Publications by authors named "Michael A Morrisey"

66 Publications

The effect of expanded insurance coverage under the Affordable Care Act on emergency department utilization in New York.

Am J Emerg Med 2021 Apr 30;48:183-190. Epub 2021 Apr 30.

Population Informatics Lab, Texas A&M University, College Station, TX, USA; Texas A&M University, School of Public Health, Department of Health Policy & Management, College Station, TX, USA.

Background: One of the proposed benefits of expanding insurance coverage under the Affordable Care Act (ACA) was a reduction in emergency department (ED) utilization for non-urgent visits related to lack of health insurance coverage and access to primary care providers. The objective of this study was to estimate the effect of the 2014 ACA implementation on ED use in New York.

Methods: We used the Healthcare Cost and Utilization Project State Emergency Department and State Inpatient Databases for all outpatient and all inpatient visits for patients admitted through an ED from 2011 to 2016. We focused on in-state residents aged 18 to 64, who were covered under Medicaid, private insurance, or were uninsured prior to the 2014 expansion. We estimated the effect of the expanded insurance coverage on average monthly ED visits volumes and visits per 1000 residents (rates) using interrupted time-series regression analyses.

Results: After ACA implementation, overall average monthly ED visits increased by around 3.0%, both in volume (9362; 95% Confidence Intervals [CI]: 1681-17,522) and in rates (0.80, 95% CI:0.12-1.49). Medicaid covered ED visits volume increased by 23,972 visits (95% CI: 16,240 -31,704) while ED visits by the uninsured declined by 13,297 (95% CI:-15,856 - -10,737), and by 1453 (95% CI:-4027-1121) for the privately insured. Medicaid ED visits rates per 1000 residents increased by 0.77 (95% CI:-1.96-3.51) and by 2.18 (95% CI:-0.55-4.92) for those remaining uninsured, while private insurance visits rates decreased by 0.48 (95% CI:-0.79 - -0.18). We observed increases in primary-care treatable ED visits and in visits related to mental health and alcohol disorders, substance use, diabetes, and hypertension. All estimated changes in monthly ED visits after the expansion were statistically significant, except for ED visit rates among Medicaid beneficiaries.

Conclusion: Net ED visits by adults 18 to 64 years of age increased in New York after the implementation of the ACA. Large increases in ED use by Medicaid beneficiaries were partially offset by reductions among the uninsured and those with private coverage. Our results suggest that efforts to expand health insurance coverage only will be unlikely to reverse the increase in ED use.
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http://dx.doi.org/10.1016/j.ajem.2021.04.076DOI Listing
April 2021

Assessing the Quality Measure for Follow-up Care After Children's Psychiatric Hospitalizations.

Hosp Pediatr 2019 11;9(11):834-843

Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, Alabama;and.

Objectives: Medicaid and Children's Health Insurance Program plans publicly report quality measures, including follow-up care after psychiatric hospitalization. We aimed to understand failure to meet this measure, including measurement definitions and enrollee characteristics, while investigating how follow-up affects subsequent psychiatric hospitalizations and emergency department (ED) visits.

Methods: Administrative data representing Alabama's Children's Health Insurance Program from 2013 to 2016 were used to identify qualifying psychiatric hospitalizations and follow-up care with a mental health provider within 7 to 30 days of discharge. Using relaxed measure definitions, follow-up care was extended to include visits at 45 to 60 days and visits to a primary care provider. Logit regressions estimated enrollee characteristics associated with follow-up care and, separately, the likelihood of subsequent psychiatric hospitalizations and/or ED visits within 30, 60, and 120 days.

Results: We observed 1072 psychiatric hospitalizations during the study period. Of these, 356 (33.2%) received follow-up within 7 days and 566 (52.8%) received it within 30 days. Relaxed measure definitions captured minimal additional follow-up visits. The likelihood of follow-up was lower for both 7 days (-18 percentage points; 95% confidence interval [CI] -26 to -10 percentage points) and 30 days (-26 percentage points; 95% CI -35 to -17 percentage points) regarding hospitalization stays of ≥8 days. Meeting the measure reduced the likelihood of subsequent psychiatric hospitalizations within 60 days by 3 percentage points (95% CI -6 to -1 percentage point).

Conclusions: Among children, receipt of timely follow-up care after a psychiatric hospitalization is low and not sensitive to measurement definitions. Follow-up care may reduce the need for future psychiatric hospitalizations and/or ED visits.
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http://dx.doi.org/10.1542/hpeds.2019-0137DOI Listing
November 2019

Impact of Mental Health Parity and Addiction Equity Act on Costs and Utilization in Alabama's Children's Health Insurance Program.

Acad Pediatr 2019 Jan - Feb;19(1):27-34. Epub 2018 Aug 3.

Department of Health Care Organization & Policy , University of Alabama at Birmingham School of Public Health.

Objective: The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 mandates equivalent insurance coverage for mental health (MH) and substance use disorders (SUD) to other medical and surgical services covered by group insurance plans, Medicaid, and Children's Health Insurance Programs (CHIP). We explored the impact of MHPAEA on enrollees in ALL Kids, the Alabama CHIP.

Methods: We use ALL Kids claims data for October 2008 to December 2014. October 2008 through September 2009 marks the period before MHPAEA implementation. We evaluated changes in MH/SUD-related utilization and program costs and changes in racial/ethnic disparities in the use of MH/SUD services for ALL Kids enrollees using 2-part models. This allowed analyses of changes from no use to any use, as well as in intensity of use.

Results: No significant effect was found on overall MH service-use. There were statistically significant increases in inpatient visits and length of stay and some increase in overall MH costs. These increases may not be clinically important and were concentrated in 2009 to 2011. Disparities in utilization between African-American and non-Hispanic white enrollees were somewhat exacerbated, whereas disparities between other minorities and non-Hispanic whites were reduced.

Conclusions: Findings indicate that MHPAEA led to a 14.3% increase in inpatient visits, a 12.5% increase in length of inpatient stay, and a 7.8% increase in MH costs. The increases appear limited to 2009 to 2011, suggesting existing pent-up "needs" among enrollees for added MH/SUD services that resulted in a temporary spike in service use and cost immediately after MHPAEA, which subsequently subsided.
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http://dx.doi.org/10.1016/j.acap.2018.07.014DOI Listing
February 2020

The Benefit of Early Preventive Dental Care for Children-Reply.

JAMA Pediatr 2017 09;171(9):918-919

Department of Health Care Organization and Policy, University of Alabama at Birmingham School of Public Health, Birmingham.

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http://dx.doi.org/10.1001/jamapediatrics.2017.2060DOI Listing
September 2017

Outcomes Associated With Early Preventive Dental Care Among Medicaid-Enrolled Children in Alabama.

JAMA Pediatr 2017 04;171(4):335-341

Department of Health Care Organization and Policy, University of Alabama at Birmingham School of Public Health, Birmingham.

Importance: There is a recommendation for children to have a dental home by 6 months of age, but there is limited evidence supporting the effectiveness of early preventive dental care or whether primary care providers (PCPs) can deliver it.

Objective: To investigate the effectiveness of preventive dental care in reducing caries-related treatment visits among Medicaid enrollees.

Design, Setting, And Participants: High-dimensional propensity scores were used to address selection bias for a retrospective cohort study of children continuously enrolled in coverage from the Alabama Medicaid Agency from birth between 2008 and 2012, adjusting for demographics, access to care, and general health service use.

Exposures: Children receiving preventive dental care prior to age 2 years from PCPs or dentists vs no preventive dental care.

Main Outcome And Measures: Two-part models estimated caries-related treatment and expenditures.

Results: Among 19 658 eligible children, 25.8% (n = 3658) received early preventive dental care, of whom 44% were black, 37.6% were white, and 16.3% were Hispanic. Compared with matched children without early preventive dental care, children with dentist-delivered preventive dental care more frequently had a subsequent caries-related treatment (20.6% vs 11.3%, P < .001), higher rate of visits (0.29 vs 0.15 per child-year, P < .001), and greater dental expenditures ($168 vs $87 per year, P < .001). Dentist-delivered preventive dental care was associated with an increase in the expected number of caries-related treatment visits by 0.14 per child per year (95% CI, 0.11-0.16) and caries-related treatment expenditures by $40.77 per child per year (95% CI, $30.48-$51.07). Primary care provider-delivered preventive dental care did not significantly affect caries-related treatment use or expenditures.

Conclusions And Relevance: Children with early preventive care visits from dentists were more likely to have subsequent dental care, including caries-related treatment, and greater expenditures than children without preventive dental care. There was no association with subsequent caries-related treatment and preventive dental care from PCPs. We observed no evidence of a benefit of early preventive dental care, regardless of the provider. Additional research beyond administrative data may be necessary to elucidate any benefits of early preventive dental care.
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http://dx.doi.org/10.1001/jamapediatrics.2016.4514DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5470412PMC
April 2017

An assessment of the CHIP/Medicaid quality measure for ADHD.

Am J Manag Care 2017 Jan 1;23(1):e1-e9. Epub 2017 Jan 1.

Department of Health Care Organization & Policy, University of Alabama at Birmingham, 1720 2nd Ave S, RPHB 330, Birmingham, AL 35294. E-mail:

Objectives: We analyzed a standard children's quality measure for attention-deficit/hyperactivity disorder (ADHD) using data from a single state to understand the characteristics of those meeting the measure, potential barriers to meeting the measure, and how meeting the measure affected outcomes.

Study Design: Retrospective study using claims from Alabama's Children's Health Insurance Program from 1999 to 2012.

Methods: We calculated the quality measure for ADHD care, as specified within CMS' Child Core Set and with an expanded denominator. We described the eligible population meeting the measure, assessed potential barriers, and measured the association with health expenditures using logit regressions and log-Poisson models.

Results: Among those receiving ADHD medication, 11% of enrollees were eligible for annual measure calculation during our study period. Calculated as specified by CMS, 38% of enrollees met the measure. Using an expanded denominator of 7615 eligible medication episodes, 14% met all aspects of the measure. Primary reasons for failing to meet the measure were lacking medication coverage (64%) and lacking a follow-up visit within 30 days (62%). The rate of meeting the measure decreased with age and was lower for black enrollees. Health service utilization and costs were greater among children meeting the measure.

Conclusions: Too few children are eligible for inclusion, and systematic differences exist among those who meet the measure. The measure may be sensitive to arbitrary criteria while missing potentially relevant clinical care. Refinements to the measure should be considered to improve generalizability to all children with ADHD and improve clinical relevance. States must consider additional analyses to direct quality improvement.
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January 2017

Turmoil in the Health Insurance Marketplaces.

LDI Issue Brief 2016 10;21(1):1-5

Department of Health Policy & Management, Texas A&M University

The first three years of the Affordable Care Act’s Health Insurance Marketplaces have been tumultuous ones, with rapid entry and exit of insurers and recent spikes in premiums. As concerns mount about the stability and viability of the Marketplaces, this brief provides some insight into the forces behind the headlines and presents six options for policymakers to consider.
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October 2016

Health Expenditure Concentration and Characteristics of High-Cost Enrollees in CHIP.

Inquiry 2016 10;53. Epub 2016 May 10.

Indiana University-Purdue University Indianapolis, USA.

Devising effective cost-containment strategies in public insurance programs requires understanding the distribution of health care spending and characteristics of high-cost enrollees. The aim was to characterize high-cost enrollees in a state's public insurance program and determine whether expenditure inequality changes over time, or with changes in cost-sharing policies or program eligibility. We use 1999-2011 claims and enrollment data from the Alabama Children's Health Insurance Program, ALL Kids. All children enrolled in ALL Kids were included in our study, including multiple years of enrollment (N = 1,031,600 enrollee-months). We examine the distribution of costs over time, whether this distribution changes after increases in cost sharing and expanded eligibility, patient characteristics that predict high-cost status, and examine health services used by high-cost children to identify what is preventable. The top 10% (1%) of enrollees account for about 65.5% (24.7%) of total program costs. Inpatient and outpatient costs are the largest components of costs incurred by high-cost utilizers. Non-urgent emergency department costs are a relatively small portion. Average expenditure increases over time, particularly after expanded eligibility, and the share of costs incurred by the top 10% and 1% increases slightly. Multivariable logistic regression results indicate that infants and older teens, Caucasian children, and those with chronic conditions are more likely to be high-cost utilizers. Increased cost sharing does not reduce cost concentration or average expenditure among high-cost utilizers. These findings suggest that identifying and targeting potentially preventable costs among high-cost utilizers are called for to help reduce costs in public insurance programs.
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http://dx.doi.org/10.1177/0046958016645000DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5798702PMC
June 2016

The Great Recession of 2007-2009 and Public Insurance Coverage for Children in Alabama: Enrollment and Claims Data from 1999-2011.

Public Health Rep 2016 Mar-Apr;131(2):348-56

Indiana University, Richard M. Fairbanks School of Public Health, Department of Health Policy and Management, Indianapolis, IN.

Objectives: This study examined the impact of the Great Recession of 2007-2009 on public health insurance enrollment and expenditures in Alabama. Our analysis was designed to provide a framework for other states to conduct similar analyses to better understand the relationship between macroeconomic conditions and public health insurance costs.

Methods: We analyzed enrollment and claims data from Medicaid and the Children's Health Insurance Program (CHIP) in Alabama from 1999 through 2011. We examined the relationship between county-level unemployment rates and enrollment in Medicaid and CHIP, as well as total county-level expenditures in the two programs. We used linear regressions with county fixed effects to estimate the impact of unemployment changes on enrollment and expenditures after controlling for population and programmatic changes in eligibility and cost sharing.

Results: A one-percentage-point increase in a county's unemployment rate was associated with a 4.3% increase in Medicaid enrollment, a 0.9% increase in CHIP enrollment, and an overall increase in public health insurance enrollment of 3.7%. Each percentage-point increase in unemployment was associated with a 6.2% increase in total public health insurance expenditures on children, with Medicaid spending rising by 7.5% and CHIP spending rising by 1.8%. In response to the 6.4 percentage-point increase in the state's unemployment rate during the Great Recession, combined enrollment of children in Alabama's public health insurance programs increased by 24% and total expenditures rose by 40%.

Conclusion: Recessions have a substantial impact on the number of children enrolled in CHIP and Medicaid, and a disproportionate impact on program spending. Programs should be aware of the likely magnitudes of the effects in their budget planning.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4765984PMC
http://dx.doi.org/10.1177/003335491613100219DOI Listing
July 2016

Preventive Dental Care and Long-Term Dental Outcomes among ALL Kids Enrollees.

Health Serv Res 2016 Dec 29;51(6):2242-2257. Epub 2016 Feb 29.

Department of Health Policy & Management, Indiana University-Purdue University, Indianapolis, IN.

Objective: To investigate whether early or regular preventive dental visit (PDV) reduces restorative or emergency dental care and costs for low-income children.

Study Setting: Enrollees during 1998-2012 in the Alabama CHIP program, ALL Kids.

Study Design: Retrospective cohort study using claims data for children continuously enrolled in ALL Kids for at least 4 years. Analyses are conducted separately for children 0-4 years, 4-9 years, and >9 years. For 0-4 years, the intervention of interest is whether they have at least one PDV before age 3. For the other two age groups, interventions of interest are if they have regular PDVs during each of the first 3 years, and if they have claims for a sealant in the first 3 years. Outcomes-namely restorative and emergency dental service and costs-are measured in the fourth year. To account for selection into PDV, a high-dimensional propensity scores approach is utilized.

Data Extraction: Claims data were obtained from ALL Kids.

Principal Findings: Only sealants are associated with a reduced likelihood of using restorative and emergency services and costs.

Conclusions: Whether PDVs without sealants actually reduce restorative/emergency pediatric dental services is questionable. Further research into benefits of PDV is needed.
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http://dx.doi.org/10.1111/1475-6773.12469DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5134206PMC
December 2016

Adverse Selection in the Children's Health Insurance Program.

Inquiry 2015 Jul 5;52. Epub 2015 Jul 5.

Indiana University, Indianapolis, IN, USA.

This study investigates whether new enrollees in the Alabama Children's Health Insurance Program have different claims experience from renewing enrollees who do not have a lapse in coverage and from continuing enrollees. The analysis compared health services utilization in the first month of enrollment for new enrollees (who had not been in the program for at least 12 months) with utilization among continuing enrollees. A second analysis compared first-month utilization of those who renew immediately with those who waited at least 2 months to renew. A 2-part model estimated the probability of usage and then the extent of usage conditional on any utilization. Claims data for 826 866 child-years over the period from 1999 to 2012 were used. New enrollees annually constituted a stable 40% share of participants. Among those enrolled in the program, 13.5% renewed on time and 86.5% of enrollees were late to renew their enrollment. In the multivariate 2-part models, controlling for age, gender, race, income eligibility category, and year, new enrollees had overall first-month claims experience that was nearly $29 less than continuing enrollees. This was driven by lower ambulatory use. Late renewals had overall first-month claims experience that was $10 less than immediate renewals. However, controlling for the presence of chronic health conditions, there was no statistically meaningful difference in the first-month claims experience of late and early renewals. Thus, differences in claims experience between new and continuing enrollees and between early and late renewals are small, with greater spending found among continuing and early renewing participants. Higher claims experience by early renewals is attributable to having chronic health conditions.
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http://dx.doi.org/10.1177/0046958015593559DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5813640PMC
July 2015

Initial Impacts of the Patient Care Networks of Alabama Initiative.

Health Serv Res 2016 Feb 9;51(1):146-66. Epub 2015 Jun 9.

Department of Medicine, University of Alabama at Birmingham, Birmingham, AL.

Objectives: To estimate the effects of medical home support on the use of clinical services and Medicaid expenditures.

Data Source: Medicaid claims.

Study Design: A difference-in-differences model where changes in utilization and expenditures of the intervention group are compared to changes in the nonintervention group.

Extraction Methods: Using Medicaid claims from October 2010 through September 2013, service use and expenditures are measured for 12 months before and 21 months after implementation. Changes for four health status groups are examined separately.

Principal Findings: The introduction of community-based support was associated with a small reduction in use and no statistically significant overall effect on expenditures. However, among those with chronic and/or mental health conditions, there were modest, statistically significant increases in use of and expenditures for a range of ambulatory and inpatient health care services, while service use for those without these conditions declined. Emergency department use increased for all groups.

Conclusions: Community-based support for medical home practices is associated with a shift in the service mix provided to higher cost, more vulnerable subgroups in Medicaid. Such systems are unlikely to be associated with significant overall cost savings, at least in the short term, but may have other benefits.
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http://dx.doi.org/10.1111/1475-6773.12319DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4722207PMC
February 2016

Enrollment, expenditures, and utilization after CHIP expansion: evidence from Alabama.

Acad Pediatr 2015 May-Jun;15(3):258-66

Department of Health Care Organization and Policy, University of Alabama at Birmingham School of Public Health, Birmingham, Ala; UAB Lister Hill Center for Health Policy, Birmingham, Ala.

Objective: In October 2009, Alabama expanded eligibility in its Children's Health Insurance Program (CHIP), known as ALL Kids, from 200% to 300% of the federal poverty level (FPL). We examined the expenditures, utilization, and enrollment behavior of expansion enrollees relative to traditional enrollees (100-200% FPL) and assessed the impact of expansion on total program expenditures.

Methods: We compared unadjusted mean person-month-level expenditures and utilization of expansion enrollees and various categories of existing enrollees and used a 2-part modeling strategy to examine differences after controlling for enrollee characteristics. We used probit models to examine adjusted differences in reenrollment behavior by eligibility category.

Results: Expansion enrollees had higher total monthly expenditures ($10.33, P < .05) than traditional ALL Kids enrollees, including higher outpatient ($5.35, P < .001) and dental ($0.85, P < .01) expenditures but lower emergency department (-$1.34, P < .001) expenditures. Expansion enrollees had marginally lower utilization of emergency department services for low-severity conditions and higher utilization of physician outpatient visits. Expansion enrollees were 4.47 percentage points (P < .001) more likely to reenroll before their contract expiration date than traditional ALL Kids enrollees. As of October 2012, expansion enrollees accounted for approximately 20% of ALL Kids enrollment and expenditures.

Conclusions: The expansion population was characterized by moderately higher health expenditures and utilization, and more persistent enrollment relative to fee group enrollees who are subject to the same levels of cost sharing and annual premiums. Although states are prohibited from changing program eligibility until 2019, the costs associated with the expansion population will be important to future policy decisions.
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http://dx.doi.org/10.1016/j.acap.2015.01.006DOI Listing
December 2016

Fractures and mortality in relation to different osteoporosis treatments.

Clin Exp Rheumatol 2015 May-Jun;33(3):302-9. Epub 2014 Jul 28.

Department of Epidemiology, and Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA.

Objectives: Few studies have assessed the effectiveness of different drugs for osteoporosis (OP). We aimed to determine if fracture and mortality rates vary among patients initiating different OP medications.

Methods: We used the Medicare 5% sample to identify new users of intravenous (IV) zoledronic acid (n=1.674), oral bisphosphonates (n=32.626), IV ibandronate (n=492), calcitonin (n=2.606), raloxifene (n=1.950), or parathyroid hormone (n=549). We included beneficiaries who were ≥65 years of age, were continuously enrolled in fee-for-service Medicare and initiated therapy during 2007-2009. Outcomes were hip fracture, clinical vertebral fracture, and all-cause mortality, identified using inpatient and physician diagnosis codes for fracture, procedure codes for fracture repair, and vital status information. Cox regression models compared users of each medication to users of IV zoledronic acid, adjusting for multiple confounders.

Results: During follow-up (median, 0.8-1.5 years depending on the drug), 787 subjects had hip fractures, 986 had clinical vertebral fractures, and 2.999 died. Positive associations included IV ibandronate with hip fracture (adjusted hazard ratio (HR), 2.37; 95% confidence interval (CI) 1.25-4.51), calcitonin with vertebral fracture (HR=1.59, 95%CI 1.04-2.43), and calcitonin with mortality (HR=1.31; 95%CI 1.02-1.68). Adjusted HRs for other drug-outcome comparisons were not statistically significant.

Conclusions: IV ibandronate and calcitonin were associated with higher rates of some types of fracture when compared to IV zolendronic acid. The relatively high mortality associated with use of calcitonin may reflect the poorer health of users of this agent.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5733785PMC
August 2015

Characteristics of low-severity emergency department use among CHIP enrollees.

Am J Manag Care 2013 Dec 1;19(12):e391-9. Epub 2013 Dec 1.

1665 University Blvd, Rm 330, Birmingham, AL 35294. E-mail:

Objectives: To describe patient characteristics among those utilizing the emergency department (ED) for low-severity conditions (ie, conditions potentially treatable or manageable in a primary care setting).

Study Design: A pooled cross-sectional study of administrative claims for ED visits among enrollees in Alabama's Children's Health Insurance Program (CHIP), ALL Kids, from January 1, 1999, through December 31, 2010.

Methods: Severity of visit was categorized based on primary diagnosis code using an established claims-based algorithm. Logistic regression was used to identify patient characteristics that predicted low-severity ED visits relative to high-severity visits.

Results: Of a total of 141,709 qualifying ED visits, 97,961 (69%) were classified as low severity, 33,941 (24%) as intermediate severity, and 9807 (7%) as high severity. Based on absolute risk differences, we found that among children utilizing the ED, low-severity visits were more likely than high-severity visits among children who were noncompliant with recommended well-child care (1.2 percentage points, 95% confidence interval [CI], 0.4-1.9); children who were nonurban residents (urban vs isolated: 1.6 percentage points, 95% CI, 1.0-2.2; urban vs small rural: 1.1 percentage points, 95% CI, 0.5-1.7); children without chronic disease (10.3 percentage points, 95% CI, 9.9-10.7) and children whose ED visits were on Sunday versus weekdays (0.9 percentage point, 95% CI, 0.6-1.3), and on Saturday versus weekdays (1.2 percentage points; 95% CI, 0.8-1.6).

Conclusions: Our results suggest that improving access to primary care on weekends and in rural areas are potential ways to improve the efficient use of ED services.
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December 2013

Trends in the utilization and outcomes of Medicare patients hospitalized for hip fracture, 2000-2008.

J Aging Health 2014 Apr 8;26(3):360-79. Epub 2014 Jan 8.

University of Alabama at Birmingham, USA.

Objective: This study examines temporal trends in hip fracture related utilization and outcomes among elderly fee-for-service Medicare beneficiaries.

Method: The study uses claims data for a 5% sample of Medicare beneficiaries with an incident hip fracture hospitalization between 2000 and 2008. We present annual mean patient characteristics, health services utilization, and outcomes and use ordinary least squares regressions to examine adjusted trends in utilization and outcomes after controlling for changes in patient characteristics.

Results: We observe a statistically significant temporal decline in inpatient acute days and a statistically significant increase in inpatient post-acute days following hip fractures. In models that control for patient characteristics, we observe statistically significant declines in 1-year hip fracture readmission and mortality rates. Rates of nursing home residence 1-year following fracture were unchanged and remain high.

Discussion: Hip fractures remain highly debilitating events and pose significant challenges for the financing of public health insurance programs.
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http://dx.doi.org/10.1177/0898264313516994DOI Listing
April 2014

Death, debility, and destitution following hip fracture.

J Gerontol A Biol Sci Med Sci 2014 Mar 19;69(3):346-53. Epub 2013 Jul 19.

MSPH, School of Public Health, University of Alabama at Birmingham, 1665 University Boulevard, RPHB 330, Birmingham, AL 35294-0022.

Background: We examined the effects of hip fracture on mortality, entry into long-term institutional care, and new evidence of poverty. We estimate of the proportion of hip fracture patients who require not just short-term rehabilitation but who become dependent on long-term institutional care, and the risk of becoming newly dependent on Medicaid or eligible for low-income subsidies following hip fracture.

Methods: We used data from 2005 through 2010 for a random 5% sample of Medicare beneficiaries (N = 3.1 million) to conduct a retrospective matched cohort study. We used high-dimensional propensity score matching to compare outcomes for patients who experienced a hip fracture with subjects who did not, but had similar propensity for suffering a hip fracture. We then compared the 1-year risk of death, debility, and destitution between groups.

Results: We matched 43,210 hip fracture patients to comparators without a hip fracture. Hip fractures were associated with more than a twofold increase in likelihood of mortality (incidence proportion ratio [IPR] of 2.27, 95% CI, 2.20-2.34), a fourfold increase in likelihood of requiring long-term nursing facility care (IPR, 3.96; 95% CI, 3.77-4.16), and a twofold increase in the probability of entering into low-income status (IPR, 2.14; 95% CI 1.99-2.31) within 1 year following hip fracture compared with subjects without a hip fracture.

Conclusions: Hip fracture in elderly patients resulted in increased death, debility, and destitution. Initiatives that lead to improved treatment of osteoporosis could result in a decrease in incidence of fractures, subsequent death, debility, and destitution for older adults.
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http://dx.doi.org/10.1093/gerona/glt105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3976138PMC
March 2014

Co-payments and the use of emergency department services in the children's health insurance program.

Med Care Res Rev 2013 Oct 14;70(5):514-30. Epub 2013 Jun 14.

1University of Alabama at Birmingham, AL, USA.

Research suggests that more than half of all emergency department (ED) visits in the United States are for nonurgent conditions, leading to billions of dollars in potentially avoidable spending annually. In this study, we examine the effects of co-payment changes on ED utilization among children enrolled in ALL Kids, Alabama's Children's Health Insurance Program We separately model the effect of the 2003 co-payment increases on the monthly probability of any ED visit, and visits within three severity categories, using linear probability models that control for beneficiary characteristics and time trends that are allowed to vary in the pre- and postperiods. We observe a small decline in the probability of ED visits 1 year after the co-payment increase. However, low-severity visits, which we hypothesize to be more price sensitive, show no significant evidence of a decline. Our study suggests that the modest co-payment changes were not effective in improving the efficiency of ED utilization.
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http://dx.doi.org/10.1177/1077558713491501DOI Listing
October 2013

Effectiveness of preventive dental visits in reducing nonpreventive dental visits and expenditures.

Pediatrics 2013 Jun 27;131(6):1107-13. Epub 2013 May 27.

Department of Health Care Organization and Policy, University of Alabama, Birmingham, AL, USA.

Background And Objective: Although preventive dental visits are considered important for maintaining pediatric oral health, there is relatively little research showing that they reduce subsequent nonpreventive dental visits or costs. At least 1 study seemed to find that early preventive dental care is associated with more restorative and emergency visits. Previous studies are limited by their inability to account for unmeasurable factors that may lead children to "select" into using both more preventive and nonpreventive dental care. We used econometric techniques that minimize selection bias to assess the effectiveness of preventive dental care in reducing subsequent nonpreventive dental service utilization among children.

Methods: Using data from Alabama's Children's Health Insurance Program (CHIP), 1998-2010., a cohort study of children's dental service utilization was conducted. Outcomes were 1-year lagged nonpreventive dental care and expenditures, and overall dental and medical expenditures. Children who were continuously enrolled for at least 3 years were included. Separate models were estimated for children aged <8 years (n = 14 972) and those aged ≥8 years (n = 21 833).

Results: More preventive visits were associated with fewer subsequent nonpreventive dental visits and lower nonpreventive dental expenditures for both groups. However, more preventive visits did not reduce overall dental or medical (inclusive of dental) expenditures.

Conclusions: Preventive dental visits can reduce subsequent nonpreventive visits and expenditures for children continuously enrolled in CHIP. However, they may not reduce overall program costs. Effective empirical research in this area must continue to address unobserved confounders and selection issues.
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http://dx.doi.org/10.1542/peds.2012-2586DOI Listing
June 2013

Mortality following bone metastasis and skeletal-related events among patients 65 years and above with lung cancer: A population-based analysis of U.S. Medicare beneficiaries, 1999-2006.

Lung India 2013 Jan;30(1):20-6

School of Public Health, University of Alabama at Birmingham. 1665 University Blvd, Birmingham, AL. 35294-0022, USA.

Background: To quantify the impact of bone metastasis and skeletal-related events (SREs) on mortality among older patients with lung cancer.

Materials And Methods: Using the linked Surveillance, Epidemiology and End Results-Medicare database, we identified patients aged 65 years or older diagnosed with lung cancer between July 1, 1999 and December 31, 2005 and followed them to determine deaths through December 31, 2006. We classified patients as having possible bone metastasis and SREs using discharge diagnoses from inpatient claims and diagnoses paired with procedure codes from outpatient claims. We used Cox regression to estimate mortality hazards ratios (HR) among patients with bone metastasis with or without SRE, compared to patients without bone metastasis.

Results: Among 126,123 patients with lung cancer having a median follow-up of 0.6 years, 24,820 (19.8%) had bone metastasis either at lung cancer diagnosis (9,523, 7.6%) or during follow-up (15,297, 12.1%). SREs occurred in 12,665 (51%) patients with bone metastasis. The HR for death was 2.4 (95% CI = 2.4-2.5) both for patients with bone metastasis but no SRE and for patients with bone metastasis plus SRE, compared to patients without bone metastasis.

Conclusions: Having a bone metastasis, as indicated by Medicare claims, was associated with mortality among patients with lung cancer. We found no difference in mortality between patients with bone metastasis complicated by SRE and patients with bone metastasis but without SRE.
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http://dx.doi.org/10.4103/0970-2113.106127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3644828PMC
January 2013

Measuring prevention more broadly: an empirical assessment of CHIPRA core measures.

Medicare Medicaid Res Rev 2013 22;3(3). Epub 2013 Aug 22.

Alabama Department of Public Health.

Objective: To assess limitations of using select Children's Health Insurance Program Reauthorization Act (CHIPRA) core claims-based measures in capturing the preventive services that may occur in the clinical setting.

Methods: We use claims data from ALL Kids, the Alabama Children's Health Insurance Program (CHIP), to calculate each of four quality measures under two alternative definitions: (1) the formal claims-based guidelines outlined in the CMS Technical Specifications, and (2) a broader definition of appropriate claims for identifying preventive service use. Additionally, we examine the extent to which these two claims-based approaches to measuring quality differ in assessments of disparities in quality of care across subgroups of children.

Results: Statistically significant differences in rates were identified when comparing the two definitions for calculating each quality measure. Measure differences ranged from a 1.9 percentage point change for measure #13 (receiving preventive dental services) to a 25.5 percentage point change for measure #12 (adolescent well-care visit). We were able to identify subgroups based upon family income, rural location, and chronic disease status with differences in quality within the core measures. However, some identified disparities were sensitive to the approach used to calculate the quality measure.

Conclusions: Differences in CHIP design and structure, across states and over time, may limit the usefulness of select claims-based core measures for detecting disparities accurately. Additional guidance and research may be necessary before reporting of the measures becomes mandatory.
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http://dx.doi.org/10.5600/mmrr.003.03.a04DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4001808PMC
August 2015

Generic alendronate use among Medicare beneficiaries: are Part D data complete?

Pharmacoepidemiol Drug Saf 2013 Jan 8;22(1):55-63. Epub 2012 Nov 8.

Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.

Background: Generic alendronate was approved in the United States on February 6, 2008. Medicare beneficiaries might pay for generic alendronate out-of-pocket without having claims submitted, resulting in misclassification of generic alendronate use in Medicare data.

Objectives: To estimate the completeness of generic alendronate use in 2008 Medicare Part D data; to identify factors associated with staying on branded alendronate versus switching to a generic product.

Methods: We identified Medicare beneficiaries highly adherent (medication possession ratio ≥80%) with branded alendronate during 1/1/06-2/6/07 ("2007 cohort") and during 1/1/07-2/6/08 ("2008 cohort"). The outcome was medication status at the end of follow-up (12/31/2007 or 12/31/2008), classified as continued branded alendronate, switched to generic alendronate, switched to another bisphosphonate or presumed discontinued bisphosphonate therapy. Cox regression estimated the hazard ratio (HR) for discontinuation in 2008 compared to 2007. Multinomial logistic regression identified factors associated with medication status for the 2008 cohort.

Results: Among 15,310 subjects using branded alendronate in the 2008 cohort, 81% switched to generic alendronate. The proportion presumably discontinuing bisphosphonate therapy was 8.9% in 2008 compared to 7.7% in the 2007 cohort (adjusted HR, 1.15; 95% confidence interval, 1.05, 1.26). Factors associated with staying on branded alendronate in 2008 were higher income, eligibility for a low income subsidy and use of Fosamax® plus vitamin D.

Conclusion: Evaluation of Medicare prescription drug data suggests that the amount of missing claims for generic alendronate in 2008 was not substantial, and misclassification of exposure in studies examining alendronate use post-generic product availability should be minimal.
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http://dx.doi.org/10.1002/pds.3361DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4052770PMC
January 2013

Favorable selection, risk adjustment, and the Medicare Advantage program.

Health Serv Res 2013 Jun 22;48(3):1039-56. Epub 2012 Oct 22.

Lister Hill Center for Health Policy, University of Alabama at Birmingham, Birmingham, AL 35294-0022, USA.

Objectives: To examine the effects of changes in payment and risk adjustment on (1) the annual enrollment and switching behavior of Medicare Advantage (MA) beneficiaries, and (2) the relative costliness of MA enrollees and disenrollees.

Data: From 1999 through 2008 national Medicare claims data from the 5 percent longitudinal sample of Parts A and B expenditures.

Study Design: Retrospective, fixed effects regression analysis of July enrollment and year-long switching into and out of MA. Similar regression analysis of the costliness of those switching into (out of) MA in the 6 months prior to enrollment (after disenrollment) relative to nonswitchers in the same county over the same period.

Findings: Payment generosity and more sophisticated risk adjustment were associated with substantial increases in MA enrollment and decreases in disenrollment. Claims experience of those newly switching into MA was not affected by any of the policy reforms, but disenrollment became increasingly concentrated among high-cost beneficiaries.

Conclusions: Enrollment is very sensitive to payment levels. The use of more sophisticated risk adjustment did not alter favorable selection into MA, but it did affect the costliness of disenrollees.
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http://dx.doi.org/10.1111/1475-6773.12006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3681242PMC
June 2013

A close examination of healthcare expenditures related to fractures.

J Bone Miner Res 2013 Apr;28(4):816-20

Department of Health Care Organization and Policy, University of Alabama at Birmingham, Birmingham, AL 35294-0022, USA.

This study evaluated reasons for healthcare expenditures both before and after the occurrence of fractures among Medicare beneficiaries. In a previous study we examined healthcare expenditures in the 6 months before and after fractures. The difference-"incremental" expenditures-provides one estimate of the potentially avoidable costs associated with fractures. We constructed a second estimate of the cost burden-"attributable" expenditures-using only those costs recorded in claims with fracture diagnosis codes. Attributable expenditures accounted for only 24% to 60% of incremental expenditures, depending on the fracture site. We examined health care expenditures between 1999 and 2005 among Medicare beneficiaries who experienced fractures (cases) and among beneficiaries who did not experience fractures (controls), matched to cases on age, race, and sex. We also examined healthcare expenditures for cases and controls for 24 months prior to the fracture index date. When expenditures associated with diagnoses for aftercare, joint pain, and osteoporosis, other musculoskeletal diagnoses, pneumonia, and pressure ulcers were included, the proportion of incremental costs directly attributable to fracture care rose to 72% to 88%. Expenditures prior to fracture were higher for cases than controls, and the rate of increase accelerated over the 12 months prior to the hip fracture. Our findings confirm that the original incremental cost analysis constituted a satisfactory method for estimating avoidable costs associated with fractures. We also conclude that those with fractures had much higher and growing healthcare expenditures in the 12 months prior to the event, compared with age-, race-, and sex-matched controls. This suggests that patterns of healthcare services utilization may provide a means to improve fracture prediction rules.
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http://dx.doi.org/10.1002/jbmr.1789DOI Listing
April 2013

Recent trends in hip fracture rates by race/ethnicity among older US adults.

J Bone Miner Res 2012 Nov;27(11):2325-32

Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA.

Hip fracture incidence has declined among whites in the United States since 1995, but data on recent trends in racial and ethnic minorities are limited. The goal of this analysis was to investigate hip fracture incidence trends in racial/ethnic subgroups of older Medicare beneficiaries. We conducted a cohort study to determine annual hip fracture incidence rates from 2000 through 2009 using the Medicare national random 5% sample. Beneficiaries were eligible if they were ≥65 years of age and had 90 days of consecutive full fee-for-service Medicare coverage with no hip fracture claims. Race/ethnicity was self-reported. The incidence of hip fracture was identified using hospital diagnosis codes or outpatient diagnosis codes paired with fracture repair procedure codes. We computed age-standardized race/ethnicity-specific incidence rates and assessed trends in the rates over time using linear regression. On average, 821,475 women and 632,162 men were included in the analysis each year. Beneficiaries were predominantly white (88%), with African, Hispanic, and Asian Americans making up 8%, 1.5%, and 1.5% of the population, respectively. We identified 102,849, 4,119, 813, and 1,294 hip fractures in white, black, Asian, and Hispanic beneficiaries over the 10 years. A significant decreasing trend (p < 0.05) in hip fracture incidence from 2000-2001 to 2008-2009 was present in white women and men. Black and Asian beneficiaries experienced nonsignificant declines. Irrespective of gender, the largest rate of decline was seen in beneficiaries ≥75 years of age. The overall and age-specific rates of Hispanic women or men changed minimally over time. Hip fracture incidence rates continued to decline in recent years among white Medicare beneficiaries. Further research is needed to understand mechanisms responsible for declining rates in some and not others, as hip fractures continue to be a major problem among the elderly.
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http://dx.doi.org/10.1002/jbmr.1684DOI Listing
November 2012

Physicians' explanations for apparent gaps in the quality of rheumatology care: results from the US Medicare Physician Quality Reporting System.

Arthritis Care Res (Hoboken) 2013 Feb;65(2):235-43

University of Alabama at Birmingham, AL 35294, USA.

Objective: The metrics used to assess quality of care and pay for performance in rheumatology are increasingly important. The Centers for Medicare and Medicaid Services established the Physician Quality Reporting System (PQRS) to allow physicians to report performance measures for many conditions, including osteoporosis and rheumatoid arthritis (RA). We described the frequency and nature of physician-reported reasons why recommended care for individual osteoporosis and RA patients was not provided.

Methods: Using national data on Medicare fee-for-service beneficiaries (2007-2009), we identified health care providers reporting on quality of care for any of 3 osteoporosis or 3 RA measures. PQRS reason codes allowed physicians to submit explanations why recommended care was not given.

Results: In 2009, 1,775 physicians reported on ≥1 osteoporosis PQRS measure and 630 physicians reported on ≥1 RA measure. For the older women whose physician reported on lifetime dual x-ray absorptiometry screening at least once since the age of 60 years via PQRS, 76% received such screening. Among the patients with physician-diagnosed osteoporosis reported via PQRS, 82% received prescription osteoporosis medication in the preceding year. For RA medication use reported via PQRS, 89% of patients received a disease-modifying antirheumatic drug or a biologic agent. For the remaining 11-24% of osteoporosis and RA patients, physicians reported medical, patient, system, or other reasons why care was considered but not provided.

Conclusion: A substantial fraction of Medicare enrollees who did not receive recommended osteoporosis or RA care had physician-documented reasons for why care was not provided. For Medicare and other health plans that implement penalties for apparent nonperformance or delivery of suboptimal care, it will be important to allow physicians to provide reasons that care was considered medically inappropriate, refused, or otherwise not feasible.
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http://dx.doi.org/10.1002/acr.21713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3414685PMC
February 2013

Did copayment changes reduce health service utilization among CHIP enrollees? Evidence from Alabama.

Health Serv Res 2012 Aug 21;47(4):1603-20. Epub 2012 Feb 21.

Lister Hill Center for Health Policy, and Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, AL, USA.

Objective: To explore whether health care utilization changed among enrollees in Alabama's CHIP program, ALL Kids, following copayment increases at the beginning of fiscal year 2004.

Data Sources: Data on all ALL Kids enrollees over 1999-2009 are obtained from claims files and the state's administrative database.

Study Design: We use pooled month-level data for all enrollees and conduct covariate-adjusted segmented regression models. Health services considered are inpatient care, emergency department (ED) visits, brand-name prescription drugs, generic prescription drugs, physician office visits and outpatient-services, ambulance services, allergy treatments, and non-preventive dental services. Physician well-visits, preventive dental services, and service use by Native-Americans--which saw no copayment increases--serve as counterfactuals.

Principal Findings: There are significant declines in utilization for inpatient care, physician visits, brand-name medications, and ED visits following the copayment increases. By and large, utilization did not decline, or declined only temporarily, for those services and for those enrollees that who not subject to increased copayments.

Conclusions: Copayment increases reduced utilization of many health services among ALL Kids enrollees. Concerns remain regarding the long-term health consequences to low-income children of copayment-induced reductions in health care utilization.
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http://dx.doi.org/10.1111/j.1475-6773.2012.01384.xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401401PMC
August 2012

The effects of premium changes on ALL Kids, Alabama's CHIP program.

Medicare Medicaid Res Rev 2012 8;2(3). Epub 2012 Mar 8.

University of Alabama at Birmingham.

Objective: Describe the trends in enrollment and renewal in the Alabama Children's Health Insurance Plan (CHIP), ALL Kids, since its creation in 1998, and to estimate the effect that an annual premium increase, along with coincident increases in service copays, had on the decision to renew participation.

Background: Unlike many other CHIP programs, ALL Kids is a standalone program that provides year long enrollment and contracts with the state's Blue Cross and Blue Shield program for its network of providers and its provider fee structure. In October 2003 premiums for individual coverage were increased by $50 per year and copays by $1 to $3 per visit.

Population Studied: This study is based upon a sample of 569,650 person-year observations of 230,255 children enrolled in the ALL Kids program between 1999 and 2009.

Study Design: The study models enrollment as a time series of cross section renewal decisions and specifies a series of linear probability regression models to estimate the effect of changes in the premium shift on the decision to renew. A second analysis includes interaction effects of the premiums shift with demographics, health status, income and previous enrollment to estimate differential response across subgroups.

Principal Findings: The increases in premiums and copays are estimated to have reduced program renewals by 6.1 to 8.3 percent depending upon how much time one allows for families to renew. Families with a child who has a chronic condition were more likely to renew coverage. However, those with chronic conditions, African-Americans and those with lower family incomes were more price-sensitive.

Conclusions: An increase in annual premiums and visit copays had a modest impact on program reenrollment with effects comparable to those found in Florida, New Hampshire, Kansas and Arizona, but smaller than those in Kentucky and Georgia.
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http://dx.doi.org/10.5600/mmrr.002.03.a01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4006389PMC
September 2015

Evaluating comorbidity scores based on health service expenditures.

Medicare Medicaid Res Rev 2012 3;2(3). Epub 2012 Oct 3.

UAB-School of Public Health.

Objective: To describe the performance of Charlson Comorbidity Index (CCI) specifications among Medicare beneficiaries and subgroups.

Data Sources: Medicare data for beneficiaries covered by Parts A and B and not Medicare Advantage throughout 2007.

Study Design: We evaluated several CCI specifications, particularly a model using expenditures related to Charlson categories, to predict 1 year mortality.

Data Collection/extraction Methods: Data were obtained from the Chronic Condition Data Warehouse.

Principal Findings: The use of Charlson related expenditures did not result in improved mortality prediction. CCI models perform less well in population subgroups with higher underlying mortality risks based on age and chronic conditions.

Conclusions: Relatively simple models provide quite adequate discrimination compared to more sophisticated models. Our proposed and more sophisticated model, which added in expenditure information, did not perform as well as much more easily executed methods.
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http://dx.doi.org/10.5600/mmrr.002.03.a05DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4006378PMC
September 2015

Central DXA utilization shifts from office-based to hospital-based settings among medicare beneficiaries in the wake of reimbursement changes.

J Bone Miner Res 2012 Apr;27(4):858-64

Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL 35294, USA.

In the United States, Medicare gradually reduced payments for central dual-energy X-ray absorptiometry (DXA) performed at physician offices (or other nonhospital settings) from an average of $139 in 2006 to about $82 in 2007 and 2008 and $72 in 2009. Reimbursement for hospital outpatient DXA service was unchanged. We investigated the utilization of hip and spine (central) DXA in the Medicare population before and after the reduction. We identified individuals from the national 5% random sample of Medicare beneficiaries who were ≥65 years of age and enrolled in Medicare Parts A and B but not in a Medicare Advantage plan from 2002 through 2009. For each calendar year, we calculated the proportion of beneficiaries who submitted claims for DXA, the proportions of DXAs performed in hospitals and in physician offices and the number of physician office-based practices that discontinued or started to provide DXA services. From 2002 to 2006, the proportion of beneficiaries who had at least one central DXA increased from 7.9% to 9.6% at an annual increase of 0.4% and from 2006 to 2009, the annual increase dropped to 0.1%. The number of DXAs performed in physician offices dropped from 1,643,720 (69% of 2,363,500 total DXAs) in 2006 to 1,534,240 (66% of 2,338,240) in 2009. This decline was offset by an increase in the number of DXAs performed in hospitals, which increased from 719,780 (31%) in 2006 to 804,000 (34%) in 2009. Among physician office-based practices, more practices initiated than discontinued DXA service each year from 2002 to 2006. However, the trend was reversed since 2007 such that in 2009, 1876 practices discontinued and only 1394 initiated DXA service. The reduction in DXA reimbursement was associated with a decrease in the number of DXAs performed in physician offices and fewer physician offices that provided DXA services.
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http://dx.doi.org/10.1002/jbmr.1534DOI Listing
April 2012