Managed Care and the Diffusion of Endoscopy in Fee-for-Service Medicare (original) (raw)
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Medicare managed care penetration and diffusion of colonoscopy among FFS Medicare
2011
Objective. To determine whether Medicare managed care penetration impacted the diffusion of endoscopy services (sigmoidoscopy, colonoscopy) among the fee-for-service (FFS) Medicare population during 2001-2006. Methods. We model utilization rates for colonoscopy or sigmoidoscopy as impacted by both market supply and demand factors. We use spatial regression to perform ecological analysis of county-area utilization rates over two time intervals (2001-2003, 2004-2006) following Medicare benefits expansion in 2001 to cover colonoscopy for persons of average risk. We examine each technology in separate cross-sectional regressions estimated over early and later periods to assess differential effects on diffusion over time. We discuss selection factors in managed care markets and how failure to control perfectly for market selection might impact our managed care spillover estimates. Results. Areas with worse socioeconomic conditions have lower utilization rates, especially for colonoscopy. Holding constant statistically the socioeconomic factors, we find that managed care spillover effects onto FFS Medicare utilization rates are negative for colonoscopy and positive for sigmoidoscopy. The spatial lag estimates are conservative and interpreted as a lower bound on true effects. Our findings suggest that managed care presence fostered persistence of the older technology during a time when it was rapidly being replaced by the newer technology.
Medicare modernization and diffusion of endoscopy in FFS medicare
Health economics review, 2017
To examine how FFS Medicare utilization of endoscopy procedures for colorectal cancer (CRC) screening changed after implementation of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) in 2006, which provided subsidized drug coverage and expanded the geographic availability of Medicare managed care plans across the US. Using secondary data from 100% FFS Medicare enrollees, we analyzed endoscopy utilization during two intervals, 2001-2005 and 2006-2009. We examined change in predictors of county-level endoscopy utilization rates based on a conceptual model of market supply and demand with spillovers from managed care practices. The equations for each period were estimated jointly in a spatial lag regression model that properly accounts for both place and time effects, allowing robust assessment of changes over time. All Medicare FFS enrollees with both Parts A and B coverage who were age 65+, remained alive and living in the same state over the interval were inc...
Has the influence of managed care waned? Evidence from the market for physician services
International Journal of Health Care Finance and Economics, 2009
Managed care has been the dominant organization of health care coverage in the United States, and seeks to achieve cost control by constraining services. The restrictive practices of managed care organizations have been widely criticized and the role of managed care in constraining health care services may be declining. Physician behavior is also believed to be influenced by the practices of managed care organization. This study examines the evolving nature of managed care and its restrictive effects on the provision of physician services. Physicians can choose whether and to what extent they are involved in managed care, so it is an endogenous decision. We employ instrumental variables method to correct for this endogeneity. Using data from the Community Tracking Study physician surveys from 2000-2001 and 2004-2005, we find that managed care organizations have became relatively less restrictive over time in terms of limiting the provision of physician services, compared to non-managed care organizations. These results suggest that managed care and non-managed care are converging in their effects on the provision of physician services.
Determinants of managed care penetration
Journal of Health Economics, 1998
This paper examines factors associated with differences in managed care penetration across geographic areas. Two alternative measures of managed care penetration are considered: the percentage of revenue physicians received from managed care contracts and market survey data on enrollments in managed care plans. Results are similar for both types of measures. Our analysis suggests that demographics, labor market characteristics and supply side variables including the level of concentration in hospital markets, hospital occupancy rates and the practice organization patterns of physicians are all important determinants of managed care penetration. q 1998 Elsevier Science B.V. All rights reserved.
The effects of institutional change on geographic variation and health services use in the USA
Social Science & Medicine, 2012
This paper examines the impact of institutional change on patient care. Using panel data on obstetric deliveries from the state of California in the United States between 1983 and 2001, it develops and tests hypotheses predicting impacts of three features of institutional changedmanaged care insurance, changing professional controls and public attention to cost-control practicesdon cesarean use and geographic variation in cesarean deliveries. It finds that managed care insurance promotes the diffusion of cost-effective patient care practices, reducing cesarean use and increasing variation. I found that over time, managed care patients experience continued lower use and reduced geographic variation as new practices become established. The combined effects of changing professional controlsdthe growing importance of clinical guidelinesdand public attention to cost-control practices also diffuses costeffective practices, increasing variation and decreasing cesarean use. Cesarean use increases and geographic variation declines in a period of managed care retreat in the late 1990s. The analysis extends prior research by documenting the impact of institutional change on health services use and variation and by suggesting that geographic variation is caused, in part, by the diffusion of new patient care practices.
Preventive Medicine, 2019
Improving the prevention and early detection of colorectal cancer is a priority for reducing ruralurban disparities in colorectal cancer mortality. By eliminating out-of-pocket (OOP) costs for preventive colonoscopies, the Affordable Care Act (ACA) could have reduced rural-urban disparities in screening. Methods: We used the Maine Health Data Organization All-Payer Claims Database including all commerciallyinsured and Medicare beneficiaries aged 50-75 between 2009 and 2012. Rural-urban commuting areas were used to classify rural/urban residence. ICD-9 and CPT codes identified colonoscopies. We summed all OOP payments per patient-day. An interrupted time series model estimated the impact of the ACA on trends in ruralurban disparities in colonoscopy rates and OOP costs. Results: Before the ACA, colonoscopy rates were 16% lower in rural than urban areas (5.1% vs. 6.1% of enrollees annually) and median OOP costs were nearly double
Managed Care and Health Care Expenditures: Evidence from Medicare, 1990 to 1994
1998
Increases in the activity of managed care organizations may have "spilover effects," influencing the entire health care delivery system's performance, so that care for both managed-care and nonmanaged-care patients is affected. Some proposals for Medicare reform have incorporated spillover effects as a way that increasing Medicare HMO enrollment could contribute to savings for Medicare. This paper investigates the relationship between HMO market share and expenditures for the care of beneficiaries enrolled in traditional fee-for-service Medicare. We find that increases in systemwide HMO market share (which includes both Medicare and non-Medicare enrollment) are associated with declines in both Part A and Part B fee-for-service expenditures. The fact that managed care can influence expenditures for this population, which should be well insulated from the direct effects of managed care, suggests that managedcare activity can have broad effects on the entire health care market. Increases in Medicare HMO market share alone are associated with increases in Part A expenditures and with small decreases in Part B expenditures. This suggests that any spillovers directly associated with Medicare HMO enrollment are small. For general health care policy discussions, these results suggest that assessment of new policies that would influence managed care should account not only for its effects on enrollees but also for its systemwide effects. For Medicare policy discussions, these findings imply that previous results that seemed to show large spillover effects associated with increases in Medicare HMO market share, but inadequately accounted for systemwide managed-care activity and relied on older data, overstated the magnitude of actual Medicare spillovers.
Geographic Variation in Health Care: The Role of Private Markets
Brookings Papers on Economic Activity, 2010
The Dartmouth Atlas of Health Care has documented substantial regional variation in health care utilization and spending, beyond what would be expected from such observable factors as demographics and disease severity. However, since these data are specific to Medicare, it is unclear to what extent this finding generalizes to the private sector. Economic theory suggests that private insurers have stronger incentives to restrain utilization and costs, while public insurers have greater monopsony power to restrain prices. We argue that these two differences alone should lead to greater regional variation in utilization for the public sector, but either more or less variation in spending. We provide evidence that variation in utilization in the public sector is about 2.8 times as great for outpatient visits ( p < 0.01) and 3.9 times as great for hospital days (p = 0.09) as in the private sector. Variation in spending appears to be greater in the private sector, consistent with the importance of public sector price restraints.