Bio

Academic Appointments


Administrative Appointments


  • Director of the Scholarly Concentration Program, Stanford University (2007 - Present)
  • Chief of Health Services Research, Department of Health Research and Policy (2001 - Present)
  • Research Associate, National Bureau of Economic Research (2002 - Present)
  • Fellow, Stanford Center for Health Policy (2000 - Present)

Honors & Awards


  • ASHE Medal, American Society of Health Economists (2008)
  • Alice S. Hersh Young Investigator Award, Academy for Health Services Research and Health Policy (2000)
  • NIHCM Research Award, National Institute for Health Care Management (1999)

Professional Education


  • PhD, Princeton University, Economics (1994)
  • MA, Princeton University, Economics (1994)

Research & Scholarship

Current Research and Scholarly Interests


Much of my current research examines the impacts of changing financial incentives, regulations, and organizational structures on health care provision and costs. One aspect of work in this area involves studying impacts of managed care and related insurance arrangements on things like health care costs, the pricing of physician services, prices for health insurance, and the availability and utilization of medical technologies. Other work examines factors influencing the adoption and use of medical technologies more generally, including particular work on imaging equipment. I am also interested in a range of other questions about health care systems, physicians organizations, provider compensation, health care cost growth, and health care quality.

Publications

Journal Articles


  • Gaps in preoperative surveillance and rupture of abdominal aortic aneurysms among Medicare beneficiaries. Journal of vascular surgery Mell, M. W., Baker, L. C., Dalman, R. L., Hlatky, M. A. 2014; 59 (3): 583-588

    Abstract

    Screening and surveillance are recommended in the management of small abdominal aortic aneurysms (AAAs). Gaps in surveillance after early diagnosis may lead to unrecognized AAA growth, rupture, and death. This study investigates the frequency and predictors of rupture of previously diagnosed AAAs.Data were extracted from Medicare claims for patients who underwent AAA repair between 2006 and 2009. Relevant preoperative abdominal imaging exams were tabulated up to 5 years prior to AAA repair. Repair for ruptured AAAs was compared with repair for intact AAAs for those with an early diagnosis of an AAA, defined as having received imaging at least 6 months prior to surgery. Gaps in surveillance were defined as no image within 1 year of surgery or no imaging for more than a 2-year time span after the initial image. Logistic regression was used to examine independent predictors of rupture despite early diagnosis.A total of 9298 patients had repair after early diagnosis, with rupture occurring in 441 (4.7%). Those with ruptured AAAs were older (80.2 ± 6.9 vs 77.6 ± 6.2 years; P < .001), received fewer images prior to repair (5.7 ± 4.1 vs 6.5 ± 3.5; P = .001), were less likely to be treated in a high-volume hospital (45.4% vs 59.5%; P < .001), and were more likely to have had gaps in surveillance (47.4% vs 11.8%; P < .001) compared with those receiving repair for intact AAAs. After adjusting for medical comorbidities, gaps in surveillance remained the largest predictor of rupture in a multivariate analysis (odds ratio, 5.82; 95% confidence interval, 4.64-7.31; P < .001).Despite previous diagnosis of AAA, many patients experience rupture prior to repair. Improved mechanisms for surveillance are needed to prevent rupture and ensure timely repair for patients with AAAs.

    View details for DOI 10.1016/j.jvs.2013.09.032

    View details for PubMedID 24246537

  • Why Are Medicare and Commercial Insurance Spending Weakly Correlated? AMERICAN JOURNAL OF MANAGED CARE Baker, L. C., Bundorf, M. K., Kessler, D. P. 2014; 20 (1): E8-E14
  • Limitations of using same-hospital readmission metrics INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE Davies, S. M., Saynina, O., McDonald, K. M., Baker, L. C. 2013; 25 (6): 633-639

    Abstract

    To quantify the limitations associated with restricting readmission metrics to same-hospital only readmission.Using 2000-2009 California Office of Statewide Health Planning and Development Patient Discharge Data Nonpublic file, we identified the proportion of 7-, 15- and 30-day readmissions occurring to the same hospital as the initial admission using All-cause Readmission (ACR) and 3M Corporation Potentially Preventable Readmissions (PPR) Metric. We examined the correlation between performance using same and different hospital readmission, the percent of hospitals remaining in the extreme deciles when utilizing different metrics, agreement in identifying outliers and differences in longitudinal performance. Using logistic regression, we examined the factors associated with admission to the same hospital.68% of 30-day ACR and 70% of 30-day PPR occurred to the same hospital. Abdominopelvic procedures had higher proportions of same-hospital readmissions (87.4-88.9%), cardiac surgery had lower (72.5-74.9%) and medical DRGs were lower than surgical DRGs (67.1 vs. 71.1%). Correlation and agreement in identifying high- and low-performing hospitals was weak to moderate, except for 7-day metrics where agreement was stronger (r = 0.23-0.80, Kappa = 0.38-0.76). Agreement for within-hospital significant (P < 0.05) longitudinal change was weak (Kappa = 0.05-0.11). Beyond all patient refined-diagnostic related groups, payer was the most predictive factor with Medicare and MediCal patients having a higher likelihood of same-hospital readmission (OR 1.62, 1.73).Same-hospital readmission metrics are limited for all tested applications. Caution should be used when conducting research, quality improvement or comparative applications that do not account for readmissions to other hospitals.

    View details for DOI 10.1093/intqhc/mzt068

    View details for Web of Science ID 000327791600003

    View details for PubMedID 24167061

  • Implications of Metric Choice for Common Applications of Readmission Metrics HEALTH SERVICES RESEARCH Davies, S., Saynina, O., Schultz, E., McDonald, K. M., Baker, L. C. 2013; 48 (6): 1978-1995

    Abstract

    OBJECTIVE: To quantify the differential impact on hospital performance of three readmission metrics: all-cause readmission (ACR), 3M Potential Preventable Readmission (PPR), and Centers for Medicare and Medicaid 30-day readmission (CMS). DATA SOURCES: 2000-2009 California Office of Statewide Health Planning and Development Patient Discharge Data Nonpublic file. STUDY DESIGN: We calculated 30-day readmission rates using three metrics, for three disease groups: heart failure (HF), acute myocardial infarction (AMI), and pneumonia. Using each metric, we calculated the absolute change and correlation between performance; the percent of hospitals remaining in extreme deciles and level of agreement; and differences in longitudinal performance. PRINCIPAL FINDINGS: Average hospital rates for HF patients and the CMS metric were generally higher than for other conditions and metrics. Correlations between the ACR and CMS metrics were highest (r = 0.67-0.84). Rates calculated using the PPR and either ACR or CMS metrics were moderately correlated (r = 0.50-0.67). Between 47 and 75 percent of hospitals in an extreme decile according to one metric remained when using a different metric. Correlations among metrics were modest when measuring hospital longitudinal change. CONCLUSIONS: Different approaches to computing readmissions can produce different hospital rankings and impact pay-for-performance. Careful consideration should be placed on readmission metric choice for these applications.

    View details for DOI 10.1111/1475-6773.12075

    View details for Web of Science ID 000327392300011

    View details for PubMedID 23742056

  • Private insurers' payments for routine physician office visits vary substantially across the United States. Health affairs Baker, L., Bundorf, M. K., Royalty, A. 2013; 32 (9): 1583-1590

    Abstract

    Anecdotal reports suggest that substantial variation exists in private insurers' payments for physician services, but systematic evidence is lacking. Using a retrospective analysis of insurance claims for routine office visits, consultations, and preventive visits from more than forty million physician claims in 2007, we examined variations in private payments to physicians and the extent to which variation is explained by patients' and physicians' characteristics and by geographic region. We found much variation in payments for these routine evaluation and management services. Physicians at the high end of the payment distribution were generally paid more than twice what physicians at the low end were paid for the same service. Little variation was explained by patients' age or sex, physicians' specialty, place of service, whether the physician was a "network provider," or type of plan, although about one-third of the variation was associated with the geographic area of the practice. Interventions that promote more price-consciousness on the part of patients could help reduce health care spending, but more data on the specific causes of price variation are needed to determine appropriate policy responses.

    View details for DOI 10.1377/hlthaff.2013.0309

    View details for PubMedID 24019363

  • Late diagnosis of abdominal aortic aneurysms substantiates underutilization of abdominal aortic aneurysm screening for Medicare beneficiaries. Journal of vascular surgery Mell, M. W., Hlatky, M. A., Shreibati, J. B., Dalman, R. L., Baker, L. C. 2013; 57 (6): 1519-1523 e1

    Abstract

    Abdominal aortic aneurysm (AAA) screening remains largely underutilized in the U.S., and it is likely that the proportion of patients with aneurysms requiring prompt treatment is much higher compared with well-screened populations. The goals of this study were to determine the proportion of AAAs that required prompt repair after diagnostic abdominal imaging for U.S. Medicare beneficiaries and to identify patient and hospital factors contributing to early vs late diagnosis of AAA.Data were extracted from Medicare claims records for patients at least 65 years old with complete coverage for 2 years who underwent intact AAA repair from 2006 to 2009. Preoperative ultrasound and computed tomography was tabulated from 2002 to repair. We defined early diagnosis of AAA as a patient with a time interval of greater than 6 months between the first imaging examination and the index procedure, and late diagnosis as patients who underwent the index procedure within 6 months of the first imaging examination.Of 17,626 patients who underwent AAA repair, 14,948 met inclusion criteria. Mean age was 77.5 ± 6.1 years. Early diagnosis was identified for 60.6% of patients receiving AAA repair, whereas 39.4% were repaired after a late diagnosis. Early diagnosis rates increased from 2006 to 2009 (59.8% to 63.4%; P < .0001) and were more common for intact repair compared with repair after rupture (62.9% vs 35.1%; P < .0001) and for women compared with men (66.3% vs 59.0%; P < .0001). On multivariate analysis, repair of intact vs ruptured AAAs (odds ratio, 3.1; 95% confidence interval, 2.7-3.6) and female sex (odds ratio, 1.4; 95% confidence interval, 1.3-1.5) remained the strongest predictors of surveillance. Although intact repairs were more likely to be diagnosed early, over one-third of patients undergoing repair for ruptured AAAs received diagnostic abdominal imaging greater than 6 months prior to surgery.Despite advances in screening practices, significant missed opportunities remain in the U.S. Medicare population for improving AAA care. It remains common for AAAs to be diagnosed when they are already at risk for rupture. In addition, a significant proportion of patients with early imaging rupture prior to repair. Our findings suggest that improved mechanisms for observational management are needed to ensure optimal preoperative care for patients with AAAs.

    View details for DOI 10.1016/j.jvs.2012.12.034

    View details for PubMedID 23414696

  • Impact of the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act on Abdominal Ultrasonography Use Among Medicare Beneficiaries ARCHIVES OF INTERNAL MEDICINE Shreibati, J. B., Baker, L. C., Hlatky, M. A., Mell, M. W. 2012; 172 (19): 1456-1462

    Abstract

    Since January 1, 2007, Medicare has covered abdominal aortic aneurysm (AAA) screening for new male enrollees with a history of smoking under the Screening Abdominal Aortic Aneurysms Very Efficiently (SAAAVE) Act. We examined the association between this program and abdominal ultrasonography for AAA screening, elective AAA repair, hospitalization for AAA rupture, and all-cause mortality.We used a 20% sample of traditional Medicare enrollees from 2004 to 2008 to identify 65-year-old men eligible for screening and 3 control groups not eligible for screening (70-year-old men, 76-year-old men, and 65-year-old women). We used logistic regression to examine the change in outcomes at 365 days for eligible vs ineligible beneficiaries before and after SAAAVE Act implementation, adjusting for comorbidities, state-level smoking prevalence, geographic variation, and time trends.Fewer than 3% of abdominal ultrasonography claims after 2007 were for SAAAVE-specific AAA screening. There was a significantly greater increase in abdominal ultrasonography use among SAAAVE-eligible beneficiaries (2.0 percentage points among 65-year-old men, from 7.6% in 2004 to 9.6% in 2008; 0.7 points [8.9% to 9.6%] among 70-year-old men; 0.7 points [10.8% to 11.5%] among 76-year-old men; and 0.9 points [7.5% to 8.4%] among 65-year-old women) (P < .001 for all comparisons with 65-year-old men). The SAAAVE Act was associated with increased use of abdominal ultrasonography in 65-year-old men compared with 70-year-old men (adjusted odds ratio [AOR], 1.15; 95% CI, 1.11-1.19) (P < .001), and this increased use remained even when SAAAVE-specific AAA screening was excluded (AOR, 1.12; 95% CI, 1.08-1.16) (P < .001). Implementation of the SAAAVE Act was not associated with changes in rates of AAA repair, AAA rupture, or all-cause mortality.The impact of the SAAAVE Act on AAA screening was modest and was based on abdominal ultrasonography use that it did not directly reimburse. The SAAAVE Act had no discernable effect on AAA rupture or all-cause morality.

    View details for DOI 10.1001/archinternmed.2012.4268

    View details for Web of Science ID 000310070200005

    View details for PubMedID 22987204

  • Exposure to Ionizing Radiation and Estimate of Secondary Cancers in the Era of High-Speed CT Scanning: Projections From the Medicare Population JOURNAL OF THE AMERICAN COLLEGE OF RADIOLOGY Meer, A. B., Basu, P. A., Baker, L. C., Atlas, S. W. 2012; 9 (4): 245-250

    Abstract

    The aims of this study were to analyze the distribution and amount of ionizing radiation delivered by CT scans in the modern era of high-speed CT and to estimate cancer risk in the elderly, the patient group most frequently imaged using CT scanning.A retrospective cohort study was conducted using Medicare claims spanning 8 years (1998-2005) to assess CT use. The data were analyzed in two 4-year cohorts, 1998 to 2001 (n = 5,267,230) and 2002 to 2005 (n = 5,555,345). The number and types of CT scans each patient received over the 4-year periods were analyzed to determine the percentage of patients exposed to threshold radiation of 50 to 100 mSv (defined as low) and >100 mSv (defined as high). The National Research Council's Biological Effects of Ionizing Radiation VII models were used to estimate the number of radiation-induced cancers.CT scans of the head were the most common examinations in both Medicare cohorts, but abdominal imaging delivered the greatest proportion (43% in the first cohort and 40% in the second cohort) of radiation. In the 1998 to 2001 cohort, 42% of Medicare patients underwent CT scans, with 2.2% and 0.5% receiving radiation doses in the low and high ranges, respectively. In the 2002 to 2005 cohort, 50% of Medicare patients received CT scans, with 4.2% and 1.2% receiving doses in the low and high ranges. In the two populations, 1,659 (0.03%) and 2,185 (0.04%) cancers related to ionizing radiation were estimated, respectively.Although radiation doses have been increasing along with the increasing reliance on CT scans for diagnosis and therapy, using conservative estimates with worst-case scenario methodology, the authors found that the risk for secondary cancers is low in older adults, the group subjected to the most frequent CT scanning. Trends showing increasing use, however, underscore the importance of monitoring CT utilization and its consequences.

    View details for DOI 10.1016/j.jacr.2011.12.007

    View details for Web of Science ID 000305449600010

    View details for PubMedID 22469374

  • Association of Coronary CT Angiography or Stress Testing With Subsequent Utilization and Spending Among Medicare Beneficiaries JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Shreibati, J. B., Baker, L. C., Hlatky, M. A. 2011; 306 (19): 2128-2136

    Abstract

    Coronary computed tomography angiography (CCTA) is a new noninvasive diagnostic test for coronary artery disease (CAD), but its association with subsequent clinical management has not been established.To compare utilization and spending associated with functional (stress testing) and anatomical (CCTA) noninvasive cardiac testing in a Medicare population.Retrospective, observational cohort study using claims data from a 20% random sample of 2005-2008 Medicare fee-for-service beneficiaries 66 years or older with no claims for CAD in the preceding year, who received nonemergent, noninvasive testing for CAD (n = 282,830).Cardiac catheterization, coronary revascularization, acute myocardial infarction, all-cause mortality, and total and CAD-related Medicare spending over 180 days of follow-up.Compared with stress myocardial perfusion scintigraphy (MPS), CCTA was associated with an increased likelihood of subsequent cardiac catheterization (22.9% vs 12.1%; adjusted odds ratio [AOR], 2.19 [95% CI, 2.08 to 2.32]; P < .001), percutaneous coronary intervention (7.8% vs 3.4%; AOR, 2.49 [2.28 to 2.72]; P < .001), and coronary artery bypass graft surgery (3.7% vs 1.3%; AOR, 3.00 [2.63 to 3.41]; P < .001). CCTA was also associated with higher total health care spending ($4200 [$3193 to $5267]; P < .001), which was almost entirely attributable to payments for any claims for CAD ($4007 [$3256 to $4835]; P < .001). Compared with MPS, there was lower associated spending with stress echocardiography (-$4981 [-$4991 to -$4969]; P < .001) and exercise electrocardiography (-$7449 [-$7452 to -$7444]; P < .001). At 180 days, CCTA was associated with a similar likelihood of all-cause mortality (1.05% vs 1.28%; AOR, 1.11 [0.88 to 1.38]; P = .32) and a slightly lower likelihood of hospitalization for acute myocardial infarction (0.19% vs 0.43%; AOR, 0.60 [0.37 to 0.98]; P = .04).Medicare beneficiaries who underwent CCTA in a nonacute setting were more likely to undergo subsequent invasive cardiac procedures and have higher CAD-related spending than patients who underwent stress testing.

    View details for Web of Science ID 000297013000019

    View details for PubMedID 22089720

  • The Relationship between Low Back Magnetic Resonance Imaging, Surgery, and Spending: Impact of Physician Self-Referral Status HEALTH SERVICES RESEARCH Shreibati, J. B., Baker, L. C. 2011; 46 (5): 1362-1381

    Abstract

    To examine the relationship between use of magnetic resonance imaging (MRI) and receipt of surgery for patients with low back pain.Medicare claims for a 20 percent sample of beneficiaries from 1998 to 2005.We identify nonradiologist physicians who appear to begin self-referral arrangements for MRI between 1999 and 2005, as well as their patients who have a new episode of low back pain care during this time. We focus on regression models that identify the relationship between receipt of MRI and subsequent use of back surgery and health care spending. Receipt of MRI may be endogenous, so we use physician acquisition of MRI as an instrument for receipt of MRI. The models adjust for demographic and socioeconomic covariates as well as month, year, and physician fixed effects.We include traditional, fee-for-service Medicare beneficiaries with a visit to an orthopedist or primary care physician for nonspecific low back pain, and no claims for low back pain in the year prior.In the first stage, acquisition of MRI equipment is a strongly correlated with patients receiving MRI scans. Among patients of orthopedists, receipt of an MRI scan increases the probability of having surgery by 34 percentage points. Among patients of primary care physicians, receiving a low back MRI is not statistically significantly associated with subsequent surgery receipt.Orthopedists and primary care physicians who begin billing for the performance of MRI procedures, rather than referring patients outside of their practice for MRI, appear to change their practice patterns such that they use more MRI for their patients with low back pain. These increases in MRI use appear to lead to increases in low back surgery receipt and health care spending among patients of orthopedic surgeons, but not of primary care physicians.

    View details for DOI 10.1111/j.1475-6773.2011.01265.x

    View details for Web of Science ID 000294739800002

    View details for PubMedID 21517834

  • Integrated Telehealth And Care Management Program For Medicare Beneficiaries With Chronic Disease Linked To Savings HEALTH AFFAIRS Baker, L. C., Johnson, S. J., Macaulay, D., Birnbaum, H. 2011; 30 (9): 1689-1697

    Abstract

    Treatment of chronically ill people constitutes nearly four-fifths of US health care spending, but it is hampered by a fragmented delivery system and discontinuities of care. We examined the impact of a care coordination approach called the Health Buddy Program, which integrates a telehealth tool with care management for chronically ill Medicare beneficiaries. We evaluated the program's impact on spending for patients of two clinics in the US Northwest who were exposed to the intervention, and we compared their experience with that of matched controls. We found significant savings among patients who used the Health Buddy telehealth program, which was associated with spending reductions of approximately 7.7-13.3 percent ($312-$542) per person per quarter. These results suggest that carefully designed and implemented care management and telehealth programs can help reduce health care spending and that such programs merit continued attention by Medicare. Meanwhile, mortality differences in the treatment and control groups suggest that the intervention may have produced noticeable changes in health outcomes, but we leave it to future research to explore these effects fully.

    View details for DOI 10.1377/hlthaff.2011.0216

    View details for Web of Science ID 000294670400011

    View details for PubMedID 21900660

  • Payment Reform HEALTH SERVICES RESEARCH Fraser, I., Encinosa, W., Baker, L. 2010; 45 (6): 1847-1853
  • Assessing Cost-Effectiveness And Value As Imaging Grows: The Case Of Carotid Artery CT HEALTH AFFAIRS Baker, L. C., Afendulis, C. C., Atlas, S. W. 2010; 29 (12): 2260-2267

    Abstract

    Computed tomographic (CT) angiography is an imaging test that is safer and less expensive than an older test in diagnosing narrowing of the carotid arteries-the most common cause of stroke in US adults. Our examination of Medicare data between 2001 and 2005 found that about 20 percent of the time this test was used, it substituted for the older test. The majority of new use, however, constituted "incremental" use, in cases where patients previously would not have received any test. We found no evidence that the growth in CT angiography led to more patients' being treated for carotid artery disease. The value of the test as a substitute for the older procedure may be enough to still justify expanding use. Tracking the uses of emerging technologies to encourage efficient use is essential, but it can be challenging in cases where new tools have multiple uses and information is incomplete.

    View details for DOI 10.1377/hlthaff.2010.0046

    View details for Web of Science ID 000285016000017

    View details for PubMedID 21134928

  • Acquisition Of MRI Equipment By Doctors Drives Up Imaging Use And Spending HEALTH AFFAIRS Baker, L. C. 2010; 29 (12): 2252-2259

    Abstract

    Some orthopedists and neurologists acquired their own magnetic resonance imaging (MRI) equipment during the early 2000s. This paper examines changes in imaging use and in overall spending by patients of orthopedists and neurologists who began billing for MRI scans between 1999 and 2005. Results show that physicians ordered substantially more scans once they began billing for MRI. For example, after orthopedists began billing for MRI, the number of MRI procedures used within thirty days of a first visit increased by about 38 percent. Not only did MRI spending increase for their patients, but spending for other aspects of care rose as well. Attention should be paid to ensuring that advanced medical equipment acquired in physician practices is used appropriately.

    View details for DOI 10.1377/hlthaff.2009.1099

    View details for Web of Science ID 000285016000016

    View details for PubMedID 21134927

  • HMO Coverage Reduces Variations In The Use Of Health Care Among Patients Under Age Sixty-Five HEALTH AFFAIRS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2010; 29 (11): 2068-2074

    Abstract

    Variation in the use of hospital and physician services among Medicare beneficiaries is well documented. However, less is known about the younger, commercially insured population. Using data from the Community Tracking Study to investigate this issue, we found significant variation in the use of both inpatient and outpatient services across twelve metropolitan areas. HMO insurance reduces, but does not eliminate, the extent of this variation. Our results suggest that health plan spending to better organize delivery systems and manage care may be efficient, and regulations that arbitrarily cap plans' spending on administration, such as minimum medical loss ratios, could undermine efforts to achieve better value in health care.

    View details for DOI 10.1377/hlthaff.2009.0810

    View details for Web of Science ID 000283668700016

    View details for PubMedID 21041750

  • The contribution of health plans and provider organizations to variations in measured plan quality INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE Baker, L. C., Hopkins, D. S. 2010; 22 (3): 210-218

    Abstract

    Some argue that health plans have minimal impacts on quality of care and that quality data collection should focus only on physician organizations. We investigate the relative impact of physician organizations and health plans on quality measures.Statistical analysis of data on 9 Healthcare Effectiveness Data and Information Set (HEDIS) measures from 6 health plans and 159 provider organizations. We use regression analyses to examine the amount of variation in HEDIS measures accounted for by variation across provider organizations, and whether accounting for health plans explains additional variation. We also examine whether accounting for provider organizations explains away variation in HEDIS scores across health plans.Six health plans and 159 contracted provider groups in California.Nine HEDIS scores.For all nine measures studied, variation across provider organizations explains much of the HEDIS score variation. But, after accounting for variation across providers, variation across plans statistically significantly explains additional variation. We also find statistically significant differences across health plans in HEDIS rates that are not substantially affected when we control for the provider organization that cared for the patient.On their face, these results suggest that plans can influence quality independent of the selection of physician organizations with which they contract, in contrast to hypotheses that plans are 'too far' from patients to have an influence. Continued attention to collecting plan-level data is warranted. Further work should address other possible sources of variations in HEDIS scores, such as variability in plan administrative databases.

    View details for DOI 10.1093/intqhc/mzq011

    View details for Web of Science ID 000277734100008

    View details for PubMedID 20299493

  • Magnetic Resonance Imaging And Low Back Pain Care For Medicare Patients HEALTH AFFAIRS Baras, J. D., Baker, L. C. 2009; 28 (6): W1133-W1140

    Abstract

    Magnetic resonance imaging (MRI) is a technology frequently used to evaluate low back pain, despite evidence that challenges the usefulness of routine MRI and the surgical interventions it may trigger. We analyze the relationship between MRI supply and care for fee-for-service Medicare patients with low back pain. We find that increases in MRI supply are related to higher use of both low back MRI and surgery. This is worrisome, and careful attention should be paid to assessing the outcomes for patients.

    View details for DOI 10.1377/hlthaff.28.6.w1133

    View details for Web of Science ID 000271622300059

    View details for PubMedID 19828486

  • Identifying organizational cultures that promote patient safety HEALTH CARE MANAGEMENT REVIEW Singer, S. J., Falwell, A., Gaba, D. M., Meterko, M., Rosen, A., Hartmann, C. W., Baker, L. 2009; 34 (4): 300-311

    Abstract

    Safety climate refers to shared perceptions of what an organization is like with regard to safety, whereas safety culture refers to employees' fundamental ideology and orientation and explains why safety is pursued in the manner exhibited within a particular organization. Although research has sought to identify opportunities for improving safety outcomes by studying patterns of variation in safety climate, few empirical studies have examined the impact of organizational characteristics such as culture on hospital safety climate.This study explored how aspects of general organizational culture relate to hospital patient safety climate.In a stratified sample of 92 U.S. hospitals, we sampled 100% of senior managers and physicians and 10% of other hospital workers. The Patient Safety Climate in Healthcare Organizations and the Zammuto and Krakower organizational culture surveys measured safety climate and group, entrepreneurial, hierarchical, and production orientation of hospitals' culture, respectively. We administered safety climate surveys to 18,361 personnel and organizational culture surveys to a 5,894 random subsample between March 2004 and May 2005. Secondary data came from the 2004 American Hospital Association Annual Hospital Survey and Dun & Bradstreet. Hierarchical linear regressions assessed relationships between organizational culture and safety climate measures.Aspects of general organizational culture were strongly related to safety climate. A higher level of group culture correlated with a higher level of safety climate, but more hierarchical culture was associated with lower safety climate. Aspects of organizational culture accounted for more than threefold improvement in measures of model fit compared with models with controls alone. A mix of culture types, emphasizing group culture, seemed optimal for safety climate.Safety climate and organizational culture are positively related. Results support strategies that promote group orientation and reduced hierarchy, including use of multidisciplinary team training, continuous quality improvement tools, and human resource practices and policies.

    View details for Web of Science ID 000270852700002

    View details for PubMedID 19858915

  • Health Care Cost Growth Among The Privately Insured HEALTH AFFAIRS Bundorf, M. K., Royalty, A., Baker, L. C. 2009; 28 (5): 1294-1304

    Abstract

    Controlling health care cost growth remains a high priority for policymakers and private decisionmakers, yet little is known about sources of this growth. We examined spending growth among the privately insured between 2001 and 2006, separating the contributions of price changes from those driven by consumption. Most spending growth was driven by outpatient services and pharmaceuticals, with growth in quantities explaining the entire growth in outpatient spending and about three-quarters of growth in spending on prescription drugs. Rising prices played a greater role in growth in spending for brand-name than for generic drugs. These findings can inform efforts to control private- sector spending.

    View details for DOI 10.1377/hlthaff.28.5.1294

    View details for Web of Science ID 000269646100008

    View details for PubMedID 19738244

  • Relationship of Safety Climate and Safety Performance in Hospitals HEALTH SERVICES RESEARCH Singer, S., Lin, S., Falwell, A., Gaba, D., Baker, L. 2009; 44 (2): 399-421

    Abstract

    To examine the relationship between measures of hospital safety climate and hospital performance on selected Patient Safety Indicators (PSIs).Primary data from a 2004 survey of hospital personnel. Secondary data from the 2005 Medicare Provider Analysis and Review File and 2004 American Hospital Association's Annual Survey of Hospitals.A cross-sectional study of 91 hospitals.Negative binomial regressions used an unweighted, risk-adjusted PSI composite as dependent variable and safety climate scores and controls as independent variables. Some specifications included interpersonal, work unit, and organizational safety climate dimensions. Others included separate measures for senior managers and frontline personnel's safety climate perceptions.Hospitals with better safety climate overall had lower relative incidence of PSIs, as did hospitals with better scores on safety climate dimensions measuring interpersonal beliefs regarding shame and blame. Frontline personnel's perceptions of better safety climate predicted lower risk of experiencing PSIs, but senior manager perceptions did not.The results link hospital safety climate to indicators of potential safety events. Some aspects of safety climate are more closely related to safety events than others. Perceptions about safety climate among some groups, such as frontline staff, are more closely related than perceptions in other groups.

    View details for DOI 10.1111/j.1475-6773.2008.00918.x

    View details for Web of Science ID 000264164400006

    View details for PubMedID 19178583

  • Are American Physicians more Satisfied? - Results from an International Study of Physicians in University Hospitals GESUNDHEITSWESEN Janus, K., Amelung, V. E., Baker, L. C., GAITANIDES, M., Rundall, T. G., Schwartz, F. W. 2009; 71 (4): 210-217

    Abstract

    Understanding the factors that affect physicians' job satisfaction is important not only to physicians themselves, but also to patients, health system managers, and policy makers. Physicians represent the crucial resource in health-care delivery. In order to enhance efficiency and quality in health care, it is indispensable to analyse and consider the motivators of physicians. Physician job satisfaction has significant effects on productivity, the quality of care, and the supply of physicians. The purpose of our study was to assess the associations between work-related monetary and non-monetary factors and physicians' work satisfaction as perceived by similar groups of physicians practicing at academic medical centres in Germany and the U.S.A., two countries that, in spite of differing health-care systems, simultaneously experience problems in maintaining their physician workforce. We used descriptive statistics, factor and correlation analyses to evaluate physicians' responses to a self-administered questionnaire. Our study revealed that overall German physicians were less satisfied than U.S. physicians. With respect to particular work-related predictors of job satisfaction we found that similar factors contributed to job satisfaction in both countries. To improve physicians' satisfaction with working conditions, our results call for the implementation of policies that reduce the time burden on physicians to allow more time for interaction with patients and colleagues, increase monetary incentives, and enhance physicians' participation in the development of care management processes and in managerial decisions that affect patient care.

    View details for DOI 10.1055/s-0028-1119367

    View details for Web of Science ID 000265711300003

    View details for PubMedID 19288428

  • Patient Safety Climate in 92 US Hospitals Differences by Work Area and Discipline MEDICAL CARE Singer, S. J., Gaba, D. M., Falwell, A., Lin, S., Hayes, J., Baker, L. 2009; 47 (1): 23-31

    Abstract

    Concern about patient safety has promoted efforts to improve safety climate. A better understanding of how patient safety climate differs among distinct work areas and disciplines in hospitals would facilitate the design and implementation of interventions.To understand workers' perceptions of safety climate and ways in which climate varies among hospitals and by work area and discipline.We administered the Patient Safety Climate in Healthcare Organizations survey in 2004-2005 to personnel in a stratified random sample of 92 US hospitals.We sampled 100% of senior managers and physicians and 10% of all other workers. We received 18,361 completed surveys (52% response).The survey measured safety climate perceptions and worker and job characteristics of hospital personnel. We calculated and compared the percent of responses inconsistent with a climate of safety among hospitals, work areas, and disciplines.Overall, 17% of responses were inconsistent with a safety climate. Patient safety climate differed by hospital and among and within work areas and disciplines. Emergency department personnel perceived worse safety climate and personnel in nonclinical areas perceived better safety climate than workers in other areas. Nurses were more negative than physicians regarding their work unit's support and recognition of safety efforts, and physicians showed marginally more fear of shame than nurses. For other dimensions of safety climate, physician-nurse differences depended on their work area.Differences among and within hospitals suggest that strategies for improving safety climate and patient safety should be tailored for work areas and disciplines.

    View details for Web of Science ID 000262186500004

    View details for PubMedID 19106727

  • Job Satisfaction and Motivation among Physicians in Academic Medical Centers: Insights from a Cross-National Study JOURNAL OF HEALTH POLITICS POLICY AND LAW Janus, K., Amelung, V. E., Baker, L. C., Gaitanides, M., Schwartz, F. W., Rundall, T. G. 2008; 33 (6): 1133-1167

    Abstract

    Our study assesses how work-related monetary and nonmonetary factors affect physicians' job satisfaction at three academic medical centers in Germany and the United States, two countries whose differing health care systems experience similar problems in maintaining their physician workforce. We used descriptive statistics and factor and correlation analyses to evaluate physicians' responses to a self-administered questionnaire. Our study revealed that German physician respondents were less satisfied overall than their U.S. counterparts. In both countries, participation in decision making that may affect physicians' work was an important correlate of satisfaction. In Germany other important factors were opportunities for continuing education, job security, extent of administrative work, collegial relationships, and access to specialized technology. In the U.S. sample, job security, financial incentives, interaction with colleagues, and cooperative working relationships with colleagues and management were important predictors of overall job satisfaction. The implications of these findings for the development of policies and management tactics to increase physician job satisfaction in German and U.S. academic medical centers are discussed.

    View details for DOI 10.1215/03616878-2008-035

    View details for Web of Science ID 000261647400007

    View details for PubMedID 19038874

  • Patient Safety Climate in US Hospitals Variation by Management Level MEDICAL CARE Singer, S. J., Falwell, A., Gaba, D. M., Baker, L. C. 2008; 46 (11): 1149-1156

    Abstract

    Strengthening hospital safety culture offers promise for reducing adverse events, but efforts to improve culture may not succeed if hospital managers perceive safety differently from frontline workers.To determine whether frontline workers and supervisors perceive a more negative patient safety climate (ie, surface features, reflective of the underlying safety culture) than senior managers in their institutions. To ascertain patterns of variation within management levels by professional discipline.A safety climate survey was administered from March 2004 to May 2005 in 92 US hospitals. Individual-level cross sectional comparisons related safety climate to management level. Hierarchical and hospital-fixed effects modeling tested differences in perceptions.Random sample of hospital personnel (18,361 respondents).Frequency of responses indicating absence of safety climate (percent problematic response) overall and for 8 survey dimensions.Frontline workers' safety climate perceptions were 4.8 percentage points (1.4 times) more problematic than were senior managers', and supervisors' perceptions were 3.1 percentage points (1.25 times) more problematic than were senior managers'. Differences were consistent among 7 safety climate dimensions. Differences by management level depended on discipline: senior manager versus frontline worker discrepancies were less pronounced for physicians and more pronounced for nurses, than they were for other disciplines.Senior managers perceived patient safety climate more positively than nonsenior managers overall and across 7 discrete safety climate domains. Patterns of variation by management level differed by professional discipline. Continuing efforts to improve patient safety should address perceptual differences, both among and within groups by management level.

    View details for Web of Science ID 000260745900004

    View details for PubMedID 18953225

  • Expanded Use Of Imaging Technology And The Challenge of Measuring Value HEALTH AFFAIRS Baker, L. C., Atlas, S. W., Afendulis, C. C. 2008; 27 (6): 1467-1478

    Abstract

    The availability of computed tomography (CT) and magnetic resonance imaging (MRI) scanning has grown rapidly, but the value of increased availability is not clear. We document the relationship between CT and MRI availability and use, and we consider potentially important sources of benefits. We discuss key questions that need to be addressed if value is to be well understood. In an example we study, expanded imaging may be valuable because it provides quicker access to more precise diagnostic information, although evidence for improved health outcomes is limited. This may be a common situation; thus, a particularly important question is how non-health-outcome benefits of imaging can be quantified.

    View details for DOI 10.1377/hlthaff.27.6.1467

    View details for Web of Science ID 000260769300003

    View details for PubMedID 18997202

  • Health plan performance measurement: Does it affect quality of care for medicare managed care enrollees? INQUIRY-THE JOURNAL OF HEALTH CARE ORGANIZATION PROVISION AND FINANCING Bundorf, M. K., Choudhry, K., Baker, L. 2008; 45 (2): 168-183

    Abstract

    Although the objective of provider performance measurement is to improve quality of care, little evidence exists on whether it has this effect. This study examines the implementation of mandatory quality reporting for Medicare managed care (MMC) plans. We compare utilization rates of performance-measured services for Medicare beneficiaries who were and were not enrolled in these plans before and after the program's introduction. We find that the use of measured services increased among both MMC and fee-for-service beneficiaries after the adoption of performance measurement. Our results provide no evidence that performance measurement increased quality of care among MMC enrollees.

    View details for Web of Science ID 000258739800004

    View details for PubMedID 18767382

  • Trends in charges and payments for nonhospitalized emergency department pediatric visits, 1996-2003. Academic emergency medicine Hsia, R. Y., MacIsaac, D., Palm, E., Baker, L. C. 2008; 15 (4): 347-354

    Abstract

    To compare charges and payments for outpatient pediatric emergency visits across payer groups to provide information on reimbursement trends.Total charges and payments for emergency department (ED) visits Medicaid/State Children's Health Insurance Program (SCHIP), privately insured, and uninsured pediatric patients from 1996 to 2003 using data from the Medical Expenditure Panel Survey. Average charges per visit and average payments per visit were also tracked, using regression analysis to adjust for changes in patient characteristics.While charges for pediatric ED visits rose over time, payments did not keep pace. This led to a decrease in reimbursement rates from 63% in 1996 to 48% in 2003. For all years, Medicaid/SCHIP visits had the lowest reimbursement rates, reaching 35% in 2003. The proportion of visits from children insured by Medicaid/SCHIP also increased over the period examined. In 2003, after adjustment, charges were $792 per visit from children covered by Medicaid/SCHIP, $913 for visits from uninsured children, and $952 for visits from privately insured children.Reimbursements for outpatient ED visits in the pediatric population have decreased from the period of 1996 to 2003 in all payer groups: public (Medicaid/SCHIP), private, and the uninsured. Medicaid/SCHIP has consistently paid less per visit than the privately insured and the uninsured. Further research on the effects of these declining reimbursements on the financial viability of ED services for children is warranted.

    View details for DOI 10.1111/j.1553-2712.2008.00075.x

    View details for PubMedID 18370988

  • Variations in hospital resource use for medicare and privately insured populations in California HEALTH AFFAIRS Baker, L. C., Fisher, E. S., Wennberg, J. E. 2008; 27 (2): W123-W134

    Abstract

    The amount of resources used in the care of chronically ill Medicare fee-for-service (FFS) patients varies widely across hospitals. We studied variations across California hospitals in hospital resource use for chronically ill patients covered by Medicare health maintenance organizations (HMOs) and private insurers and found substantial variation in all of the coverage groups studied. Resource-use measures based on Medicare FFS data often reflect patterns evident for other payers. Previous estimates of savings if the most resource-intensive hospitals more closely resembled less resource-intensive hospitals, based on just Medicare FFS spending, could underestimate possible savings when other payers are taken into account.

    View details for DOI 10.1377/hlthaff.27.2.w123

    View details for Web of Science ID 000257188500060

    View details for PubMedID 18270221

  • Decreasing reimbursements for outpatient emergency department visits across payer groups from 1996 to 2004 ANNALS OF EMERGENCY MEDICINE Hsia, R. Y., MacIsaac, D., Baker, L. C. 2008; 51 (3): 265-274

    Abstract

    There is increasing concern that decreasing reimbursements to emergency departments (EDs) will negatively affect their functioning, but little evidence has been published identifying trends in reimbursement rates. We seek to examine and document the trends in reimbursement for outpatient ED visits throughout the past decade.We use Medical Expenditure Panel Survey data covering a 9-year span from 1996 to 2004, using outpatient ED visits as the unit of analysis. Our primary outcome variables were total and per-visit charges and payments across insurance. Using regression analyses with a generalized linear models approach, we also derived the adjusted mean payment and mean charge for each ED visit, as well as the average payment ratio.Overall, adjusted mean charges for an outpatient ED visit increased from $713 (95% confidence interval [CI] $665 to $771) in 1996 to $1,390 (95% CI $1,317 to $1,462) in 2004. The adjusted mean payment also increased from $410 (95% CI $366 to $453) in 1996 to $592 (95% CI $551 to $634) in 2004. Because payments increased at a slower rate in all payer groups compared with charges, the overall share of charges that were paid decreased over time from 57% in 1996 (n=3,433) to 42% in 2004 (n=5,763; P<.001). The proportion of total charges paid in 2004 was highest for privately insured visits (56%; n=2,005) and lowest for Medicaid visits (33%; n=1,618). For visits by uninsured patients (n=996), 35% of charges were paid in 2004.The proportion of charges paid for outpatient ED visits from Medicaid, Medicare, and privately insured and uninsured patients persistently decreased from 1996 to 2004. These concerning decreases may threaten the survival of EDs and their ability to continue to provide care as safety nets in the US health care system.

    View details for DOI 10.1016/j.annemergmed.2007.08.009

    View details for Web of Science ID 000253739300008

    View details for PubMedID 17997503

  • Ongoing physical activity advice by humans versus computers: The community health advice by telephone (CHAT) trial HEALTH PSYCHOLOGY King, A. C., Friedman, R., Marcus, B., Castro, C., Napolitano, M., Alm, D., Baker, L. 2007; 26 (6): 718-727

    Abstract

    Given the prevalence of physical inactivity among American adults, convenient, low-cost interventions are strongly indicated. This study determined the 6- and 12-month effectiveness of telephone interventions delivered by health educators or by an automated computer system in promoting physical activity.Initially inactive men and women age 55 years and older (N = 218) in stable health participated. Participants were randomly assigned to human advice, automated advice, or health education control.The validated 7-day physical activity recall interview was used to estimate minutes of moderate to vigorous physical activity. Physical activity differences by experimental arm were verified on a random subsample via accelerometry.Using intention-to-treat analysis, at 6 months, participants in both interventions, although not differing from one another, showed significant improvements in weekly physical activity compared with controls. These differences were generally maintained at 12 months, with both intervention arms remaining above the target of 150 min per week of moderate to vigorous physical activity on average.Automated telephone-linked delivery systems represent an effective alternative for delivering physical activity advice to inactive older adults.

    View details for DOI 10.1037/0278-6133.26.6.718

    View details for Web of Science ID 000250861700011

    View details for PubMedID 18020844

  • Workforce perceptions of hospital safety culture: Development and validation of the patient safety climate in healthcare organizations survey HEALTH SERVICES RESEARCH Singer, S., Meterko, M., Baker, L., Gaba, D., Falwell, A., Rosen, A. 2007; 42 (5): 1999-2021

    Abstract

    To describe the development of an instrument for assessing workforce perceptions of hospital safety culture and to assess its reliability and validity.Primary data collected between March 2004 and May 2005. Personnel from 105 U.S. hospitals completed a 38-item paper and pencil survey. We received 21,496 completed questionnaires, representing a 51 percent response rate.Based on review of existing safety climate surveys, we developed a list of key topics pertinent to maintaining a culture of safety in high-reliability organizations. We developed a draft questionnaire to address these topics and pilot tested it in four preliminary studies of hospital personnel. We modified the questionnaire based on experience and respondent feedback, and distributed the revised version to 42,249 hospital workers.We randomly divided respondents into derivation and validation samples. We applied exploratory factor analysis to responses in the derivation sample. We used those results to create scales in the validation sample, which we subjected to multitrait analysis (MTA).We identified nine constructs, three organizational factors, two unit factors, three individual factors, and one additional factor. Constructs demonstrated substantial convergent and discriminant validity in the MTA. Cronbach's alpha coefficients ranged from 0.50 to 0.89.It is possible to measure key salient features of hospital safety climate using a valid and reliable 38-item survey and appropriate hospital sample sizes. This instrument may be used in further studies to better understand the impact of safety climate on patient safety outcomes.

    View details for DOI 10.1111/j.1475-6773.2007.00706.x

    View details for Web of Science ID 000249429000012

    View details for PubMedID 17850530

  • Laws requiring health plans to provide direct access to obstetricians and gynecologists, and use of cancer screening by women HEALTH SERVICES RESEARCH Baker, L. C., Chan, J. 2007; 42 (3): 990-1007

    Abstract

    Many states have passed legislation mandating that health plans provide direct access to obstetricians/gynecologists (hereinafter "ob/gyns") for women, limiting the ability of plans to require referrals or otherwise restrict access. One benefit of these laws may be improved preventive screening rates, but no literature has examined the relationship between ob/gyn direct access laws and use of breast cancer and cervical cancer screening.We use repeated cross-sections of privately insured women age 18-64 (Pap test) and 40-64 (mammography) from the Behavioral Risk Factor Surveillance System for 1996-2000, linked to data on the presence of ob/gyn direct access laws by state. Outcome measures are receipt of mammography and receipt of a Pap test within the past 2 years. Regression analyses are used to assess the relationship between the presence of ob/gyn direct access laws and screening, adjusting for a range of individual characteristics, fixed state characteristics, and time trends.We find no statistically significant relationships between the presence of an ob/gyn direct access law and receipt of either mammography or Pap test screening. We explore a range of alternate specifications and find none that yield clear evidence of a relationship.Laws requiring direct access to ob/gyns are not associated with large or consistent measurable impacts on use of cancer screening.

    View details for DOI 10.1111/j.1475-6773.2006.00646.x

    View details for Web of Science ID 000246201400006

    View details for PubMedID 17489900

  • Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants NEW ENGLAND JOURNAL OF MEDICINE Phibbs, C. S., Baker, L. C., Caughey, A. B., Danielsen, B., Schmitt, S. K., Phibbs, R. H. 2007; 356 (21): 2165-2175

    Abstract

    There has been a large increase in both the number of neonatal intensive care units (NICUs) in community hospitals and the complexity of the cases treated in these units. We examined differences in neonatal mortality among infants with very low birth weight (below 1500 g) among NICUs with various levels of care and different volumes of very-low-birth-weight infants.We linked birth certificates, hospital discharge abstracts (including interhospital transfers), and fetal and infant death certificates to assess neonatal mortality rates among 48,237 very-low-birth-weight infants who were born in California hospitals between 1991 and 2000.Mortality rates among very-low-birth-weight infants varied according to both the volume of patients and the level of care at the delivery hospital. The effect of volume also varied according to the level of care. As compared with a high level of care and a high volume of very-low-birth-weight infants (more than 100 per year), lower levels of care and lower volumes (except for those of two small groups of hospitals) were associated with significantly higher odds ratios for death, ranging from 1.19 (95% confidence interval [CI], 1.04 to 1.37) to 2.72 (95% CI, 2.37 to 3.12). Less than one quarter of very-low-birth-weight deliveries occurred in facilities with NICUs that offered a high level of care and had a high volume, but 92% of very-low-birth-weight deliveries occurred in urban areas with more than 100 such deliveries.Mortality among very-low-birth-weight infants was lowest for deliveries that occurred in hospitals with NICUs that had both a high level of care and a high volume of such patients. Our results suggest that increased use of such facilities might reduce mortality among very-low-birth-weight infants.

    View details for Web of Science ID 000246673100006

    View details for PubMedID 17522400

  • Proposition 71 and CIRM - assessing the return on investment NATURE BIOTECHNOLOGY Longaker, M. T., Baker, L. C., Greely, H. T. 2007; 25 (5): 513-521

    Abstract

    Given that Californian voters authorized state coffers to sell $3 billion in bonds to fund the California Institute for Regenerative Medicine (CIRM) with the expectation of health and financial benefits, what benchmarks should be used to measure the initiative's success?

    View details for Web of Science ID 000246369400014

    View details for PubMedID 17483831

  • Does quality improvement implementation affect hospital quality of care? Hospital topics Alexander, J. A., Weiner, B. J., Shortell, S. M., Baker, L. C. 2007; 85 (2): 3-12

    Abstract

    The authors examined how the association between quality improvement (QI) implementation in hospitals and hospital clinical quality is moderated by hospital organizational and environmental context. The authors used Ordinary Least Squares regression analysis of 1,784 community hospitals to model seven quality indicators as a function of four measures of QI implementation and a variety of control variables. They found that forces that are external and internal to the hospital condition the impact of particular QI activities on quality indicators: specifically data use, statistical tool use, and organizational emphasis on Continuous Quality Improvement (CQI). Results supported the proposition that QI implementation is unlikely to improve quality of care in hospital settings without a commensurate fit with the financial, strategic, and market imperatives faced by the hospital.

    View details for PubMedID 17650463

  • Differences in neonatal mortality among whites and Asian American subgroups - Evidence from California ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE Baker, L. C., Afendulis, C. C., Chandra, A., McConville, S., Phibbs, C. S., Fuentes-Afflick, E. 2007; 161 (1): 69-76

    Abstract

    To obtain information about health outcomes in neonates in 9 subgroups of the Asian population in the United States.Cross-sectional comparison of outcomes for births to mothers of Cambodian, Chinese, Filipino, Indian, Japanese, Korean, Laotian, Thai, and Vietnamese origin and for births to non-Hispanic white mothers. Regression models were used to compare neonatal mortality across groups before and after controlling for various risk factors.All California births between January 1,1991, and December 31, 2001.More than 2.3 million newborn infants.Racial and ethnic groups.Neonatal mortality (death within 28 days of birth).The unadjusted mortality rate for births to non-Hispanic white mothers was 2.0 per 1000. The unadjusted mortality rate for births to Chinese and Japanese mothers was significantly lower (Chinese: 1.2 per 1000, P<.001; Japanese: 1.2 per 1000, P=.004), and for births to Korean mothers the rate was significantly higher (2.7 per 1000, P=.003). For infants of Chinese mothers, observed risk factors explain the differences observed in unadjusted data. For infants of Cambodian, Japanese, Korean, and Thai mothers, differences persist or widen after risk factors are considered. After risk adjustment, infants of Cambodian, Japanese, and Korean mothers have significantly lower neonatal mortality rates compared with infants born to non-Hispanic white mothers (adjusted odds ratios, 0.58 for infants of Cambodian mothers, 0.67 for infants of Japanese mothers, and 0.69 for infants of Korean mothers; all P<.05); infants of Thai mothers have higher neonatal mortality rates (adjusted odds ratio, 1.89; P<.05).There are significant variations in neonatal mortality between subgroups of the Asian American population that are not entirely explained by differences in observable risk factors. Efforts to improve clinical care that treat Asian Americans as a homogeneous group may miss important opportunities for improving infant health in specific subgroups.

    View details for Web of Science ID 000243273800010

    View details for PubMedID 17199070

  • Physician practice size and variations in treatments and outcomes: Evidence from medicare patients with AMI HEALTH AFFAIRS Ketcham, J. D., Baker, L. C., MacIsaac, D. 2007; 26 (1): 195-205

    Abstract

    Little is known about the relationships between physician practice size and patient treatments or outcomes. We examined whether the practice size of attending physicians was related to within-hospital differences in care for Medicare patients with acute myocardial infarction (AMI). We found that patients treated by solo physicians were less likely to receive cardiac catheterization and angioplasty within a day of admission and more likely to die than other patients in the same hospital, even after a number of patient and physician characteristics were taken into account. These differences suggest that solo practitioners are less likely to follow guidelines calling for quick use of angioplasty.

    View details for DOI 10.1377/hlthaff.26.1.195

    View details for Web of Science ID 000244223200022

    View details for PubMedID 17211029

  • Effect of opening midlevel neonatal intensive care units on the location of low birth weight births in California PEDIATRICS Haberland, C. A., Phibbs, C. S., Baker, L. C. 2006; 118 (6): E1667-E1679

    Abstract

    Despite evidence and recommendations encouraging the delivery of high-risk newborns in hospitals with subspecialty or high-level NICUs, increasing numbers are being delivered in other facilities. Causes for this are unknown. We sought to explore the impact of diffusion of specialty or midlevel NICUs on the types of hospitals in which low birth weight newborns are born.We used birth certificate, death certificate, and hospital discharge data for essentially all low birth weight, singleton California newborns born between 1993 and 2000. We identified areas likely to have been affected by the opening of a new nearby midlevel unit, analyzed changes over time in the share of births that took place in midlevel NICU hospitals, and compared patterns in areas that were and were not likely affected by the opening of a new midlevel unit. We also tracked the corresponding changes in the share of births in high-level hospitals and in those without NICU facilities (low-level).The probability of a 500- to 1499-g infant being born in a midlevel unit increased by 17 percentage points after the opening of a new nearby unit. More than three quarters of this increase was accounted for by reductions in the probability of birth in a hospital with a high-level unit (-15 points), and the other portion was resulting from reductions in the share of newborns delivered in hospitals with low-level centers (-2 points). Similar patterns were observed in 1500- to 2499-g newborns.The introduction of new midlevel units was associated with significant shifts of births from both high-level and low-level hospitals to midlevel hospitals. In areas in which new midlevel units opened, the majority of the increase in midlevel deliveries was attributable to shifts from high-level unit births. Continued proliferation of midlevel units should be carefully assessed.

    View details for DOI 10.1542/peds.2006-0612

    View details for Web of Science ID 000242478900060

    View details for PubMedID 17116699

  • Do mandates requiring insurers to pay for emergency care influence the use of the emergency department? HEALTH AFFAIRS Hsia, R. Y., Chan, J., Baker, L. C. 2006; 25 (4): 1086-1094

    Abstract

    Many states have "prudent layperson" mandates that require health plans to reimburse hospitals for emergency department (ED) care delivered to patients who believe that they have symptoms warranting emergency treatment. Increased, and possibly unnecessary, ED use has often been attributed to these policies. We use data from thirty-five states to study relationships between passage of prudent layperson policies in the late 1990s and ED use among the privately insured. None of the analyses show evidence that the mandates are associated with increased use. We conclude that prudent layperson mandates are not associated with increases in ED visits among privately insured patients.

    View details for DOI 10.1377/hlthaff.25.4.1086

    View details for Web of Science ID 000239629900026

    View details for PubMedID 16835190

  • Who searches the internet for health information? HEALTH SERVICES RESEARCH Bundorf, M. K., Wagner, T. H., Singer, S. J., Baker, L. C. 2006; 41 (3): 819-836

    Abstract

    To determine what types of consumers use the Internet as a source of health information.A survey of consumer use of the Internet for health information conducted during December 2001 and January 2002.We estimated multivariate regression models to test hypotheses regarding the characteristics of consumers that affect information seeking behavior.Respondents were randomly sampled from an Internet-enabled panel of over 60,000 households. Our survey was sent to 12,878 panel members, and 69.4 percent of surveyed panel members responded. We collected information about respondents' use of the Internet to search for health information and to communicate about health care with others using the Internet or e-mail within the last year.Individuals with reported chronic conditions were more likely than those without to search for health information on the Internet. The uninsured, particularly those with a reported chronic condition, were more likely than the privately insured to search. Individuals with longer travel times for their usual source of care were more likely to use the Internet for health-related communication than those with shorter travel times.Populations with serious health needs and those facing significant barriers in accessing health care in traditional settings turn to the Internet for health information.

    View details for DOI 10.1111/j.1475-6773.2006.00510.x

    View details for Web of Science ID 000237464400013

    View details for PubMedID 16704514

  • Quality improvement implementation and hospital performance on quality indicators HEALTH SERVICES RESEARCH Weiner, B. J., Alexander, J. A., Shortell, S. M., Baker, L. C., Becker, M., Geppert, J. J. 2006; 41 (2): 307-334

    Abstract

    To examine the association between the scope of quality improvement (QI) implementation in hospitals and hospital performance on selected indicators of clinical quality.Secondary data from 1997 mailed survey of hospital QI practices, Medicare Inpatient Database, American Hospital Association's Annual Survey of Hospitals, the Bureau of Health Professions' Area Resource File, and two proprietary data sets compiled by Solucient Inc. containing data on managed care penetration and hospital financial performance.Cross-sectional study of 1,784 community hospitals to assess relationship between QI implementation approach and six hospital-level quality indicators. DATA COLLECTION/ABSTRACTION METHODS: Two-stage instrumental variables estimation in which predicted values (instruments) of four QI scope variables and control (exogenous) variables used to estimate hospital-level quality indicators.Involvement by multiple hospital units in QI effort is associated with worse values on hospital-level quality indicators. Percentage of hospital staff and percentage of senior managers participating in formally organized QI teams are associated with better values on quality indicators. Percentage of physicians participating in QI teams is not associated with better values on the hospital-level quality indicators studied.Results supported the proposition that the scope of QI implementation in hospitals is significantly associated with hospital-level quality indicators. However, the direction of the association varied across different measures of QI implementation scope.

    View details for DOI 10.1111/j.1475-6773.2005.00483.x

    View details for Web of Science ID 000235892500003

    View details for PubMedID 16584451

  • Quality improvement implementation and hospital performance on patient safety indicators MEDICAL CARE RESEARCH AND REVIEW Weiner, B. J., Alexander, J. A., Baker, L. C., Shortell, S. M., Becker, M. 2006; 63 (1): 29-57

    Abstract

    This study examines the association between scope of Quality Improvement (QI) implementation in hospitals and hospital performance on patient safety indicators. Secondary data sources included a 1997 survey of hospital QI practices, Medicare Inpatient Database, American Hospital Association's Annual Survey of Hospitals, the Bureau of Health Professions' Area Resource File, and two proprietary data sets. Using a sample of 1,784 community hospitals, the study employed two-stage instrumental variables estimation in which predicted values of four QI scope variables and control variables were used to estimate four patient safety indicators. Involvement by multiple hospital units in the QI effort is associated with worse values on all four patient safety indicators. Percentages of hospital staff and of senior managers participating in QI teams exhibited no statistically significant association with any patient safety indicator. Percentage of physicians participating in QI teams is associated with better values on two patient safety indicators.

    View details for DOI 10.1177/1077558705283122

    View details for Web of Science ID 000235711000002

    View details for PubMedID 16686072

  • Impact of instructional practices on student satisfaction with attendings' teaching in the inpatient component of internal medicine clerkships JOURNAL OF GENERAL INTERNAL MEDICINE Guarino, C. M., Ko, C. Y., Baker, L. C., KLEIN, D. J., Quiter, E. S., Escarce, J. J. 2006; 21 (1): 7-12

    Abstract

    To determine the prevalence and influence of specific attending teaching practices on student evaluations of the quality of attendings' teaching in the inpatient component of Internal Medicine clerkships.Nationwide survey using a simple random sample. Setting: One hundred and twenty-one allopathic 4-year medical schools in the United States.A total of 2,250 fourth-year medical students.In the spring of 2002, student satisfaction with the overall quality of teaching by attendings in the inpatient component of Internal Medicine clerkships was measured on a 5-point scale from very satisfied to very dissatisfied (survey response rate, 68.3%). Logistic regression was used to determine the association of specific teaching practices with student evaluations of the quality of their attendings' teaching. Attending physicians' teaching practices such as engaging students in substantive discussions (odds ratio (OR)=3.0), giving spontaneous talks and prepared presentations (OR=1.6 and 1.8), and seeing new patients with the team (OR=1.2) were strongly associated with higher student satisfaction, whereas seeming rushed and eager to finish rounds was associated with lower satisfaction (OR=0.6).Findings suggest that student satisfaction with attendings' teaching is high overall but there is room for improvement. Specific teaching behaviors used by attendings affect student satisfaction. These specific behaviors could be taught and modified for use by attendings and clerkship directors to enhance student experiences during clerkships.

    View details for DOI 10.1111/j.1525-1497.2005.0253.x

    View details for Web of Science ID 000235163600002

    View details for PubMedID 16423117

  • Evaluating the efficiency of California providers in caring for patients with chronic illnesses HEALTH AFFAIRS Wennberg, J. E., Fisher, E. S., Baker, L., Sharp, S. M., Bronner, K. K. 2006; 25 (1): W5526-W5543
  • The role of organizational infrastructure in implementation of hospitals' quality improvement. Hospital topics Alexander, J. A., Weiner, B. J., Shortell, S. M., Baker, L. C., Becker, M. P. 2006; 84 (1): 11-20

    Abstract

    Quality improvement (QI) is an organized approach to planning and implementing continuous improvement in performance. Although QI holds promise for improving quality of care and patient safety, hospitals that adopt QI often struggle with its implementation. This article examines the role of organizational infrastructure in implementation of quality improvement practices and structures in hospitals. The authors focus specifically on four elements of hospital support and infrastructure for QI-integrated data systems, financial support for QI, clinical integration, and information system capability. These macrolevel factors provide consistent, ongoing support for the QI efforts of clinical teams engaging in direct patient care, thus promoting institutionalization of QI. Results from the multivariate analysis of 1997 survey data on 2350 hospitals provide strong support for the hypotheses. Results signal that organizations intent upon improving quality must attend to the context in which QI efforts are practiced, and that such efforts are unlikely to be effective unless appropriate support systems are in place to ensure full implementation.

    View details for PubMedID 16573012

  • Medicaid managed care and health care for children HEALTH SERVICES RESEARCH Baker, L. C., Afendulis, C. 2005; 40 (5): 1466-1488

    Abstract

    Many states expanded their Medicaid managed care programs during the 1990s, causing concern about impacts on health care for affected populations. We investigate the relationship between Medicaid managed care enrollment and health care for children. DATA SOURCES AND MEASURES: Repeated cross-sections of Medicaid-covered children under 18 years of age from the 1996/1997 and 1998/1999 Community Tracking Study Household Surveys (n=2,602) matched to state-year CMS Medicaid managed care enrollment data. For each individual, we constructed measures of health care utilization (provider and emergency department visits, hospitalizations, surgeries); health care access (usual source of care, unmet medical needs, put-off needed care); and satisfaction (satisfaction overall, with doctor choice, and with last visit).Regression analysis of the relationship between within-state changes in Medicaid managed care enrollment rates and changes in mean utilization, access, and satisfaction measures for children covered by Medicaid, controlling for a range of potentially confounding factors.Increases in Medicaid health maintenance organization (HMO) enrollment are associated with less emergency room use, more outpatient visits, fewer hospitalizations, higher rates of reporting having put off care, and lower satisfaction with the most recent visit. Medicaid primary care case management (PCCM) plans are associated with increases in outpatient visits, but also with higher rates of reporting unmet medical needs, putting off care, and having no usual source of care.Both Medicaid HMO and PCCM plans can have important impacts on health care utilization, access, and satisfaction. Some impacts may be positive (e.g., less ED use and more outpatient provider use), although concern about increasing challenges in access to care and satisfaction is also warranted.

    View details for DOI 10.1111/j.1475-6773.2005.00427.x

    View details for Web of Science ID 000231708000012

    View details for PubMedID 16174143

  • Effect of an Internet-based system for doctor-patient communication on health care spending JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION Baker, L., Rideout, J., Gertler, P., Raube, K. 2005; 12 (5): 530-536

    Abstract

    We studied the effect of a structured electronic communication service on health care spending, comparing doctor office and laboratory spending for a group of patients before and after the service became available to them relative to changes in a control group. In the treatment group, doctor office spending and laboratory spending fell in the period after the service became available, relative to the control group (p < 0.05). A rough estimate is that average doctor office spending per treatment group member per month fell $1.71 after availability of the service, and laboratory spending fell roughly $0.12. Spending associated with use of the electronic service was $0.29 per member per month. We conclude that use of structured electronic visits can reduce health care spending.

    View details for DOI 10.1197/jamia.M1778

    View details for Web of Science ID 000232419100004

    View details for PubMedID 15905484

  • Evaluating the efficiency of california providers in caring for patients with chronic illnesses. Health affairs Wennberg, J. E., Fisher, E. S., Baker, L., Sharp, S. M., Bronner, K. K. 2005: W5-526 43

    Abstract

    In this paper we compare the relative efficiency of health care providers in managing patients with severe chronic illnesses over fixed periods of time. To minimize the contribution of differences in severity of illness to differences in care management, we evaluate performance over fixed intervals prior to death for patients who died during a five-year period, 1999-2003. Medicare spending, hospital bed and full-time equivalent (FTE) physician inputs, and utilization varied extensively between regions, among hospitals located within a given region, and among hospitals belonging to a given hospital system. The data point to important opportunities to improve efficiency.

    View details for PubMedID 16291779

  • Free Internet access, the digital divide, and health information MEDICAL CARE Wagner, T. H., Bundorf, M. K., Singer, S. J., Baker, L. C. 2005; 43 (4): 415-420

    Abstract

    The Internet has emerged as a valuable tool for health information. Half of the U.S. population lacked Internet access in 2001, creating concerns about those without access. Starting in 1999, a survey firm randomly invited individuals to join their research panel in return for free Internet access. This provides a unique setting to study the ways that people who had not previously obtained Internet access use the Internet when it becomes available to them.In 2001-2002, we surveyed 12,878 individuals 21 years of age and older on the research panel regarding use of the Internet for health; 8935 (69%) responded. We analyzed respondents who had no prior Internet access, and then compared this group to those who had prior Internet access.Among those newly provided free Internet access, 24% had used the Internet for health information in the past year, and users reported notable benefits, such as improved knowledge and self-care abilities. Not surprisingly, the no-prior-Internet group reported lower rates of using the Internet (24%) than the group that had obtained Internet access prior to joining the research panel (40%), but the 2 groups reported similar perceptions of the Internet and self-reported effects.Those who obtained Internet access for the first time by joining the panel used the Internet for health and appeared to benefit from it. Access helps explain the digital divide, although most people given free access do not use the Internet for health information.

    View details for Web of Science ID 000227914000013

    View details for PubMedID 15778645

  • Predictors of surgery resident satisfaction with teaching by attendings - A national survey ANNALS OF SURGERY Ko, C. Y., Escarce, J. J., Baker, L., Sharp, J., Guarino, C. 2005; 241 (2): 373-380

    Abstract

    To identify factors that predict fourth- and fifth-year surgical resident satisfaction of attending teaching quality.With the training of surgical residents undergoing major changes, a key issue facing surgical educators is whether high-quality surgeons can still be produced. Innovative techniques (eg, computer simulation surgery) are being developed to substitute partially for conventional teaching methods. However, an aspect of training that cannot be so easily replaced is the faculty-resident interaction. This study investigates resident perceptions of attending teaching quality and the factors associated with this faculty-resident interaction to identify predictors of resident educational satisfaction.A national survey of clinical fourth- and fifth-year surgery residents in 125 academically affiliated general surgery training programs was performed. The survey contained 67 questions and addressed demographics, hospital, and service characteristics, as well as surgery, education, and clinical care-related factors. Univariate analyses were performed to describe the characteristics of the sample; multivariate analyses were performed to evaluate the factors associated with resident educational satisfaction.The response rate was 61.5% (n = 756). Average age was 32 years; most were male (79%), white (72%), and married (69%); 42% had children. Ninety-five percent of respondents graduated from U.S. medical schools, and the average debt was $80,307. Of 20 potentially mutable factors, 6 variables had positive associations with resident education satisfaction and 7 had negative associations. Positive factors included the resident being the operating surgeon in major surgeries, substantial citing of evidence-based literature by the attending, attending physicians giving spontaneous or unplanned presentations, increasing the continuity of care, clinical teaching aimed at the chief resident level, and having clinical decisions made together by both the attending and resident. There were 7 negative factors such as overly supervising in surgery, being interrupted so much that teaching was ineffective, and attending physicians being rushed and/or eager to finish rounds.This study identifies several factors that were associated with resident educational satisfaction. It offers the perspective of the learners (ie, residents) and, importantly, highlights mutable factors that surgery faculty (and departments) may consider changing to improve surgery resident education and satisfaction. Improving such satisfaction may help to produce a better product.

    View details for DOI 10.1097/01.sla.0000150257.04889.70

    View details for Web of Science ID 000226567200025

    View details for PubMedID 15650650

  • The relationship between SCHIP enrollment and hospitalizations for ambulatory care sensitive conditions in California JOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVED Bermudez, D., Baker, L. 2005; 16 (1): 96-110

    Abstract

    The State Children's Health Insurance Program (SCHIP) was implemented in 1998, providing new funds for states to cover uninsured children. This study examines the relationship between SCHIP implementation in California and hospitalizations for ambulatory care sensitive conditions (ACSCs), an indicator of primary care access and quality. We use administrative SCHIP enrollment records for urban California counties, linked with corresponding rates of hospitalization for seven ACSCs among children ages 1-18 for 1996-2000. Results from multivariate regression models indicate that increases of 1 percentage point in SCHIP enrollment are associated with reductions of 0.42 ACSC admissions per 100,000 children age 1-18 (p = 0.009). Models that use lagged effects of SCHIP enrollment indicate an even stronger relationship. These are population-level relationships, and translate to much larger effects on the specific population subset that enrolled in SCHIP. These results suggest a strong beneficial effect of SCHIP on primary care among the children covered.

    View details for Web of Science ID 000227618500011

    View details for PubMedID 15741712

  • Benefits of interoperability: a closer look at the estimates. Health affairs Baker, L. C. 2005: W5-22 W5 25

    Abstract

    The paper by Jan Walker and colleagues provides an estimate of savings to be gained by increased health care information exchange and interoperability (HIEI). However, the assumptions on which their analysis was based seem very optimistic and could produce estimates that are not achievable. This commentary outlines some questions about their assumptions and suggests that less-aggressive assumptions could lead to more realistic expectations about the financial implications of achieving interoperability.

    View details for PubMedID 15659455

  • The effect of area HMO market share on cancer screening HEALTH SERVICES RESEARCH Baker, L. C., Phillips, K. A., Haas, J. S., Liang, S. Y., Sonneborn, D. 2004; 39 (6): 1751-1772

    Abstract

    Managed care may have widespread impacts on health care delivery for all patients in the areas where they operate. We examine the relationship between area managed care activity and screening for breast, cervical, and prostate cancer among patients enrolled in more managed care plans and patients who are enrolled in less managed plans.Data on cancer screening from the 1996 Medical Expenditure Panel Survey (MEPS) were linked to data on health maintenance organization (HMO) and preferred provider organization (PPO) market share and HMO competition at the metropolitan statistical area (MSA) level. Logistic regression analysis was used to examine the relationship between area managed care prevalence and the use of mammography, clinical breast examination, Pap smear, and prostate cancer screening in the past two years, controlling for important covariates.Among all patients, increases in area-level HMO market share are associated with increases in the appropriate use of mammography, clinical breast exam, and Pap smear (OR for high relative to low managed care areas are 1.75, p < .01, for mammography, 1.58, p < .05, for clinical breast exam, and 1.71, p < .01, for Pap smear). In analyses of subgroups, the relationship is significant only for individuals who are enrolled in the nonmanaged plans; there is no relationship for individuals in more managed plans. No relationship is observed between area HMO market share and prostate cancer screening in any analysis. Neither the level of competition between area HMOs nor area PPO market share is associated with screening rates.Area-level managed care activity can influence preventive care treatment patterns.

    View details for Web of Science ID 000226743200008

    View details for PubMedID 15533185

  • Use of the Internet for health information by the chronically ill. Preventing chronic disease Wagner, T. H., Baker, L. C., Bundorf, M. K., Singer, S. 2004; 1 (4): A13-?

    Abstract

    Chronic conditions are among the leading causes of death and disability in the United States. The Internet is a source of health information and advice for individuals with chronic conditions and shows promise for helping individuals manage their conditions and improve their quality of life.We assessed Internet use for health information by people who had one or more of five common chronic conditions. We conducted a national survey of adults aged 21 and older, then analyzed data from 1980 respondents who had Internet access and who reported that they had hypertension, diabetes, cancer, heart problems, and/or depression.Adjusted rates for any Internet use for health information ranged from 33.8% (heart problems only) to 52.0% (diabetes only). A sizable minority of respondents - particularly individuals with diabetes - reported that the Internet helped them to manage their condition themselves, and 7.9% said information on the Internet led them to seek care from a different doctor.Use of the Internet for health information by chronically ill patients is moderate. Self-reported effects on choice of treatment or provider are small but noteworthy.

    View details for PubMedID 15670445

  • Predictors for medical students entering a general surgery residency: National survey results SURGERY Ko, C. Y., Escarce, J. J., Baker, L., Klein, D., Guarino, C. 2004; 136 (3): 567-572

    Abstract

    The number of general surgery (GS) residency applicants had been decreasing before 2003. This national survey of fourth-year medical students elucidates factors related to the basic surgery clerkship that are associated with the decision to enter a GS residency.A national sample of 2250 fourth-year medical students from all 4-year allopathic US medical schools was surveyed in spring 2002. Multivariate analyses were performed to identify mutable predictors for students entering GS.Data from 1531 fourth-year medical students from 121 different medical schools (response rate=68%) showed that 5.6% planned to enter GS. In multivariate analyses, the strongest predictor of entering GS was satisfaction with the quality of attending teaching (odds ratio 2.14, P <.01) in surgery clerkships. Several clerkship factors, such as frequency of call nights and total hours worked., were not as strongly associated with entering GS residency, Subsequent analyses showed that predictors of satisfaction with the quality of attending teaching included intraoperative activities (ie, suturing, cutting, and stapling), having attending-led rounds, and performing a history and physical with an attending. Significant negative predictors of satisfaction included observing or retracting only in surgery.In this national survey, factors are identified that are significantly associated with students entering a GS residency. Some of these mutable factors may increase the pool of GS residency applicants.

    View details for DOI 10.1016/j.surg.2004.05.021

    View details for Web of Science ID 000223844300011

    View details for PubMedID 15349103

  • Consumers' use of the Internet for health insurance AMERICAN JOURNAL OF MANAGED CARE Bundorf, M. K., Singer, S. J., Wagner, T. H., Baker, L. 2004; 10 (9): 609-616

    Abstract

    We examined consumers' search for information about health insurance choices and their use of the Internet for that search and to manage health benefits.We surveyed a random sample of more than 4500 individuals aged 21 years and older who were members of a survey research panel during December 2001 and January 2002.The survey included questions about searching for health insurance information in 3 health insurance markets: Medicare, individual or nongroup, and employer-sponsored group. We also asked questions about use of the Internet to manage health benefits. We tabulated means of responses to each question by market and tested for independence across demographic groups using the Pearson chi-square test.We identified important differences across and within markets in the extent to which people look for information about health insurance alternatives and the role of the Internet in their search. Although many individuals were unaware of whether their employer or health plan provided a website to manage health benefits, those who used the sites generally evaluated them favorably.Our results suggest that the Internet is an important source of health insurance information, particularly for individuals purchasing coverage individually in the nongroup and Medicare markets relative to those obtaining coverage from an employer. In the case of Medicare coverage, studies focusing on beneficiaries' use of Internet resources may underestimate the Internet's importance by neglecting caregivers who use the Internet. Many individuals may be unaware of the valuable resources available through employers or health plans.

    View details for Web of Science ID 000223835600005

    View details for PubMedID 15515993

  • Relationship between HMO market share and the diffusion and use of advanced MRI technologies. Journal of the American College of Radiology Baker, L. C., Atlas, S. W. 2004; 1 (7): 478-487

    Abstract

    Financial incentives associated with managed care may shift incentives associated with the adoption of new medical technologies. This study examined whether managed-care activity was associated with the adoption rate of magnetic resonance imaging (MRI) equipment during the 1990s.Data from three nationwide "censuses" of MRI sites conducted in 1993, 1997, and 1999 were used. The number of MRI sites and magnets; magnet field strength; MRI procedures; the use of contrast media; and the presence of power injectors, echoplanar imaging, cardiac MRI, and interventional MRI were measured in each of 322 metropolitan statistical areas each year. Regression analysis was used to assess the relationship between area MRI availability and overall area health maintenance organization (HMO) market share, controlling for potential confounders.Areas with higher HMO activity had markedly lower adoption and use of MRI. By 1999, high-HMO areas had about 40% fewer MRI scanners per 100,000 people than low-HMO areas (1.02 vs. 1.73, P < .01). High-HMO areas had fewer 1.5-T scanners than low areas in all 3 years and tended to use contrast media less often in 1993 and 1997 (all P < .01). There were statistically insignificant trends toward less availability of echoplanar imaging, cardiac MRI, and interventional MRI in high-HMO areas.The fact that managed care is associated with the slower adoption of MRI and less availability of some of the most advanced MRI equipment suggests the need for attention to the potential for managed care to have important effects on the quality of care and health care spending by influencing technology growth.

    View details for PubMedID 17411636

  • Variation in access to health care for different racial/ethnic groups by the racial/ethnic composition of an individual's county of residence MEDICAL CARE Haas, J. S., Phillips, K. A., Sonneborn, D., McCulloch, C. E., Baker, L. C., Kaplan, C. P., Perez-Stable, E. J., Liang, S. Y. 2004; 42 (7): 707-714

    Abstract

    Although the majority of studies examining racial/ethnic disparities in health care have focused on the characteristics of the individual, more recently there has been growing attention to the notion that an individual's health practices could be influenced by the characteristics of the place where they reside.The objective of this study was to examine whether access to care for individuals of different racial/ethnic groups varies by the prevalence of blacks and the prevalence of Latinos in their county of residence.We conducted a cross-sectional cohort.Individuals from the 1996 Medical Expenditure Panel Survey, a nationally representative sample of U.S. households, who described their race/ethnicity as white, black, or Latino, and who resided in 1 of 677 counties (n = 14740) were studied.Counties were assigned to 6 groups based on the prevalence of blacks and Latinos who resided there (<6% referred to as "low prevalence," 6-39% referred to as "midprevalence," >or=40% referred to as "high prevalence" separately for both blacks and Latinos). Outcomes included whether during the past year any family members: 1). experienced difficulty obtaining any type of health care, delayed obtaining care, or did not receive health care they thought they needed (referred to as "difficulty obtaining care"); or (2). did not receive a doctor's care or a prescription medication because the family needed money to buy food, clothing, or pay for housing (referred to as "financial barriers").After controlling for other individual and area-level covariates, blacks reported lower rates of both outcome variables when they lived in a county with a high prevalence of blacks compared with blacks who lived in a county with a low prevalence of blacks (difficulty obtaining care: 4.3% vs. 18.8%, P <0.005; financial barriers: 1.6% vs. 10.5%, P <0.005). There was a similar association for Latinos by the prevalence of Latinos in the county for difficulty obtaining care (high: 5.0% vs. low: 13.4%, P <0.05), but not the financial barriers outcome (high: 2.2% vs. low: 2.4%, P = 0.90). Whites who lived in an area with a high prevalence of Latinos were more likely to report both outcomes compared with whites who lived in a county with a low prevalence of Latinos (difficulty obtaining care: 17.7% vs. 9.4%, P <0.05; financial barriers: 8.5% vs. 3.2%, P <0.005) .Blacks and Latinos may perceive fewer barriers to care when they live in a county with a high prevalence of people of similar race/ethnicity. Conversely, whites may perceive more difficulty receiving care when they live in an area with a high prevalence of Latinos. Diminishing disparities in access to health care may require interventions that extend beyond the individual.

    View details for DOI 10.1097/01.mlr.0000129906.95881.83

    View details for Web of Science ID 000222440300012

    View details for PubMedID 15213496

  • Managed care, information, and diffusion: The case of treatment for heart-attack patients AMERICAN ECONOMIC REVIEW Baker, L. C., Afendulis, C. C., Heidenreich, P. A. 2004; 94 (2): 347-351
  • Are gatekeeper requirements associated with cancer screening utilization? HEALTH SERVICES RESEARCH Phillips, K. A., Haas, J. S., Liang, S. Y., Baker, L. C., Tye, S., Kerlikowske, K., Sakowski, J., Spetz, A. 2004; 39 (1): 153-178

    Abstract

    There is widespread debate over whether health plans should require enrollees to use "gatekeepers," which are primary care providers that coordinate care and control access to specialists. However, little is known about whether health plan gatekeeper requirements improve or reduce quality-of-care. Our objective was to examine whether gatekeeper requirements are associated with the utilization of cancer screening for breast, cervical, and prostate cancer.Three linked sources (N = 13,534): (1) 1996 Medical Expenditure Panel Survey (MEPS) Household Survey, a nationally representative, ongoing survey sponsored by the Agency for Healthcare Research and Quality; (2) 1996 MEPS Health Insurance Plan Abstraction, which codes data from health plan booklets obtained from privately insured respondents, and (3) 1995 National Health Interview Survey.Cross-sectional, multivariate logistic regression analysis using secondary data.We found in multivariate analyses that women in gatekeeper plans were significantly more likely to obtain mammography screening (Odds Ratio [OR] = 1.22, 95 percent Confidence Interval [CI] 1.07-1.40), clinical breast examinations (OR = 1.39, 95 percent CI 1.23-1.57), and Pap smears (OR = 1.33, 95 percent CI 1.16-1.52) than women not in gatekeeper plans. In contrast, gatekeeper requirements were not associated with prostate cancer screening (OR = 1.11, 95 percent CI 0.93-1.33). We found no association between screening utilization and aggregate plan types (HMO, POS, PPO, FFS).Gatekeeper requirements are associated with higher utilization of widely recommended cancer screening procedures, but not with utilization of a less uniformly recommended cancer screening procedure. Researchers should consider the analysis of specific plan characteristics rather than aggregate plan types in conducting future research, and insurers and policymakers should consider the potential benefits of gatekeepers with respect to preventive care when designing health plans and legislation.

    View details for Web of Science ID 000188758000011

    View details for PubMedID 14965082

  • Do health plans influence quality of care? INTERNATIONAL JOURNAL FOR QUALITY IN HEALTH CARE Baker, L. C., Hopkins, D., Dixon, R., Rideout, J., Geppert, J. 2004; 16 (1): 19-30

    Abstract

    To investigate the relative impact of physician groups and health plans on quality of care measures.Secondary data analysis of receipt of preventive care services included in the Health Plan Employer Data and Information Set (HEDIS) among 10 758 patients representing 21 health maintenance organizations and 22 large provider groups in the San Francisco and Los Angeles, California, areas in 1997. Each patient was eligible for (at least) one of six HEDIS-measured services. Data identify whether or not the service was provided, the patient's health plan, and the provider group responsible for the care. We used logistic regression to examine variations across plans in HEDIS rates, and whether variations persist after controls for provider groups are included.Patients from 21 health maintenance organizations serving San Francisco and Los Angeles, California, in 1997.Breast cancer screening, childhood immunizations, cervical cancer screening, diabetic retinal exam, prenatal care in the first trimester, and check-ups after delivery among patients for whom these services are appropriate.There are statistically significant differences across health plans in utilization rates for the six services examined. These differences are not substantially affected when we control for the provider group that cared for the patient. That is, controlling for provider group does not explain variations across plans, consistent with the view that health plans have an impact on HEDIS quality measures independent of the providers that they contract with.There are activities that plans can undertake which influence their HEDIS scores. On the face of it, these results suggest that plans can independently improve quality, in contrast to hypotheses that plans would be "too far" from patients to have an influence. Continued attention to collecting plan-level data is warranted. Further work should address other possible sources of variations in HEDIS scores, such as variability in the quality of plan administrative databases.

    View details for DOI 10.1093/intqhc/mzh003

    View details for Web of Science ID 000188796200004

    View details for PubMedID 15020557

  • Within-year variation in hospital utilization and its implications for hospital costs JOURNAL OF HEALTH ECONOMICS Baker, L. C., Phibbs, C. S., Guarino, C., Supina, D., Reynolds, J. L. 2004; 23 (1): 191-211

    Abstract

    Variability in demand for hospital services may have important effects on hospital costs, but this has been difficult to examine because data on within-year variations in hospital use have not been available for large samples of hospitals. We measure daily occupancy in California hospitals and examine variation in hospital utilization at the daily level. We find substantial day-to-day variation in hospital utilization, and noticeable differences between hospitals in the amount of day-to-day variation in utilization. We examine the impact of variation on hospital costs, showing that increases in variance are associated with increases in hospital expenditures, but that the effects are qualitatively modest.

    View details for DOI 10.1016/j.jhealeco.2003.09.005

    View details for Web of Science ID 000189210600009

    View details for PubMedID 15154694

  • The relationship between technology availability and health care spending HEALTH AFFAIRS Baker, L., Birnbaum, H., Geppert, J., Mishol, D., Moyneur, E. 2003; 22 (6): W537-W551
  • The relationship between technology availability and health care spending. Health affairs Baker, L., Birnbaum, H., Geppert, J., Mishol, D., Moyneur, E. 2003: W3-537 51

    Abstract

    We analyze the relationship between the supply of new technologies and health care utilization and spending, focusing on diagnostic imaging, cardiac, cancer, and newborn care technologies. As anticipated by previous research, increases in the supply of technology tend to be related to higher utilization and spending on the service in question. In some cases, notably diagnostic imaging, increases in availability appear associated with incremental utilization rather than substitution for other services. Policy efforts to assess and manage the availability of new technologies could benefit society where the additional spending produced by new services is not associated with strong quality improvements.

    View details for PubMedID 15506158

  • Use of the Internet and e-mail for health care information - Results from a national survey JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Baker, L., Wagner, T. H., Singer, S., Bundorf, M. K. 2003; 289 (18): 2400-2406

    Abstract

    The Internet has attracted considerable attention as a means to improve health and health care delivery, but it is not clear how prevalent Internet use for health care really is or what impact it has on health care utilization. Available estimates of use and impact vary widely. Without accurate estimates of use and effects, it is difficult to focus policy discussions or design appropriate policy activities.To measure the extent of Internet use for health care among a representative sample of the US population, to examine the prevalence of e-mail use for health care, and to examine the effects that Internet and e-mail use has on users' knowledge about health care matters and their use of the health care system.Survey conducted in December 2001 and January 2002 among a sample drawn from a research panel of more than 60 000 US households developed and maintained by Knowledge Networks. Responses were analyzed from 4764 individuals aged 21 years or older who were self-reported Internet users.Self-reported rates in the past year of Internet and e-mail use to obtain information related to health, contact health care professionals, and obtain prescriptions; perceived effects of Internet and e-mail use on health care use.Approximately 40% of respondents with Internet access reported using the Internet to look for advice or information about health or health care in 2001. Six percent reported using e-mail to contact a physician or other health care professional. About one third of those using the Internet for health reported that using the Internet affected a decision about health or their health care, but very few reported impacts on measurable health care utilization; 94% said that Internet use had no effect on the number of physician visits they had and 93% said it had no effect on the number of telephone contacts. Five percent or less reported use of the Internet to obtain prescriptions or purchase pharmaceutical products.Although many people use the Internet for health information, use is not as common as is sometimes reported. Effects on actual health care utilization are also less substantial than some have claimed. Discussions of the role of the Internet in health care and the development of policies that might influence this role should not presume that use of the Internet for health information is universal or that the Internet strongly influences health care utilization.

    View details for Web of Science ID 000182831200030

    View details for PubMedID 12746364

  • Is the prevalence of gatekeeping in a community associated with individual trust in medical care? MEDICAL CARE Haas, J. S., Phillips, K. A., Baker, L. C., Sonneborn, D., McCulloch, C. E. 2003; 41 (5): 660-668

    Abstract

    Consumer concerns about the restrictions of managed care may lead to distrust.To examine whether a community's level of gatekeeping activity is associated with an individual's trust in medical care.Cross-sectional cohort (N = 49,929).Participants in a nationally representative sample derived from the Community Tracking Survey who had health insurance, had a usual source of care, made at least 1 physician visit, and resided in one of the sampled metropolitan areas with corresponding community-level data, including the prevalence of gatekeeping activity.Four questions measuring trust in physician.Individuals from communities with a higher prevalence of gatekeeping activity report less trust than individuals from areas with a lower prevalence of gatekeeping activity, after adjusting for whether that individual had a health plan with a gatekeeper requirement. For example, in communities with the highest prevalence of gatekeeping activity relative to the lowest, the odds ratio for individuals to agree strongly that they trusted their doctor to put their medical needs above all other considerations was 0.77 (95% confidence interval, 0.71-0.84). Also, a higher prevalence of gatekeeping in the community was positively associated with the perception that a physician was strongly influenced by insurance company rules when making decisions about medical care. Conversely, a higher prevalence of gatekeeping in the community was negatively associated with the perception that a doctor might perform an unnecessary test or procedure and with concern about restricted referral for specialty care.Individuals' trust in their physicians may be influenced by wider contextual variables, like the prevalence of gatekeeping in the community.

    View details for Web of Science ID 000182695900014

    View details for PubMedID 12719690

  • Managed care spillover effects ANNUAL REVIEW OF PUBLIC HEALTH Baker, L. C. 2003; 24: 435-456

    Abstract

    In addition to influencing care for patients enrolled in managed care plans, growth in managed care could lead to broad changes in the structure and functioning of the health care system that could ultimately influence care for all patients, even those not covered by managed care plans. This paper summarizes the mechanisms by which these effects could arise, including shifts in the types of services available in markets and changes in physician practice patterns. The paper summarizes available empirical evidence on broad-level effects of managed care, concluding that the literature supports the view that managed care can have generalized effects on health care spending, utilization patterns, and infrastructure, although existing literature has not clearly identified effects on health outcomes.

    View details for DOI 10.1146/annurev.publhealth.24.100901.141000

    View details for Web of Science ID 000185094600022

    View details for PubMedID 12471276

  • Managed care, technology adoption, and health care: the adoption of neonatal intensive care RAND JOURNAL OF ECONOMICS Baker, L. C., Phibbs, C. S. 2002; 33 (3): 524-548

    Abstract

    Managed care may influence technology diffusion in health care. This article empirically examines the relationship between HMO market share and the diffusion of neonatal intensive care units. Higher HMO market share is associated with slower adoption of mid-level units, but not with adoption of the most advanced high-level units. Opposite the common supposition that slowing technology growth will harm patients, results suggest that health outcomes for seriously ill newborns are better in higher-level units and that reduced availability of mid-level units may increase their chance of receiving care in a high-level center, so that slower mid-level growth could have benefitted patients.

    View details for Web of Science ID 000179256800010

    View details for PubMedID 12585306

  • Management of ventricular arrhythmias in diverse populations in California AMERICAN HEART JOURNAL Alexander, M., Baker, L., Clark, C., McDonald, K. M., Rowell, R., Saynina, O., Hlatky, M. A. 2002; 144 (3): 431-439

    Abstract

    The use of coronary angiography and revascularization is lower than expected among black patients. It is uncertain whether use of other cardiac procedures also varies according to race and ethnicity and whether outcomes are affected.We analyzed discharge abstracts from all nonfederal hospitals in California of patients hospitalized for a primary diagnosis of ventricular tachycardia or ventricular fibrillation between 1992 and 1994. We compared mortality rates and use of electrophysiologic study (EPS) and implantable cardioverter-defibrillator (ICD) procedures according to the race and ethnicity of the patient.Among 8713 patients admitted with ventricular tachycardia or ventricular fibrillation, 29% (n = 2508) had a subsequent EPS procedure, and 9% (n = 818) had an ICD implanted. After controlling for potential confounding factors, we found that black patients were significantly less likely than white patients to undergo EPS (odds ratio 0.72, CI 0.56-0.92) or ICD implantation (odds ratio 0.39, CI 0.25-0.60). Blacks discharged alive from the initial hospital admission had higher mortality rates over the next year than white patients, even after controlling for multiple confounding risk factors (risk ratio 1.18, CI 1.03-1.36). The use of EPS and ICD procedures was also significantly affected by several other factors, most notably by on-site procedure availability but also by age, sex, and insurance status.In a large population of patients hospitalized for ventricular arrhythmia, blacks had significantly lower rates of utilization for EPS and ICD procedures and higher subsequent mortality rates.

    View details for DOI 10.1067/mhj.2002.125500

    View details for Web of Science ID 000178086800010

    View details for PubMedID 12228779

  • Effect of managed care on preventable hospitalization rates in California MEDICAL CARE Backus, L., Moron, M., Bacchetti, P., Baker, L. C., Bindman, A. B. 2002; 40 (4): 315-324

    Abstract

    Hospitalization rates for ambulatory care-sensitive (ACS) conditions have emerged as a potential indicator of health care access and quality. The effect of managed care on reducing these potentially preventable hospitalizations is unknown.To ascertain whether increases in managed care penetration were associated with changes in hospitalization rates for ACS conditions.Longitudinal analysis between 1990 and 1997 of all California hospitalizations for ACS conditions aggregated to 394 small areas.Association of change in ACS hospitalization rate with change in managed care penetration.In unadjusted analysis there was no association between the change in managed care penetration and the change in hospitalization rates for ACS conditions over time. However, in a multivariate model that controlled for changes in area demographics and hospitalization rates for marker conditions that were assumed to be stable over time, the change in managed care penetration was negatively associated with a small but statistically significant change in the ACS hospitalization rate. Each 10-point increase in percentage private managed care penetration was associated with a 3.1% decrease in the ACS hospitalization rate (95% CI, -5.4% to -0.8%)Overall, in California, an increase in the penetration of private managed care in a community was associated with a decrease in ACS admission rates. Additional research is needed to determine if the observed association is causal, the mechanism of the effect and whether it represents an improvement in patients' health outcomes.

    View details for Web of Science ID 000174712000007

    View details for PubMedID 12021687

  • Managed care, medical technology, and the well-being of society. Topics in magnetic resonance imaging Baker, L. 2002; 13 (2): 107-113

    Abstract

    The growth of managed care could have widespread effects on the structure and functioning of the health care delivery system, potentially influencing all patients, even those not enrolled in managed care plans. One important mechanism by which managed care could have such broad effects is by influencing technology development and adoption. This article examines available literature on the effects of managed care activity on technology adoption and the implications of any effects on patient care, outcomes, and health care costs. Existing literature supports the view that managed care has contributed to slowing the adoption of new technologies, particularly the high-cost, high-profile technologies that have been the focus of the most attention. The literature outlining the effects of managed-care-induced changes in technology adoption on patient care and outcomes is not large, but what literature there is tends not to find negative effects on patient care and outcomes. Specific evidence about costs also is somewhat sparse, but it suggests that managed care has contributed to some reduction in health care spending, although the extent to which savings will persist over time is unclear. Although evidence thus far does not suggest important detrimental effects of managed care on care or outcomes and even indicates some benefit through savings, it should be noted that existing literature has only explored a small number of the many technologies and services that might have been influenced, and there remain issues for the future that deserve vigilance.

    View details for PubMedID 12055455

  • The burden of out-of-pocket payments for health care in Tbilisi, Republic of Georgia JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Skarbinski, J., Walker, H. K., Baker, L. C., Kobaladze, A., Kirtava, Z., Raffin, T. A. 2002; 287 (8): 1043-1049

    Abstract

    In the 1990s, the Republic of Georgia instituted health care reforms to convert the centralized, state-operated health care system inherited from the Soviet Union to a decentralized, market-driven system of health care delivery. Under the new system, 87% of health care expenditures are financed through out-of-pocket payments at the point of service.To describe the effects of health care reforms on access to care and health care financing among ill residents of Tbilisi, Georgia.A probability-proportionate-to-size cluster survey conducted in 1999 of 248 households containing 306 household members who had been ill in the past 6 months in Tbilisi, Georgia.Reported health care utilization, out-of-pocket expenditures, and financing practices.Of sick household members, 51% used official health care services at hospitals and clinics; 49% did not use official services and sought advice from relatives or friends, used traditional medicines, or did nothing. Those with serious illness were more likely to seek care through official services (82%) than those with nonserious illness (27%). Ninety-three percent of respondents said costs were the major deterrent to obtaining health care. Ten percent of ill household members reported that they were unable to obtain health care because of high costs; 16% reported being unable to afford all the medications necessary to treat their illness. Sixty-one percent of ill household members used savings to pay for health care expenditures and 19% of those able to obtain care had to use strategies such as borrowing money or selling personal items to pay for health care. Total out-of-pocket health care expenditures (53%) were paid for by borrowing money or selling personal items. A significant portion of households with ill members (87%) reported an interest in purchasing health care insurance.Economic disruption and health care reforms have led to access problems and out-of-pocket financing strategies that include reliance on personal savings, selling personal items, and borrowing money. Future reforms should consider an appropriate system for health care insurance risk pooling for the population of Tbilisi, Georgia.

    View details for Web of Science ID 000174052100036

    View details for PubMedID 11866656

  • The relation between managed care market share and the treatment of elderly fee-for-service patients with myocardial infarction AMERICAN JOURNAL OF MEDICINE Heidenreich, P. A., McClellan, M., Frances, C., Baker, L. C. 2002; 112 (3): 176-182

    Abstract

    To determine if greater managed care market share is associated with greater use of recommended therapies for fee-for-service patients with acute myocardial infarction.We examined the care of 112,900 fee-for-service Medicare beneficiaries aged > or = 65 years who resided in one of 320 metropolitan statistical areas and who were admitted with an acute myocardial infarction between February 1994 through July 1995. Use of recommended medical treatments and 30-day survival were determined for areas with low (<10%), medium (10% to 30%), and high (>30%) managed care market share.After adjustment for severity of illness, teaching status of the admission hospital, and area characteristics, areas with high levels of managed care had greater use of beta-blockers (relative risk [RR] for greater use = 1.18; 95% confidence interval [CI]: 1.06 to 1.29) and aspirin at discharge (RR = 1.05; 95% CI: 1.02 to 1.07), but less appropriate coronary angiography (RR = 0.93; 95% CI: 0.86 to 1.01) and reperfusion (RR = 0.95; 95% CI: 0.85 to 1.03) when compared with areas with low levels of managed care.Medicare beneficiaries with fee-for-service insurance who resided in areas with high managed care activity were more likely to have received appropriate treatment with beta-blockers and aspirin, and less likely to have undergone coronary angiography following admission for myocardial infarction. Thus, the effects of managed care may not be limited to managed care enrollees.

    View details for Web of Science ID 000174602100002

    View details for PubMedID 11893343

  • Managed care and technology adoption in health care: evidence from magnetic resonance imaging JOURNAL OF HEALTH ECONOMICS Baker, L. C. 2001; 20 (3): 395-421

    Abstract

    This paper empirically examines the relationship between HMO market share and the diffusion of magnetic resonance imaging (MRI) equipment. Across markets, increases in HMO market share are associated with slower diffusion of MRI into hospitals between 1983 and 1993, and with substantially lower overall MRI availability in the mid- and later 1990s. High managed care areas also had markedly lower rates of MRI procedure use. These results suggest that technology adoption in health care can respond to changes in financial and other incentives associated with managed care, which may have implications for health care costs and patient welfare.

    View details for Web of Science ID 000168292500006

    View details for PubMedID 11373838

  • The impact of practice setting on physician perceptions of the quality of practice and patient care in the managed care era ARCHIVES OF INTERNAL MEDICINE Chehab, E. L., Panicker, N., Alper, P. R., Baker, L. C., Wilson, S. R., Raffin, T. A. 2001; 161 (2): 202-211

    Abstract

    Managed care is practiced in both traditional institutional health maintenance organization (HMO) settings and in a variety of complex and decentralized office-based arrangements. This study examines how practice setting affects physician perceptions of the quality of professional practice and patient care in a managed care environment.A survey was conducted in 1998 of 1081 physicians in San Mateo County, California, who practice in either a traditional staff group model HMO (SGM-HMO) (n = 113) or office-based independent practice (OBIP) (n = 250). Respondents were surveyed about current and past practice characteristics, income changes, current satisfaction with professional and patient care matters, utility of treatment guidelines and formularies, and general perceptions of managed care. Responses were compared between practice settings using bivariate comparisons and logistic regression analyses.Physicians in the SGM-HMO and those in OBIP reported similar hours worked per week, time spent with patients during office visits, and total patient encounters per week. Declining income was more frequent in OBIP (61% vs 47%) and relatively more substantial (27% with income declines >25% vs 4% in SGM-HMO). Adjusting for income changes, practice setting, years in practice, and sex, SGM-HMO physicians were significantly more satisfied with a variety of professional and quality of care issues (P<.001), viewed more favorably the utility of treatment guidelines and drug formularies (P<.001), and held more positive general perceptions of managed care (P<.001) than OBIP physicians.In a managed care environment, SGM-HMO physicians are significantly more satisfied with the quality of practice and patient care than physicians in OBIP. This study suggests that the myriad managed care contracts, formularies, and guidelines received by physicians in OBIPs may lead to more negative perceptions of the quality of professional practice and patient care.

    View details for Web of Science ID 000166480500008

    View details for PubMedID 11176733

  • Managed Care, Health Care Quality, and Regulation Journal of Legal Studies Baker LC, McClellan MB 2001; 30 (2, part 2): 715-742
  • The effect of passing an "anti-immigrant" ballot proposition on the use of prenatal care by foreign-born mothers in California. Journal of immigrant health Spetz, J., Baker, L., Phibbs, C., Pedersen, R., TAFOYA, S. 2000; 2 (4): 203-212

    Abstract

    This study examines whether the passage of California's Proposition 187, a proposition designed to restrict undocumented immigrants from using public services, had a negative effect on the use of prenatal care and birth outcomes. Comparisons of prenatal care use and birth outcomes before and after the passage of the proposition are made between low-education foreign-born and U.S.-born mothers using California's Birth Public Use files. Multivariate linear and logistic regressions were used to control for regional and maternal characteristics. We find a significant but small decline in the use of prenatal care by low-education foreign-born women after Proposition 187 passed; however, there was no detectable deterioration of birth outcomes. Whether future reductions in the availability of prenatal care would damage the health of children is unclear.

    View details for PubMedID 16228741

  • HMO market penetration and costs of employer-sponsored health plans HEALTH AFFAIRS Baker, L. C., Cantor, J. C., Long, S. H., Marquis, M. S. 2000; 19 (5): 121-128

    Abstract

    Using two employer surveys, we evaluate the role of increased health maintenance organization (HMO) market share in containing costs of employer-sponsored coverage. Total costs for employer health plans are about 10 percent lower in markets in which HMOs' market share is above 45 percent than they are in markets with HMO enrollments of below 25 percent. This is the result of lower premiums for HMOs than for non-HMO plans, as well as the competitive effect of HMOs that leads to lower non-HMO premiums for employers that continue to offer these benefits. Slower growth in premiums in areas with high HMO enrollments suggests that expanded HMO market share may also lower the long-run growth in costs.

    View details for Web of Science ID 000089288200014

    View details for PubMedID 10992659

  • Medicaid policy, physician behavior, and health care for the low-income population JOURNAL OF HUMAN RESOURCES Baker, L. C., Royalty, A. B. 2000; 35 (3): 480-502
  • 'Competition' among employers offering health insurance JOURNAL OF HEALTH ECONOMICS Dranove, D., Spier, K. E., Baker, L. 2000; 19 (1): 121-140

    Abstract

    Most employees contribute towards the cost of employer-sponsored insurance, despite tax laws that favor zero contributions. Contribution levels vary markedly across firms, and the average contribution (as a percentage of the premium) has increased over time. We offer a novel explanation for these facts: employers raise contribution levels to encourage their employees to obtain coverage from their spouses' employer. We develop a model to show how the employee contribution required by a given firm depends on characteristics of the firm and its work force, and find empirical support for many of the model's predictions.

    View details for Web of Science ID 000084635300005

    View details for PubMedID 10947570

  • Medicaid Policy, Physician Behavior, and Health Care for the Low-Income Population Journal of Human Resources Baker LC, Royalty AB 2000; 35 (3): 480-502
  • Physicians' perceptions of autonomy and satisfaction in California HEALTH AFFAIRS Burdi, M. D., Baker, L. C. 1999; 18 (4): 134-145

    Abstract

    This study compares levels of satisfaction and autonomy among California physicians using data from a 1991 survey of physicians and a 1996 survey of California physicians. The surveys measured physicians' perceived freedom to undertake eight common activities that may be threatened by marketplace changes, satisfaction with current practice, and inclination to attend medical school again. Young physicians in 1996 were significantly less likely to report that they were able to spend enough time on the eight identified patient-care activities. They also were significantly less satisfied with their current practice and less likely to say that they would go to medical school again. Satisfaction also declined for older physicians between 1991 and 1996.

    View details for Web of Science ID 000081518400015

    View details for PubMedID 10425851

  • Managed care, consolidation among health care providers, and health care: evidence from mammography RAND JOURNAL OF ECONOMICS Baker, L. C., Brown, M. L. 1999; 30 (2): 351-U2

    Abstract

    We discuss the effects of managed care on the structure of the health care delivery system, focusing on managed-care-induced consolidation among health care providers. We empirically investigate the relationship between HMO market share and mammography providers. We find evidence of consolidation: increases in HMO activity are associated with reductions in the number of mammography providers and with increases in the number of services produced by remaining providers. We also find that increases in HMO market share are associated with reductions in costs for mammography and with increases in waiting times for appointments, but not with worse health outcomes.

    View details for Web of Science ID 000080841000009

    View details for PubMedID 10558503

  • Association of managed care market share and health expenditures for fee-for-service Medicare patients JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Baker, L. C. 1999; 281 (5): 432-437

    Abstract

    Managed care has the potential to transform fundamentally the structure and functioning of the entire health care system, including the care provided to patients who are not enrolled in managed care plans.To determine whether increasing health maintenance organization (HMO) market share is associated with decreased expenditures for the care of patients covered by Medicare's traditional fee-for-service plan, a group cared for well outside the boundaries of managed care.Data from the Health Care Financing Administration were used to compare expenditures for the care of Medicare fee-for-service beneficiaries for 802 market areas, representing the entire United States, for 1990 to 1994. These data were matched with data on system-wide (Medicare and non-Medicare) HMO market share in these areas.All fee-for-service Medicare beneficiaries (1990-1994) except for those with end-stage renal disease.Average fee-for-service expenditure per fee-for-service Medicare beneficiary by market area.In a regression model, increases in system-wide HMO market share were associated with declines in both Part A and Part B fee-for-service expenditures per Medicare beneficiary (P<.001). Increases from 10% market share to 20% market share were associated with 2.0% decreases in Part A fee-for-service expenditures and 1.5% decreases in Part B fee-for-service expenditures.Managed care can have widespread effects on the health care system. Health care for individuals who are not covered by managed care organizations can be influenced by the presence of managed care. Lower expenditures in areas with high HMO market shares may indicate that traditional Medicare beneficiaries in areas with high market shares received fewer or less intensive services than traditional Medicare beneficiaries in other areas.

    View details for Web of Science ID 000078318500031

    View details for PubMedID 9952203

  • Effect of an intensive educational program for minority college students and recent graduates on the probability of acceptance to medical school JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Cantor, J. C., Bergeisen, L., Baker, L. C. 1998; 280 (9): 772-776

    Abstract

    Increasing the number of minority physicians is a long-standing goal of professional associations and government.To determine the effectiveness of an intensive summer educational program for minority college students and recent graduates on the probability of acceptance to medical school.Nonconcurrent prospective cohort study based on data from medical school applications, Medical College Admission Tests, and the Association of American Medical Colleges Student and Applicant Information Management System.Eight US medical schools or consortia of medical schools.Underrepresented minority (black, Mexican American, mainland Puerto Rican, and American Indian) applicants to US allopathic medical schools in 1997 (N =3830), 1996 (N = 4654), and 1992 (N =3447).The Minority Medical Education Program (MMEP), a 6-week, residential summer educational program focused on training in the sciences and improvement of writing, verbal reasoning, studying, test taking, and presentation skills.Probability of acceptance to at least 1 medical school.In the 1997 medical school application cohort, 223 (49.3%) of 452 MMEP participants were accepted compared with 1406 (41.6%) of 3378 minority nonparticipants (P= .002). Positive and significant program effects were also found in the 1996 (P=.01) and 1992 (P=.005) cohorts and in multivariate analysis after adjusting for nonprogrammatic factors likely to influence acceptance (P<.001). Program effects were also observed in students who participated in the MMEP early in college as well as those who participated later and among those with relatively high as well as low grades and test scores.The MMEP enhanced the probability of medical school acceptance among its participants. Intensive summer education is a strategy that may help improve diversity in the physician workforce.

    View details for Web of Science ID 000075609900004

    View details for PubMedID 9729987

  • Managed care and technology diffusion: The case of MRI HEALTH AFFAIRS Baker, L. C., Wheeler, S. K. 1998; 17 (5): 195-207

    Abstract

    A growing body of evidence suggests that managed care can reduce overall health care costs but provides little insight into how this could happen. One possibility is that managed care influences the adoption of new medical technologies. In examining the relationship between health maintenance organization (HMO) activity and market-level availability and use of magnetic resonance imaging (MRI), we find that high HMO market share is associated with low levels of MRI availability and use. This suggests that managed care may be able to reduce health care costs by influencing the adoption and use of new medical equipment and technologies.

    View details for Web of Science ID 000075974700016

    View details for PubMedID 9769583

  • Factors associated with women's adherence to mammography screening guidelines HEALTH SERVICES RESEARCH Phillips, K. A., Kerlikowske, K., Baker, L. C., Chang, S. W., Brown, M. L. 1998; 33 (1): 29-53

    Abstract

    To examine individual and environmental factors associated with adherence to mammography screening guidelines.A unique data set that combines a national probability sample (1992 National Health Interview Survey); a national probability sample of mammography facility characteristics (1992 National Survey of Mammography Facilities); county-level data on 1990 HMO market share; and county-level data on the supply of primary care providers (1991 Area Resource File).The design was cross-sectional. DATA EXTRACTION/ANALYSIS: Data sets were linked to create an individual-level sample of women ages 50-74 (weighted n = 2,026). We used multipart, sequential logistic regression models to examine the predictors of having ever had mammography, having had recent mammography, and adherence to guidelines. We categorized women as adherent if they reported a lifetime number of exams appropriate for their age (based on screening every two years) and they reported having had an exam in the past two years.Only 27 percent of women had the age-appropriate number of screening exams (range 16 percent-37 percent), while 59 percent of women had been screened within two years. Women were significantly more likely to adhere to screening guidelines if they reported participating with their doctor in the decision to be screened; were younger; had smaller families, higher education and income, and a recent Pap smear; reported breast problems; and lived in an area with a higher percentage of mammography facilities with reminder systems, no shortage of primary care providers, higher HMO market share, and higher screening charges.A small percentage of women adhere to screening guidelines, suggesting that adherence needs to become a focus of clinical, programmatic, and policy efforts.

    View details for Web of Science ID 000072969900004

    View details for PubMedID 9566176

  • Factors associated with the perception that debt influences physicians' specialty choices ACADEMIC MEDICINE Baker, L. C., Barker, D. C. 1997; 72 (12): 1088-1096

    Abstract

    To investigate the responses of individual physicians to educational debt.Data on 5,175 physicians were taken from the 1991 Robert Wood Johnson Foundation Survey of Young Physicians, a nationally representative survey of physicians under age 45 who had had two to ten years of practice experience as of 1991. The physicians' overall perceptions about the extents to which debt had been an important determinant of specialty choice were explored using multivariate logistic regression analyses.Only 3.2% of the physicians indicated that debt had had a major influence on their specialty choices. About half (56%) of those who felt that debt had been a major influence indicated that they had foregone some training because of their debt levels. Controlling for debt level, the physicians who had had children during medical school and those whose parents had less education and lower incomes were more likely to say that debt had been an influence (p < .05). An examination of the specialties that the physicians reported having foregone because of debt indicated that these physicians had reacted to debt in different ways--some had chosen more specialized fields while others had chosen more generalized fields.While the overall effect of debt was small, some individuals were influenced by debt in a variety of ways. Paying attention to the effects of debt on this small population may improve training for some physicians and help better target programs that attempt to influence physicians by alleviating debt.

    View details for Web of Science ID 000071232800028

    View details for PubMedID 9435716

  • Market-level health maintenance organization activity and physician autonomy and satisfaction AMERICAN JOURNAL OF MANAGED CARE Burdi, M. D., Baker, L. C. 1997; 3 (9): 1357-1366

    Abstract

    Managed care is widely expected to affect physicians throughout the healthcare system. In this study, we examined the relationship between health maintenance organization (HMO) activity and the level of competition, autonomy, and satisfaction perceived by physicians who do not work for HMOs. We obtained data on physicians from the 1991 Survey of Young Physicians, which contains a nationally representative sample of physicians younger than age 45 who had 2 to 9 years of practice experience in 1991. We examined the relationships between HMO market share and perceived competition, autonomy, and satisfaction using multivariate logistic regression. The main outcome measures were perceived level of competition; several measures of physicians' freedom to undertake common tasks that might be threatened by managed care (e.g., hospitalizing patients, ordering tests and procedures); satisfaction with current practice situation; perceived ability to practice quality medicine; whether the physician would attend medical school again; and satisfaction with medicine as a career. We found that an increase of 10 percentage points in HMO market share was associated with a 28% increase in the probability that physicians will regard their practice situation as very competitive as opposed to somewhat or not competitive (P < 0.01). Examinations of the relationship between HMO market share and autonomy and satisfaction revealed few significant results. We found no evidence that increases in HMO activity adversely affect physician autonomy. Only a limited amount of evidence indicates that increases in HMO activity reduce the satisfaction of specialist physicians, and no evidence associates HMO activity with the satisfaction of generalists. Although physicians perceive HMOs as competitors, HMO activity has not had a strong negative effect on the autonomy and satisfaction of physicians.

    View details for Web of Science ID A1997YJ15500008

    View details for PubMedID 10178484

  • The effect of HMOs on fee-for-service health care expenditures: Evidence from Medicare JOURNAL OF HEALTH ECONOMICS Baker, L. C. 1997; 16 (4): 453-481

    Abstract

    This paper examines the relationship between HMO market share and fee-for-service health care expenditures using 1986-1990 county- and metropolitan statistical area-level data on Medicare expenditures and HMO market share. Fixed-effects estimates imply that fee-for-service expenditures are concave and decreasing in market share. Increases in market share from 20% to 30% are associated with 3-7% expenditure reductions. Instrumental variable estimates that exploit cross-sectional variation in HMO activity also indicate a concave relationship, with expenditures declining in market share for market shares above 15-18%, but imply larger expenditure responses to market share changes.

    View details for Web of Science ID A1997XJ67900005

    View details for PubMedID 10169101

  • Physician service to the underserved: Implications for affirmative action in medical education INQUIRY-THE JOURNAL OF HEALTH CARE ORGANIZATION PROVISION AND FINANCING Cantor, J. C., Miles, E. L., Baker, L. C., Barker, D. C. 1996; 33 (2): 167-180

    Abstract

    Affirmative action is under increasing scrutiny. In medicine, the observation that minority physicians disproportionately serve minority patients has been one rationale for affirmative action. Using two large physician surveys, we find that minority and women physicians are much more likely to serve minority, poor, and Medicaid populations. Weaker, but significant association exists between physician and patient socioeconomic background. Service patterns are sustained over time and are generally consistent with physician career preferences. Ending affirmative action in medicine may imperil access to care. Results do not support affirmative action based on economic disadvantage instead of race, ethnicity, and sex.

    View details for Web of Science ID A1996UW89300009

    View details for PubMedID 8675280

  • Differences in earnings between male and female physicians NEW ENGLAND JOURNAL OF MEDICINE Baker, L. C. 1996; 334 (15): 960-964

    Abstract

    Male physicians have long earned more than female physicians, even after differences in the number of hours worked, specialty, practice setting, and other characteristics are taken into account. Whether earnings patterns have changed recently is not known.I examined data on earnings from the 1991 Survey of Young Physicians, a nationwide survey of physicians under 45 years of age with two to nine years of practice experience. The results were compared with data from the 1987 Survey of Young Physicians and with data on the earnings of physicians with 10 or more years of experience from the American Medical Association's 1991 Socioeconomic Monitoring System survey.In 1990, young male physicians earned 41 percent more per year than young female physicians (male:female earnings ratio, 1.41; 95 percent confidence interval, 1.34 to 1.49). Per hour, young men earned 14 percent more than young women (ratio, 1.14; 95 percent confidence interval, 1.09 to 1.20). However, after adjusting for differences in specialty, practice setting, and other characteristics, no earnings difference was evident (ratio, 1.00; 95 percent confidence interval, 0.96 to 1.04). In general practice and family practice, women earned more than men, after adjustment for differences in other characteristics (ratio, 0.87; 95 percent confidence interval, 0.78 to 0.97). In internal-medicine subspecialties and emergency medicine, men earned more than women (ratio, 1.26; 95 percent confidence interval, 1.10 to 1.44). Among physicians with 10 or more years of experience, men also earned more than women (ratio, 1.17; 95 percent confidence interval, 1.07 to 1.27).Young male and female physicians with similar characteristics earn equal amounts of money. However, differences in earnings between men and women remain among older physicians and in some specialties.

    View details for Web of Science ID A1996UD59600006

    View details for PubMedID 8596598

  • Medical costs in workers' compensation insurance JOURNAL OF HEALTH ECONOMICS Baker, L. C., Krueger, A. B. 1995; 14 (5): 531-549

    Abstract

    We examine whether patients covered by workers' compensation insurance, which covers the cost of medical care for injured workers without cost sharing and with relatively little oversight, are charged more for treatment or receive more services than patients covered by traditional insurance. Our findings indicate that workers compensation recipients are charged more for treatment. This difference persists in individual services--workers' compensation recipients are charged more per X-ray and per examination than our patients. We consider different explanations and argue that price discrimination probably plays a role.

    View details for Web of Science ID A1995TX26300002

    View details for PubMedID 10156500

  • Tracking the changes in physician practice settings. Archives of family medicine Hughes, R. G., Baker, L. C. 1995; 4 (9): 759-765

    Abstract

    To describe the relationships among types of practice settings and physician characteristics and to document changes in these relationships over time.Two national telephone surveys of randomly selected young physicians were conducted in 1987 and 1991. The 1991 survey included reinterviews of 1987 respondents, providing both cohort and repeated cross-sectional data.The 1987 survey included data on 5312 physicians who had between 2 and 6 years of practice experience and were under age 41 years. The 1991 survey included data on 5002 physicians under age 45 years and in practice between 2 and 10 years, including 2151 reinterviews of 1987 respondents.Practice settings were classified as traditional, government, group, or managed, based on ownership, practice type, group size, and managed care contracts.Physician sex, race/ethnicity, specialty, and type of medical school were related to the type of practice setting. Young physicians were less likely to practice in traditional settings in 1991 than in 1987 and were more likely to practice in organized practice settings, especially in managed practices.Between 1987 and 1991, there was a significant shift away from traditional physician practice settings toward organized practice settings.

    View details for PubMedID 7647941

  • What makes young HMO physicians satisfied? HMO practice / HMO Group Baker, L. C., Cantor, J. C., Miles, E. L., Sandy, L. G. 1994; 8 (2): 53-57

    Abstract

    While much attention has been paid to the effect of managed care on patient outcomes and health care costs, little attention has been focused on the ways in which managed care affects the satisfaction of physicians. Examination of the practice and career satisfaction of 189 young physicians practicing in group and staff model HMOs finds high levels of satisfaction. More than 82% are satisfied with their current practice. The most important factor influencing physician satisfaction appears to be the extent of perceived autonomy. Neither the number of hours worked per week nor yearly income were strongly associated with decreases in satisfaction. The fact that minority and female physicians report less satisfaction with some dimensions of practice raises important issues for HMO physicians and managers.

    View details for PubMedID 10135262

  • EXCESS COST OF EMERGENCY DEPARTMENT VISITS FOR NONURGENT CARE HEALTH AFFAIRS Baker, L. C., Baker, L. S. 1994; 13 (5): 162-171

    Abstract

    After examining data for patients with selected conditions and statistically adjusting for patient, diagnosis, and treatment characteristics, this Data Watch finds that charges for emergency department visits were two to three times more than charges for visits in other settings. Large differences persist when conditions are examined individually and when total episode charges are examined. Based on our findings, a rough estimate of nationwide excess charges is $5-$7 billion for 1993.

    View details for Web of Science ID A1994QB58700017

    View details for PubMedID 7868020

  • PREPAREDNESS FOR PRACTICE - YOUNG PHYSICIANS VIEWS OF THEIR PROFESSIONAL-EDUCATION JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Cantor, J. C., Baker, L. C., Hughes, R. G. 1993; 270 (9): 1035-1040

    Abstract

    To describe the views of young physicians (younger than age 45 years) regarding the appropriateness of specific aspects of medical training that have often been criticized as inadequate.Proportional analysis of survey data, stratified by medical school type and graduate medical education specialty and adjusted for demographics.National sample of 4756 allopathic and osteopathic physicians trained in allopathic residencies representing a variety of practice settings. DEPENDENT VARIABLES: Overall satisfaction with medical training, including medical school through residency and fellowship; satisfaction with preparedness for five aspects of practice and six types of patients; and satisfaction with the amount of time spent in each of six training settings.Eighty percent of young physicians reported that their formal medical training did an excellent or good job of preparing them for medical practice. Much smaller proportions (21% to 78%) reported excellent or good preparation to treat specific conditions or types of patients, and few (3%) reported being well prepared to manage business aspects of practice. Large proportions (35% to 63%) would prefer to have received more training in settings outside of hospitals, including managed care settings (67%). Significant differences in preparedness were observed by type of training; those trained in general and family practice reported better preparedness along many dimensions than did those trained in general internal medicine.Young physicians generally confirm critiques of medical training noted by scholars and commissions. Health care reform is likely to increase the urgency for remedial action.

    View details for Web of Science ID A1993LU51200002

    View details for PubMedID 8350444

  • PHYSICIAN SATISFACTION UNDER MANAGED CARE HEALTH AFFAIRS Baker, L. C., Cantor, J. C. 1993; 12: 258-270

    Abstract

    Data from a survey of young physicians have been analyzed to study the relationship between practicing medicine under managed care and the levels of perceived professional autonomy, practice satisfaction, and career satisfaction. Although practicing under managed care is associated with lower levels of perceived autonomy in patient selection and time allocation, it is associated with higher levels of perceived autonomy in use of hospital care, tests, and procedures. Specialists associated with managed care perceive more autonomy than generalists. Analyses of physicians' satisfaction with their practices and careers show that practicing under managed care is not uniformly associated with lower levels of satisfaction. Overall, managed care does not seem to have had the deleterious impact on medical practice that was forecast for it.

    View details for Web of Science ID A1993KT25500020

    View details for PubMedID 8477938

  • Twenty-four-hour coverage and workers' compensation insurance. Health affairs Baker, L. C., Krueger, A. B. 1993; 12: 271-281

    Abstract

    Workers' compensation insurance provides cash benefits and health care for workers who are injured on the job. This DataWatch considers the costs and benefits of combining the health insurance component of workers' compensation with universal health insurance, creating a twenty-four-hour coverage plan. The paper documents a large potential savings from twenty-four-hour coverage: Workers' compensation medical charges are about twice as high as those for comparable off-work injuries. This disparity seems to result from price discrimination and lack of cost controls in workers' compensation. Twenty-four-hour coverage, however, may be difficult to implement.

    View details for PubMedID 8477939

Conference Proceedings


  • Impact of new mid-level neonatal intensive care units on the level of care received by low-birthweight infants Haberland, C. A., Phibbs, C. S., Baker, L. C. NATURE PUBLISHING GROUP. 2004: 517A-517A
  • The effects of NICU patient volume and NICU level at the hospital of birth on neonatal mortality over time for infants with a birth weight < 2000 g: California 1991-1999 Phibbs, C. S., Baker, L. C., Schmitt, S. K., Danielsen, B., Phibbs, R. H. NATURE PUBLISHING GROUP. 2003: 442A-442A
  • The effects of NICU patient volume and NICU level at the hospital of birth on neonatal mortality overtime for infants with a birth weight < 2000g ; California 1991-1999. Phibbs, C. S., Baker, L. C., Schmitt, S. K., Phibbs, R. H. LIPPINCOTT WILLIAMS & WILKINS. 2003: S120-S120
  • Measuring competition in health care markets Baker, L. C. WILEY-BLACKWELL PUBLISHING, INC. 2001: 223-251

    Abstract

    Measuring competition is increasingly important for analysis of health care markets and policies. Measurement of competition in health care is made complex by the breadth of potential issues under study, by the lack of necessary data, and by rapid changes in health care financing and delivery. This study reviews key issues in the measurement of competition and is designed to familiarize researchers and policymakers interested in competition measurement, but not steeped in its practice, with key concepts, data sources, and ways of adapting measures to fit ongoing changes in health care markets.Attention to several key issues will strengthen measurement. Important components of successful measurement are: careful identification of the products and market areas for study; selection of Herfindahl-Hirschman or other indices to fit the issues being considered; consideration of econometric problems, like endogeneity, with common measures; and attention to the ways that current marketplace changes, like growth in managed care, affect the performance of classic measures. Data needed for constructing measures are also frequently scarce, insufficient, or both. Measurement could be improved with access to better data.

    View details for Web of Science ID 000168024100004

    View details for PubMedID 11327175

  • Can we explain the differences in neonatal mortality between patients insured by health maintenance organizations and patients insured by other private insurance in California? Phibbs, C. S., Baker, L. C., Wheeler, S. K., Phibbs, R. H. LIPPINCOTT WILLIAMS & WILKINS. 1998: 158A-158A
  • HMO penetration and the cost of health care: Market discipline or market segmentation? Baker, L. C., Corts, K. S. AMER ECONOMIC ASSOC. 1996: 389-394

    View details for Web of Science ID A1996UL37300074

    View details for PubMedID 10160551

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