medicaid costs. Frequent ED users have a substantial burden of disease, and they have high rates of primary and specialty care use. They also have linkages to outpatient care that are comparable to those of other ED patients. It is possible to use predictive modeling to identify who will become a repeat ED user and thus to help target interventions. However, policy makers should view reducing frequent ED use as only one element of more-comprehensive intervention strategies for frequent health system users.
Disparities in Service Quality Among Insured Adult Patients Seen in Physicians’ Offices
Journal of General Internal Medicine, 2010. Volume 25 / Issue 04 / April 2010, pp 357-362, Published online
Dan Ly, Sherry Glied
To examine racial disparities in health care service quality.
Secondary data analyses of visits by primary care service users in the Community Tracking Study household sample.
Sixty communities across the United States.
A total of 41,537 insured adult patients making sick visits to primary care physicians in 1996–1997, 1998–1999, 2000–2001, and 2003.
Lag between appointment and physician visit, waiting time in physician office, and satisfaction with care were analyzed.
Blacks but not other minorities were more likely to have an appointment lag of more than 1 week (13% white vs. 21% black, p < 0.001). Blacks, Hispanics, and other minorities were more likely to wait more than 30 min before being seen by the physician (16% white vs. 26% black, p < 0.001; vs. 27% Hispanic and 22% other minority, p < 0.001 and p = 0.02, respectively) and were less likely to report that they were very satisfied with their care (65% white vs. 60% black, p = 0.02; vs. 57% Hispanic and 48% other minority, p = 0.004 and p < 0.001, respectively). The differences in appointment lag and wait time remain large and statistically significant after the inclusion of multiple covariates, including geographic controls for CTS site. For all groups, satisfaction with care was affected by objective measures of service quality. Differences in objective measures of service quality explained much of the black-white difference in satisfaction, though not differences for other minority groups.
There are substantial racial/ethnic disparities in satisfaction with care, and these are related to objective quality measures that can be improved.
Review: The Net Benefits of Depression Management in Primary Care
Medical Care Research and Review, 2010. Volume 67 / Issue 03 / January 2010, pp 251-274, Published online
Sherry Glied, Karin Herzog and Richard Frank
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.
Advancing Research Data Infrastructure for Patient-Centered Outcomes Research
JAMA: The Journal of the American Medical Association, 2011. Volume 306 / Issue 11 / September 2011, pp 1254-1255, Published online
Amol Navathe, Carolyn Clancy and Sherry Glied
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.
We All Want It, but We Don't Know What It Is: Toward a Standard of Affordability for Health Insurance Premiums
Journal of Health Politics, Policy and Law, 2011. Volume 36 / Issue 05 / July 2011, pp 829-853, Published online
Peter Muennig, Bhaven Sampat, Nicholas Tilipman, Lawrence D. Brown and Sherry A. Glied
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 Evolving Private Psychiatric Inpatient Market
The Journal of Behavioral Health Services & Research, 2011. Volume 38 / Issue 01 / January 2011, pp 122-131, Published online
Erica Hutchins, Richard Frank and Sherry Glied
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.
Aligning Ideologies and Institutions: Reorganization in the HIV/AIDS Services Administration of New York City
Public Administration Review, 2011. Volume 71 / Issue 02 / March 2011, pp 243–252, Published online
Kimberley Isett, Michael Sparer, Sherry Glied and Lawrence Brown
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.
Using Electronically Available Inpatient Hospital Data for Research
Clinical and Translational Science, 2011. Volume 4 / Issue 05 / October 2011, pp 338-345, Published online
Mandar Apte, Matthew Neidell, E. Yoko Furuya, David Caplan, Sherry Glied, and Elaine Larson
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
Higher Fees Paid to US Physicians Drive Higher Spending for Physician Services Compared to Other Countries
Health Affairs, 2011. Volume 30 / Issue 09 / September 2011, pp 1647-1656, Published online
Sherry Glied and Miriam Laugesen
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.
Chronic Condition: Why Health Reform Fails
Cambridge: Harvard University Press, 1998.
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.
The Oxford Handbook of Health Economics
Oxford University Press.
Glied, Sherry and Peter C. Smith
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.
Access to primary care in Hong Kong, Greater London and New York City
Cambridge University Press 2013. Health Economics, Policy and Law / Volume 8 / Issue 01 / January 2013, pp 95 109, Published online
Pui Hing Chau, Jean Woo, Michael K. Gusmano, Daniel Weisz, Victor G. Rodwin and Kam Che Chan
We investigate avoidable hospital conditions (AHC) in three world cities as a way to assess access to primary care. Residents of Hong Kong are healthier than their counterparts in Greater London or New York City. In contrast to their counterparts in New York City, residents of both Greater London and Hong Kong face no financial barriers to an extensive public hospital system. We compare residence-based hospital discharge rates for AHC, by age cohorts, in these cities and find that New York City has higher rates than Hong Kong and Greater London. Hong Kong has the lowest hospital discharge rates for AHC among the population 15–64, but its rates are nearly as high as those in New York City among the population 65 and over. Our findings suggest that in contrast to Greater London, older residents in Hong Kong and New York face significant barriers in accessing primary care. In all three cities, people living in lower socioeconomic status neighborhoods are more likely to be hospitalized for an AHC, but neighborhood inequalities are greater in Hong Kong and New York than in Greater London.
Situation analysis and capacity development issues for basic health in Vietnam: Issues paper for UNDP/UNFPA/UNICEF joint report Capacity Development for Poverty Alleviation
United Nations Development Program, Vietnam
Final impact evaluation synthesis report: The Vietnam National Health Support Project
Ministry of Health and World Bank, Vietnam
Managing the health workforce in Vietnam: Situation analysis and recommendations
World Bank, Vietnam
From infrastructure to institutions: Reforming primary health care in Vietnam.
In Social Issues in Vietnam’s Economic Transformation: Vol 2 (ed: Giang Thanh Long), Hanoi: National Political Publishing House, pp. 51-86.
Legacies of Primary Health Care in an era of health sector reform: Vietnam’s commune clinics in transition
Social Science & Medicine 64: 1611-1623.
Developing countries that were early, enthusiastic adopters of Primary Health Care often developed an extensive – but eventually dilapidated and under-utilized – network of public clinics at the grassroots. As paradigms and investment patterns of health sector reform have shifted, the question of what role these public clinics can meaningfully play, and how best to revitalize them, has become important in a number of countries. This paper evaluates the strategy taken by, and outcomes of, a major attempt in Vietnam to revitalize the grassroots infrastructure of primary health care against the backdrop of the country’s economic transition. The project’s substantial supply-side investments in infrastructure led to marginal increases in utilization and the quality of preventive health services provided by the centers. But because the project failed to take adequate stock of broader, public sector-wide trends and reforms over the transition, the investments had little impact on the incentives, accountability patterns and capacities of clinic staff and the local authorities. Such institutional factors are heavily implicated, in Vietnam as elsewhere, in the substantial and often increasing disparities in service access and quality that continue to afflict transitional health sectors.
Efficient Funding: Auditing in the Nonprofit Sector
Manufacturing & Service Operations Management. 13(4) 471-488.
N. Privett and F. Erhun
Nonprofit organizations are a critical part of society as well as a growing sector of the economy. For funders there is an increasing and pressing need to ensure that society reaps the most social benefit for their money while also developing the nonprofit sector as a whole. By routinely scrutinizing nonprofit reports in an effort to deduce whether a nonprofit organization is efficient, funders may believe that they are, in fact, giving responsibly. However, we find that these nonprofit reports are unreliable, supporting a myriad of empirical research and revealing that report-based funding methods do not facilitate efficient allocation of funds. In response, we develop audit contracts that put funders in a position to enact change. Auditing, perhaps obviously, supports funders; however, we find that it also benefits the population of nonprofits. Moreover, auditing results in improved efficiency for the nonprofit sector overall. Indeed, our conclusions indicate that nonprofits may want to work with funders to increase the use of auditing, consequently increasing efficiency for the sector overall and impacting society as a whole.
The Long-Term Effects of Military Conscription on Mortality: Estimates From the Vietnam-Era Draft Lottery
Conley, Dalton and Jennifer Heerwig.
Research on the effects of Vietnam military service suggests that Vietnam veterans experienced significantly higher mortality than the civilian population at large. These results, however, may be biased by nonrandom selection into the military if unobserved background differences between veterans and nonveterans affect mortality directly. To generate unbiased estimates of exposure to conscription on mortality, the present study compares the observed proportion of draft-eligible male decedents born 1950–1952 to the (1) expected proportion of draft-eligible male decedents given Vietnam draft-eligibility cutoffs; and (2) observed proportion of draft-eligible decedent women. The results demonstrate no effect of draft exposure on mortality, including for cause-specific death rates. When we examine population subgroups—including splits by race, educational attainment, nativity, and marital status—we find weak evidence for an interaction between education and draft eligibility. This interaction works in the opposite direction of putative education-enhancing, mortality-reducing effects of conscription that have, in the past, led to concern about a potential exclusion restriction violation in instrumental variable (IV) regression models. We suggest that previous research, which has shown that Vietnam-era veterans experienced significantly higher mortality than nonveterans, might be biased by nonrandom selection into the military and should be further investigated.
Growing Older in Hong Kong, New York and London
The Hong Kong Jockey Club Charities Trust. Hong Kong, 2012.
P. Chau, J. Woo, M. Gusmano, D. Weisz, and Rodwin, V.
Declining birth rates, increasing longevity and urbanization have created a new challenge for cities: how to respond to an ageing population. Although population ageing and urbanization are not new concerns for national governments around the world, the consequences of these trends for quality of life in cities has only recently started to receive attention from policy makers and researchers. Few comparative studies of world cities examine their health or long-term care systems; nor have comparisons of national systems for the provision of long-term care focused on cities, let alone world cities.
By extending the work of the CADENZA and World Cities Projects , this report investigates how three world cities -- Hong Kong, New York and London -- are coping with this challenge. These world cities are centers of finance, information, media, arts, education, specialized legal services and advanced business services, and contribute disproportionate shares of GDP to their national economies. But are these influential centers prepared to meet the challenge posed by the “revolution of longevity?” How will these world cities accommodate this revolutionary demographic change? Are they prepared to implement the health and social policy innovations that may be required to serve their residents, both old and young? Will they be able to identify the new opportunities that increased longevity may offer? Can they learn from one another as they seek to develop creative solutions to the myriad issues that arise? Finally, can other cities learn from the experience of these three cities as they confront this challenge?
To address these questions, we examine comparable data on the economic and health status of older persons, as well as the availability and use of health, social and long-term care across and within these cities. In the report “How Well Are Seniors in Hong Kong Doing? An International Comparison”, a first attempt was made to compare the situation in Hong Kong with five economically developed countries. This report extends this study by comparing the situation in Hong Kong with two other world cities—New York City and London, which are more comparable in terms of population size and economic characteristics.