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Weinick R.M.,RAND Corporation | Burns R.M.,RAND | Mehrotra A.,University of Pittsburgh
Health Affairs | Year: 2010

Americans seek a large amount of nonemergency care in emergency departments, where they often encounter long waits to be seen. Urgent care centers and retail clinics have emerged as alternatives to the emergency department for nonemergency care. We estimate that 13.7-27.1 percent of all emergency department visits could take place at one of these alternative sites, with a potential cost savings of approximately $4.4 billion annually. The primary conditions that could be treated at these sites include minor acute illnesses, strains, and fractures. There is some evidence that patients can safely direct themselves to these alternative sites. However, more research is needed to ensure that care of equivalent quality is provided at urgent care centers and retail clinics compared to emergency departments. © 2010 Project HOPE-The People-to-People Health Foundation, Inc.


Jena A.B.,Harvard University | Seabury S.,RAND | Lakdawalla D.,University of Southern California | Chandra A.,Harvard University
New England Journal of Medicine | Year: 2011

BACKGROUND: Data are lacking on the proportion of physicians who face malpractice claims in a year, the size of those claims, and the cumulative career malpractice risk according to specialty. METHODS: We analyzed malpractice data from 1991 through 2005 for all physicians who were covered by a large professional liability insurer with a nationwide client base (40,916 physicians and 233,738 physician-years of coverage). For 25 specialties, we reported the proportion of physicians who had malpractice claims in a year, the proportion of claims leading to an indemnity payment (compensation paid to a plaintiff), and the size of indemnity payments. We estimated the cumulative risk of ever being sued among physicians in high- and low-risk specialties. RESULTS: Each year during the study period, 7.4% of all physicians had a malpractice claim, with 1.6% having a claim leading to a payment (i.e., 78% of all claims did not result in payments to claimants). The proportion of physicians facing a claim each year ranged from 19.1% in neurosurgery, 18.9% in thoracic-cardiovascular surgery, and 15.3% in general surgery to 5.2% in family medicine, 3.1% in pediatrics, and 2.6% in psychiatry. The mean indemnity payment was $274,887, and the median was $111,749. Mean payments ranged from $117,832 for dermatology to $520,923 for pediatrics. It was estimated that by the age of 65 years, 75% of physicians in lowrisk specialties had faced a malpractice claim, as compared with 99% of physicians in high-risk specialties. CONCLUSIONS: There is substantial variation in the likelihood of malpractice suits and the size of indemnity payments across specialties. The cumulative risk of facing a malpractice claim is high in all specialties, although most claims do not lead to payments to plaintiffs. (Funded by the RAND Institute for Civil Justice and the National Institute on Aging.) Copyright © 2011 Massachusetts Medical Society. All rights reserved.


Hussey P.S.,South Hayes Street W7W | Wertheimer S.,Harvard University | Mehrotra A.,RAND
Annals of Internal Medicine | Year: 2013

Background: Although there is broad policy consensus that both cost containment and quality improvement are critical, the association between costs and quality is poorly understood. Purpose: To systematically review evidence of the association between health care quality and cost. Data Sources: Electronic literature search of PubMed, EconLit, and EMBASE databases for U.S.-based studies published between 1990 and 2012. Study Selection: Title, abstract, and full-text review to identify relevant studies. Data Extraction: Two reviewers independently abstracted data with differences reconciled by consensus. Studies were categorized by level of analysis, type of quality measure, type of cost measure, and method of addressing confounders. Data Synthesis: Of 61 included studies, 21 (34%) reported a positive or mixed-positive association (higher cost associated with higher quality); 18 (30%) reported a negative or mixed-negative association; and 22 (36%) reported no difference, an imprecise orindeterminate association, or a mixed association. The associations were of low to moderate clinical significance in many studies. Of 9 studies using instrumental variables analysis to address confounding by unobserved patient health status, 7 (78%) reported a positive association, but other characteristics of these studies may have affected their findings. Limitations: Studies used widely heterogeneous methods and measures. The review is limited by the quality of underlying studies. Conclusion: Evidence of the direction of association between health care cost and quality is inconsistent. Most studies have found that the association between cost and quality is small to moderate, regardless of whether the direction is positive or negative. Future studies should focus on what types of spending are most effective in improving quality and what types of spending represent waste. Primary Funding Source: Robert Wood Johnson Foundation. © 2013 American College of Physicians.


Barcellos S.H.,RAND | Goldman D.P.,University of Southern California | Smith J.P.,RAND Corporation
Health Affairs | Year: 2012

Newly arrived Mexican immigrants in the United States generally report better health than do native-born Americans, but this health advantage erodes over time. At issue is whether the advantage is illusory-a product of disease that goes undiagnosed in Mexico but is discovered after immigration. Using results from the National Health and Nutrition Examination Survey, we compared clinical to self-reported diagnosed disease prevalence and found that Mexican immigrants are not as healthy as previously thought when undiagnosed disease is taken into account, particularly with respect to diabetes. About half of recent immigrants with diabetes were unaware that they had the disease-an undiagnosed prevalence that was 2.3 times higher than that among Mexican Americans with similar characteristics. Diagnosed prevalence was 47 percent lower among recent Mexican immigrants than among native-born Americans for both diabetes and hypertension, but undiagnosed disease explained one-third of this recent immigrant advantage for diabetes and one-fifth for hypertension. The remaining health advantage might be explained in part by immigrant selectivity-the notion that healthier people might be more likely to come to the United States. Lack of disease awareness is clearly a serious problem among recent Mexican immigrants. Since undiagnosed disease can have adverse health consequences, medical practice should emphasize disease detection among new arrivals as part of routine visits. Although we found little evidence that health insurance plays much of a role in preventing these diseases, we did find that having health insurance was an important factor in promoting awareness of both hypertension and diabetes. © 2012 Project HOPE- The People-to-People Health Foundation, Inc.


White C.,RAND | Reschovsky J.D.,Mathematica Policy Research | Bond A.M.,University of Pennsylvania
Health Affairs | Year: 2014

Private insurers pay widely varying prices for inpatient care across hospitals. Previous research indicates that certain hospitals use market clout to obtain higher payment rates, but there have been few in-depth examinations of the relationship between hospital characteristics and pricing power. This study used private insurance claims data to identify hospitals receiving inpatient prices significantly higher or lower than the median in their market. High-price hospitals, compared to other hospitals, tend to be larger; be major teaching hospitals; belong to systems with large market shares; and provide specialized services, such as heart transplants and Level I trauma care. High-price hospitals also receive significant revenues from nonpatient sources, such as state Medicaid disproportionate-share hospital funds, and they enjoy healthy total financial margins. Quality indicators for high-price hospitals were mixed: High-price hospitals fared much better than low-price hospitals did in U.S. News & World Report rankings, which are largely based on reputation, while generally scoring worse on objective measures of quality, such as postsurgical mortality rates. Thus, insurers may face resistance if they attempt to steer patients away from high-price hospitals because these facilities have good reputations and offer specialized services that may be unique in their markets. © 2014 Project HOPE-The People-to-People Health Foundation, Inc.

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