Publications by authors named "Zachary Levin"

10 Publications

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Patient Portal Use, Perceptions of Electronic Health Record Value, and Self-Rated Primary Care Quality Among Older Adults: Cross-sectional Survey.

J Med Internet Res 2021 May 10;23(5):e22549. Epub 2021 May 10.

Department of Kinesiology and Community Health, University of Illinois at Urbana-Champaign, Urbana-Champaign, IL, United States.

Background: Older adults are increasingly accessing information and communicating using patient-facing portals available through their providers' electronic health record (EHR). Most theories of technology acceptance and use suggest that patients' overall satisfaction with care should be independent of their chosen level of portal engagement. However, achieving expected benefits of portal use depends on demonstrated support from providers to meet these expectations. This is especially true among older adults, who may require more guidance. However, little is known about whether misalignment of expectations around technology-facilitated care is associated with lower perceptions of care quality.

Objective: The aims of this study were to analyze whether older adults' assessment of primary care quality differs across levels of patient portal engagement and whether perceptions of how well their provider uses the EHR to support care moderates this relationship.

Methods: We conducted a cross-sectional survey analysis of 158 older adults over the age of 65 (average age 71.4 years) across Michigan using a 13-measure composite of self-assessed health care quality. Portal use was categorized as none, moderate (use of 1-3 functionalities), or extensive (use of 4-7 functionalities). EHR value perception was measured by asking respondents how they felt their doctor's EHR use improved the patient-provider relationship.

Results: Moderate portal users, compared to those who were extensive users, had lower estimated care quality (-0.214 on 4-point scale; P=.03). Differences between extensive portal users and nonportal users were not significant. Quality perception was only particularly low among moderate portal users with low EHR value perception; those with high EHR value perception rated quality similarly to other portal user groups.

Conclusions: Older adults who are moderate portal users are the least satisfied with their care, and the most sensitive to perceptions of how well their provider uses the EHR to support the relationship. Encouraging portal use without compromising perceptions of quality requires thinking beyond patient-focused education. Achieving value from use of patient-facing technologies with older adults is contingent upon matched organizational investments that support technology-enabled care delivery. Providers and staff need policies and practices that demonstrate technology adeptness. Older adults may need more tailored signaling and accommodation for technology to be maximally impactful.
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http://dx.doi.org/10.2196/22549DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8145092PMC
May 2021

Trends in Pediatric Hospitalizations for Coronavirus Disease 2019.

JAMA Pediatr 2021 04;175(4):415-417

Department of Finance, Medical Industry Leadership Institute, University of Minnesota Carlson School of Management, Minneapolis.

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http://dx.doi.org/10.1001/jamapediatrics.2020.5535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802004PMC
April 2021

New Allopathic Medical Schools Train Fewer Family Physicians Than Older Ones.

J Am Board Fam Med 2019 Sep-Oct;32(5):653-654

From the Christiana Care Health System, Wilmington, DE (BB); Robert Graham Center, Washington, DC (YJ, DBK, EW); University of Minnesota School of Public Health, Minneapolis, MN; American Board of Family Medicine, Lexington, KY (AB).

The first significant expansion of allopathic medical schools since the 1970s was anticipated to produce more physicians capable of addressing the nation's current and projected primary care shortages. However, our analysis of the early outputs of new allopathic medical schools suggests that these students were nearly 40% less likely to specialize in family medicine than existing schools.
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http://dx.doi.org/10.3122/jabfm.2019.05.190105DOI Listing
September 2020

Residency Program Characteristics and Individual Physician Practice Characteristics Associated With Family Physician Scope of Practice.

Acad Med 2019 10;94(10):1561-1566

A.J. Coutinho was, when this research occurred, a third-year family medicine resident, Santa Rosa Family Medicine Residency Program, Santa Rosa, California. Z. Levin was, when this research occurred, research assistant, Robert Graham Center, Washington, DC. S. Petterson is research director, Robert Graham Center, Washington, DC. R.L. Phillips Jr is executive director, Center for Professionalism and Value in Health Care, Washington, DC. L.E. Peterson is vice president of research, American Board of Family Medicine, Lexington, Kentucky.

Purpose: A family physician's ability to provide continuous, comprehensive care begins in residency. Previous studies show that patterns developed during residency may be imprinted upon physicians, guiding future practice. The objective was to determine family medicine residency characteristics associated with graduates' scope of practice (SCoP).

Method: The authors used (1) residency program data from the 2012 Accreditation Council for Graduate Medicine Education Accreditation Data System and (2) self-reported data supplied by family physicians when they registered for the first recertification examination with the American Board of Family Medicine (2013-2016)-7 to 10 years after completing residency. The authors used linear regression analyses to examine the relationship between individual physician SCoP (measured by the SCoP for primary care [SP4PC] score [scale of 0-30; low = small scope]) and individual, practice, and residency program characteristics.

Results: The authors sampled 8,261 physicians from 423 residencies. The average SP4PC score was 15.4 (standard deviation, 3.2). Models showed that SCoP broadened with increasing rurality. Physicians from unopposed (single) programs had higher SCoP (0.26 increase in SP4PC); those from major teaching hospitals had lower SCoP (0.18 decrease in SP4PC).

Conclusions: Residency program characteristics may influence family physicians' SCoP, although less than individual characteristics do. Broad SCoP may imply more comprehensive care, which is the foundation of a strong primary care system to increase quality, decrease cost, and reduce physician burnout. Some residency program characteristics can be altered so that programs graduate physicians with broader SCoP, thereby meeting patient needs and improving the health system.
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http://dx.doi.org/10.1097/ACM.0000000000002838DOI Listing
October 2019

Practice Intentions of Family Physicians Trained in Teaching Health Centers: The Value of Community-Based Training.

J Am Board Fam Med 2019 Mar-Apr;32(2):134-135

From The Robert Graham Center, Washington, DC (ZL, AB); West Side Community Health Services, Saint Paul, MN (PM); The American Board of Family Medicine, Lexington, KY (LP); Department of Family and Community Medicine, University of Kentucky, Lexington, KY (LP); Dartmouth College, Hanover, NH (AH).

Family medicine residents who graduate from Federally Qualified Health Center-aligned Teaching Health Center (THC) training residencies are nearly twice as likely to pursue employment in safety-net settings compared with non-THC graduates. This trend has been consistent over the past few years, suggesting that the program is fulfilling its mission to strengthen primary care in underserved settings.
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http://dx.doi.org/10.3122/jabfm.2019.02.180292DOI Listing
April 2020

Comparing Spending on Medical Care in the United States and Other Countries.

JAMA 2018 08;320(8):839

The Robert Graham Center, Washington, DC.

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http://dx.doi.org/10.1001/jama.2018.8004DOI Listing
August 2018

Contrasting Effectiveness and Cost-Effectiveness of Colorectal Cancer Screening Under Commercial Insurance vs. Medicare.

Am J Gastroenterol 2018 12 15;113(12):1836-1847. Epub 2018 Jun 15.

Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA. Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA. Predictive Health, Paradise Valley, AZ, USA. Department of Family, Community and Preventive Medicine, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA. Department of Health Research and Policy, Stanford University School of Medicine, Stanford, CA, USA. National Bureau of Economic Research, Cambridge, MA, USA.

Objectives: Most cost-effectiveness analyses of colorectal cancer (CRC) screening assume Medicare payment rates and a lifetime horizon. Our aims were to examine the implications of differential payment levels and time horizons for commercial insurers vs. Medicare on the cost-effectiveness of CRC screening.

Methods: We used our validated Markov cohort simulation of CRC screening in the average risk US population to examine CRC screening at ages 50-64 under commercial insurance, and at ages 65-80 under Medicare, using a health-care sector perspective. Model outcomes included discounted quality-adjusted life-years (QALYs) and costs per person, and incremental cost/QALY gained.

Results: Lifetime costs/person were 20-44% higher when assuming commercial payment rates rather than Medicare rates for people under 65. Most of the substantial clinical benefit of screening at ages 50-64 was realized at ages ≥65. For commercial payers with a time horizon of ages 50-64, fecal occult blood testing (FOBT) and fecal immunochemical testing (FIT) were cost-effective (<$61,000/QALY gained), but colonoscopy was costly (>$185,000/QALY gained). Medicare experienced substantial clinical benefits and cost-savings from screening done at ages <65, even if screening was not continued. Among those previously screened, continuing FOBT and FIT under Medicare was cost-saving and continuing colonoscopy was highly cost-effective (<$30,000/QALY gained), and initiating any screening in those previously unscreened was highly effective and cost-saving.

Conclusions: Modeling suggests that CRC screening is highly cost-effective over a lifetime even when considering higher payment rates by commercial payers vs. Medicare. Screening may appear relatively costly for commercial payers if only a time horizon of ages 50-64 is considered, but it is predicted to yield substantial clinical and economic benefits that accrue primarily at ages ≥65 under Medicare.
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http://dx.doi.org/10.1038/s41395-018-0106-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6768591PMC
December 2018

Physician practice competition and prices paid by private insurers for office visits.

JAMA 2014 Oct 22-29;312(16):1653-62

Stanford University School of Medicine, Stanford, California.

Importance: Physician practice consolidation could promote higher-quality care but may also create greater economic market power that could lead to higher prices for physician services.

Objective: To assess the relationship between physician competition and prices paid by private preferred provider organizations (PPOs) for 10 types of office visits in 10 prominent specialties.

Design And Setting: Retrospective study in 1058 US counties in urbanized areas, representing all 50 states, examining the relationship between measured physician competition and prices paid for office visits in 2010 and the relationship between changes in competition and prices between 2003 and 2010, using regression analysis to control for possible confounding factors.

Exposures: Variation in the mean Hirschman-Herfindahl Index (HHI) of physician practices within a county by specialty (HHIs range from 0, representing maximally competitive markets, to 10,000 in markets served by a single [monopoly] practice).

Main Outcomes And Measures: Mean price paid by county to physicians in each specialty by private PPOs for intermediate office visits with established patients (Current Procedural Terminology [CPT] code 99213) and a price index measuring the county-weighted mean price for 10 types of office visits with new and established patients (CPT codes 99201-99205, 99211-99215) relative to national mean prices.

Results: In 2010, across all specialties studied, HHIs were 3 to 4 times higher in the 90th-percentile county than the 10th-percentile county (eg, for family practice: 10th percentile HHI = 1023 and 90th percentile HHI = 3629). Depending on specialty, mean price for a CPT code 99213 visit was between $70 and $75. After adjustment for potential confounders, depending on specialty, prices at the 90th-percentile HHI were between $5.85 (orthopedics; 95% CI, $3.46-$8.24) and $11.67 (internal medicine; 95% CI, $9.13-$14.21) higher than at the 10th percentile. Including all types of office visits, price indexes at the 90th-percentile HHI were 8.3% (orthopedics; 95% CI, 5.0%-11.6%) to 16.1% (internal medicine; 95% CI, 12.8%-19.5%) higher. Between 2003 and 2010, there were larger price increases in areas that were less competitive in 2002 than in initially more competitive areas.

Conclusions And Relevance: More competition among physicians is related to lower prices paid by private PPOs for office visits. These results may inform work on policies that influence practice competition.
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http://dx.doi.org/10.1001/jama.2014.10921DOI Listing
October 2014

Colorectal testing utilization and payments in a large cohort of commercially insured US adults.

Am J Gastroenterol 2014 Oct 1;109(10):1513-25. Epub 2014 Jul 1.

1] Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California, USA [2] National Bureau of Economic Research, Cambridge, Massachusetts, USA.

Objectives: Screening decreases colorectal cancer (CRC) mortality. The national press has scrutinized colonoscopy charges. Little systematic evidence exists on colorectal testing and payments among commercially insured persons. Our aim was to characterize outpatient colorectal testing utilization and payments among commercially insured US adults.

Methods: We conducted an observational cohort study of outpatient colorectal test utilization rates, indications, and payments among 21 million 18-64-year-old employees and dependants with noncapitated group health insurance provided by 160 self-insured employers in the 2009 Truven MarketScan Databases.

Results: Colonoscopy was the predominant colorectal test. Among 50-64-year olds, 12% underwent colonoscopy in 1 year. Most fecal tests and colonoscopies were associated with screening/surveillance indications. Testing rates were higher in women, and increased with age. Mean payments for fecal occult blood and immunochemical tests were $5 and $21, respectively. Colonoscopy payments varied between and within sites of service. Mean payments for diagnostic colonoscopy in an office, outpatient hospital facility, and ambulatory surgical center were $586 (s.d. $259), $1,400 (s.d. $681), and $1,074 (s.d. $549), respectively. Anesthesia and pathology services accompanied 35 and 52% of colonoscopies, with mean payments of $494 (s.d. $354) and $272 (s.d. $284), respectively. Mean payments for the most prevalent colonoscopy codes were 1.4- to 1.9-fold the average Medicare payments.

Conclusions: Most outpatient colorectal testing among commercially insured adults was associated with screening or surveillance. Payments varied widely across sites of service, and payments for anesthesia and pathology services contributed substantially to total payments. Cost-effectiveness analyses of CRC screening have relied on Medicare payments as proxies for costs, but cost-effectiveness may differ when analyzed from the perspectives of Medicare or commercial insurers.
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http://dx.doi.org/10.1038/ajg.2014.64DOI Listing
October 2014
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