Inquiry : a journal of medical care organization, provision and financing
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Hospital capital investment is important for acquiring and maintaining technology and equipment needed to provide health care. Reduction in capital investment by a hospital has negative implications for patient outcomes. Most hospitals rely on debt and internal cash flow to fund capital investment. ⋯ I estimated the model with California Office of Statewide Health Planning and Development data and system generalized method of moments. Findings suggest that not-for-profit and public hospitals were liquidity constrained during the recession. Comparing the changes in hospital capital investment between 2006 and 2009 showed that hospitals used cash flow to increase capital investment by $2.45 million, other things equal.
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Overprescribing of antibiotics for acute respiratory infections (ARIs) is common. Our objective was to develop and validate a vignette-based method to estimate clinician ARI antibiotic prescribing. We surveyed physicians (n = 78) and retail clinic clinicians (n = 109) between January and September 2013. ⋯ Responses to 3 vignettes partitioned clinicians into 4 groups with chart-based comprehensive ARI management rates of 61% (n = 121), 50% (n = 47), 31% (n = 12), and 22% (n = 7). Responses to 3 clinical vignettes can identify clinicians with relatively poor quality ARI antibiotic prescribing. Vignettes may be a mechanism to target clinicians for quality improvement efforts.
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The Affordable Care Act (ACA) included financial and regulatory incentives and goals for states to bolster their health insurance rate review programs, increase their anticipated loss ratio requirements, expand Medicaid, and establish state-based exchanges. We grouped states by political party control and compared their reactions across these policy goals. To identify changes in states' rate review programs and anticipated loss ratio requirements in the individual and small group markets since the ACA's enactment, we conducted legal research and contacted each state's insurance regulator. ⋯ This finding is likely the result of the relatively low administrative burden associated with reviewing health insurance rates and the fact that doing so prevents federal intervention in rate review. However, Republican-controlled states were less likely than non-Republican-controlled states to increase their anticipated loss ratio requirements to align with the federal retrospective medical loss ratio requirement, expand Medicaid, and establish state-based exchanges, because of their general opposition to the ACA. We conclude that federal incentives for states to strengthen their health insurance rate review programs were more effective than the incentives for states to adopt other insurance-related policy goals of the ACA.
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For many surgeries and high-risk medical conditions, higher volume providers provide higher quality care. The impact of volume on more common medical conditions such as acute respiratory infections (ARIs) has not been examined. Using electronic health record data for adult ambulatory ARI visits, we divided primary care physicians into ARI volume quintiles. ⋯ Physicians with a higher volume of cases manage ARI very differently and are more likely to prescribe antibiotics. When they prescribe an antibiotic for a diagnosis for which an antibiotic may be indicated, they are less likely to prescribe guideline-concordant antibiotics. Given that high-volume physicians account for the bulk of ARI visits, efforts targeting this group are likely to yield important population effects in improving quality.
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The Affordable Care Act (ACA) expanded Medicaid eligibility to adults with incomes under 138% of the federal poverty level, leading to substantial reductions in uninsured rates among low-income adults. Despite large gains in coverage, studies suggest that Latinos may be less likely than other racial/ethnic groups to apply and enroll in health insurance, and they remain the group with the highest uninsured rate in the United States. We explore two potential factors related to racial/ethnic differences in ACA enrollment-awareness of the law and receipt of application assistance such as navigator services. ⋯ Higher education was the strongest positive predictor of ACA awareness. In contrast, Latinos were much more likely to receive assistance from navigators or social workers when applying, relative to other racial/ethnic groups. Taken together, these results highlight the importance of ACA outreach efforts to increase awareness among low-income and less educated populations, two groups that are overrepresented in the Latino population, to close existing disparities in coverage.