► We study the causal impact of medical malpractice liability on social welfare. ► Growth in malpractice payments contributed up to 15% of growth in medical costs from 1990 to 2003. ► The threat of ...malpractice liability also led to modest mortality reductions during this period. ► Reducing liability may not be cost-effective given conventional value of life estimates.
We use variation in the generosity of local juries to identify the causal impact of medical malpractice liability on social welfare. Growth in malpractice payments contributed at most 5% points to the 33% total real growth in medical expenditures from 1990 to 2003. On the other hand, malpractice leads to modest mortality reductions; the value of these more than likely exceeds the costs of malpractice liability. Therefore, reducing malpractice liability is unlikely to have a major impact on health care spending, and unlikely to be cost-effective over conventionally accepted values of a statistical life.
To determine rates of eye examinations and diabetic eye disease in the first 5 years after diagnosis of type 2 diabetes (DM2) among continuously insured adults.
Retrospective, longitudinal cohort ...study.
Insured patients aged 40 years or older with newly diagnosed DM2 (n = 42 684), and control patients without diabetes matched on age, sex, and race were identified from a nationwide commercial claims database containing data from 2007 to 2015.
All patients were tracked for 6 years: 1 year before and 5 years after the index diabetes diagnosis. Receipt of eye care for individual patients was identified using International Classification of Diseases 9th edition (ICD-9) procedure codes or Current Procedural Terminology (CPT) codes indicating an eye examination, as well as encounters indicating the patient was seen by an ophthalmologist. A diagnosis of diabetic eye disease was determined by using ICD-9 codes.
Outcome measures included annual receipt of eye care and development of diabetic eye disease, namely, diabetic retinopathy (DR). Associations between these outcomes and demographic factors were tested with multivariable logistic regression.
Diabetic patients received more eye examinations than controls in each year, but no more than 40.4% of diabetic patients received an examination in any given year. Patients with Medicare Advantage received fewer eye examinations at 5 years (odds ratio OR, 0.79; P < 0.01) than those with private insurance but were less likely to develop DR (OR, 0.71; P < 0.01). Hispanic patients had higher rates of DR (OR, 1.60; P < 0.01) and received fewer eye examinations (OR, 0.75; P < 0.01) at 5 years compared with White patients. Men received fewer eye examinations (OR, 0.84; P < 0.01) and were more likely to develop DR at 5 years (OR, 1.17; P < 0.01) than women. Patients with higher education were more likely to receive an eye examination and less likely to develop DR.
The majority of diabetic patients do not receive adequate eye care within the 5 years after initial diabetes diagnosis despite having insurance. Efforts should be made to improve adherence to screening guidelines, especially for vulnerable populations.
•We study the impact of employer-based Return to Work programs at large, self-insured firms.•Return to Work programs generated positive returns by reducing time off work after a workplace ...injury.•Modifying work equipment was the most effective RTW program component.•Programs had the greatest impact on men and workers with a permanent disability.•Short-term benefits were not nullified by long-term adverse employment outcomes.
Reducing the recovery time for workers who are injured or disabled by a workplace accident is a key policy goal. This has motivated the promotion of employer-based return to work programs, despite a lack of systematic evidence on the effectiveness of such programs. We combine data on duration of time out of work for workers’ compensation claimants with information on employer return to work programs to estimate the impact of the programs on time out of work. Discrete-time hazard estimates suggest that the workers in a program return approximately 1.4 times sooner compared to workers injured at a firm without a program. The biggest reductions in work-injury absence are experienced by men, likely due to occupational differences, and by workers with a permanent disability. Modifying work equipment is associated with the greatest reductions in injury durations relative to other program components. Back-of-the-envelope calculations indicate that these programs are cost-effective for large, self-insured employers. More work is needed to determine whether these programs could be adopted successfully by smaller firms.
Medication adherence is increasingly being considered as a measure for performance-based reimbursement contracts in healthcare systems. However, the association between health outcomes and adherence ...at the plan level is unknown.
Retrospective analysis of medical and pharmacy claims from a large private sector claims database from 2000 to 2009.
We compared plan-level measures of medication adherence and health outcomes for patients with diabetes and congestive heart failure (CHF). Plan performance was based on average rates of disease complications. Medication adherence was calculated as the percent of patients having 80% of days covered for medications treating diabetes or CHF. Both adherence and outcomes were adjusted for patient differences using multivariate regression. Plans were stratified into low, moderate, and high adherence, based on adherence in the bottom quartile, middle 2 quartiles, and top quartile, respectively.
Average adherence varied significantly across plans. Plans with low adherence to diabetes medications had adjusted rates of uncontrolled diabetes admissions of 13.2 per 1000 patients, compared with 11.2 in moderate adherence plans and 8.3 in high adherence plans (P < .001). The adjusted rate of CHF-related hospitalization was 15.3% in low adherence plans, compared with 12.4% in moderate adherence plans and 12.2% in high adherence plans (P < .001). These patterns were consistent across different types of complications for both diabetes and CHF.
Private health plans vary considerably in average adherence to medications treating chronic diseases. Plans with higher average adherence had lower rates of disease complications, suggesting that medication adherence measures are potentially useful tools for improving the performance of health plans.
Patients with Crohn's disease (CD) or ulcerative colitis (UC) have high morbidity rates owing to debilitating intestinal complications and extraintestinal manifestations (EIMs). We retrospectively ...identified patients in the Truven MarketScan databases with an incident CD or UC diagnosis from January 2008 to September 2015 to quantify the incremental lifetime risk of experiencing an intestinal complication or EIM after CD or UC diagnosis. Seven intestinal complications and 13 categories of EIMs by site were identified, and lifetime risk of experiencing an intestinal complication or EIM from age at CD or UC diagnosis to end of life was estimated using parametric models. Results were compared with controls' propensity score matched by age, sex, health plan, and pre-index Charlson Comorbidity Index. The CD or UC incremental risk was calculated using the difference in rates between CD or UC patients and matched controls. A total of 34,692 CD patients and 48,196 UC patients with 1:1 matched controls were included. CD and UC patients had an increased lifetime risk of intestinal complications, which varied across ages, inflammatory bowel disease (IBD) types, and categories of intestinal complications and EIMs. CD and UC patients aged 0 to 11 years had the highest incremental lifetime risk for all 7 intestinal complications and the majority of EIMs, with blood EIMs associated with the highest incremental risk (CD: 32%; UC: 21%). CD and UC patients of all ages have a higher lifetime risk of experiencing intestinal complications and EIMs than patients without CD or UC. When evaluating the burden of disease on patients with IBD, it is important to include the burden of these intestinal complications and EIMs in the assessment.
To measure the impact of state Medicaid formulary policies on costs for patients with schizophrenia and bipolar disorder.
Retrospective analysis of medical and pharmacy claims for patients diagnosed ...with schizophrenia or bipolar disorder in 24 state Medicaid programs.
We combined information on formulary restrictions in Medicaid with the medical and pharmacy claims of 117,908 patients with schizophrenia and 170,596 patients with bipolar disorder in Medicaid who were single-eligible, and newly prescribed a second-generation antipsychotic from 2001 to 2008. We tested the impact of formulary restrictions on the medical costs and utilization of patients in the 12 months after the index prescription. To capture social costs in addition to medical expenditures in Medicaid, we estimated the incremental costs of incarcerating patients with schizophrenia and bipolar disorder associated with formulary restrictions.
Patients with schizophrenia subject to formulary restrictions were more likely to be hospitalized (odds ratio 1.13, P <.001), had 23% higher inpatient costs (P <.001), and 16% higher total costs (P <.001). Similar effects were observed for patients with bipolar disorder. Our estimates suggest restrictive formulary policies in Medicaid increased the number of prisoners by 9920 and incarceration costs by $362 million nationwide in 2008.
Applying formulary restrictions to atypical antipsychotics is associated with higher total medical expenditures for patients with schizophrenia and bipolar disorder in Medicaid. Combined with the other social costs such as an increase in incarceration rates, these formulary restrictions could increase state costs by $1 billion annually, enough to offset any savings in pharmacy costs.
Importance Mild traumatic brain injury (mTBI) may impair the ability to work. Strategies to facilitate return to work are understudied. Objective To assess employment and economic outcomes for ...employed, working-age adults with mTBI in the 12 months after injury and the association between return to work and employer assistance. Design, Setting, and Participants Using data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a cohort study of patients with mTBI presenting to emergency departments of 11 level I US trauma centers was performed. Patients with mTBI enrolled in the TRACK-TBI cohort study from February 26, 2014, to May 4, 2016, were followed up at 2 weeks and 3, 6, and 12 months after injury. Work status and income decline of participants were documented in the first year after injury. Associations between work status, injury characteristics, and offer of employer assistance and associations between follow-up care and employer assistance were investigated. Results were adjusted for unobserved outcomes using inverse probability weighting. Data were extracted July 12, 2020; analyses were completed March 24, 2021. Analyses included 435 participants aged 18 to 64 years who were working before the injury, had a Glasgow Coma Scale score of 13 to 15, and completed all postinjury follow-up surveys. Main Outcomes and Measures Primary outcomes were work status (working or not working) at each study follow-up milestone. Employer assistance included sick leave, reduced hours, modified schedule, transfer to different tasks, assistive technology, and coaching offered during the first 3 months after injury. Results Of 435 participants (147 34% female; 320 74% White; mean SD age 37.3 12.9 years), 258 (59%) reported not working at 2 weeks after injury and 74 (17%) reported not working at 12 months after injury. More than one-fifth (92 21%) experienced a decline in annual income. Work status at 12 months was significantly associated with postconcussion symptoms experienced at 3 months after injury (73% of patients with 3 or more symptoms reported working at 12 months after injury vs 89% of patients with 2 or fewer symptoms;P < .001) but not with other injury characteristics. Participants offered employer assistance in the first 3 months after injury were more likely to report working after injury than those not offered such assistance (at 6 months: 88% vs 78%;P = .02; at 12 months: 86% vs 72%;P = .005). Conclusions and Relevance In this cohort study, mTBI was associated with substantial employment and economic consequences for some patients. Clinicians should systematically follow up with patients with mTBI and coordinate with employers to promote successful return to work.
Lost productivity in the workplace represents a significant portion of the economic burden of cancer in the United States. Cancer treatments have historically been physician-administered, while ...recent innovations have led to the development of self-administered, usually oral, agents. Self-administered treatments have the potential to reduce healthcare utilization and time away from work, but the magnitude of these effects is unknown.
To compare the effects of self- and physician-administered cancer treatment on work productivity and health care utilization.
Cancer subtypes with self- and physician-administered treatment options were selected. Patients with female breast, or lung or bronchus cancer diagnosed in 2004–2013 were identified in the Truven Health Analytics Commercial Claims and Encounters and Health and Productivity Management databases. Using multivariate regression models, work productivity and healthcare utilization were compared for patients receiving self- versus physician-administered treatment in the 12 months after initial diagnosis. Work productivity outcomes included the number of sick days and short-term disability claims.
One month of self- versus physician-administered treatment significantly reduced cancer-related outpatient services, doctor visits, and infusions in the 12 months after initial diagnosis for both cancers of interest. In addition, breast and lung or bronchus cancer patients who received self-administered treatment were less likely to have short-term disability claims, and breast cancer patients with non-metastatic disease who received self-administered treatment had significantly fewer sick days.
Self-administered cancer treatment was associated with fewer cancer-related outpatient services and reduced time away from work compared to physician-administered cancer treatment.
► Little is known about how litigants form expectations about likely trial outcomes. ► Forming expectations based on tried cases can make litigants less likely to settle cases. ► I find that an ...increase in average verdicts changes settlement behavior in similar cases. ► In response, litigants appear to be more willing to go to trial with relatively less valuable cases.
The expectations that litigants hold about what would happen if they took their case to trial drive settlement behavior. Jury verdicts from previous trials provide information that could be used to help set beliefs about the potential damage award that would be granted in a dispute if it were to go to trial. But if past jury verdicts do have an impact on litigant beliefs then growth in observed awards could alter behavior in ways that change which cases ultimately get resolved at trial. In other words, the average jury award today could influence the set of cases we see at trial in the future. This paper derives and tests some empirical predictions about how past verdicts change the number of future trials and the expected trial outcomes. The findings suggest that recent verdicts alter the settlement behavior of litigants, making them more likely to proceed to trial with lower value cases.
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