M. Kate Bundorf

All Publications

Effect of a Lay Health Worker Intervention on Goals-of-Care Documentation and on Health Care Use, Costs, and Satisfaction Among Patients With Cancer: A Randomized Clinical Trial. JAMA oncology Patel, M. I., Sundaram, V., Desai, M., Periyakoil, V. S., Kahn, J. S., Bhattacharya, J., Asch, S. M., Milstein, A., Bundorf, M. K. 2018
Abstract

Importance: Although lay health workers (LHWs) improve cancer screening and treatment adherence, evidence on whether they can enhance other aspects of care is limited.Objective: To determine whether an LHW program can increase documentation of patients' care preferences after cancer diagnosis.Design, Setting, and Participants: Randomized clinical trial conducted from August 13, 2013, through February 2, 2015, among 213 patients with stage 3 or 4 or recurrent cancer at the Veterans Affairs Palo Alto Health Care System. Data analysis was by intention to treat and performed from January 15 to August 18, 2017.Interventions: Six-month program with an LHW trained to assist patients with establishing end-of-life care preferences vs usual care.Main Outcomes and Measures: The primary outcome was documentation of goals of care. Secondary outcomes were patient satisfaction on the Consumer Assessment of Health Care Providers and Systems "satisfaction with provider" item (on a scale of 0 [worst] to 10 [best possible]), health care use, and costs.Results: Among the 213 participants randomized and included in the intention-to-treat analysis, the mean (SD) age was 69.3 (9.1) years, 211 (99.1%) were male, and 165 (77.5%) were of non-Hispanic white race/ethnicity. Within 6 months of enrollment, patients randomized to the intervention had greater documentation of goals of care than the control group (97 [92.4%] vs 19 [17.5%.]; P<.001) and larger increases in satisfaction with care on the Consumer Assessment of Health Care Providers and Systems "satisfaction with provider" item (difference-in-difference, 1.53; 95% CI, 0.67-2.41; P<.001). The number of patients who died within 15 months of enrollment did not differ between groups (intervention, 60 of 105 [57.1%] vs control, 60 of 108 [55.6%]; P=.68). In the 30 days before death, patients in the intervention group had greater hospice use (46 [76.7%] vs 29 [48.3%]; P=.002), fewer emergency department visits (mean [SD], 0.05 [0.22] vs 0.60 [0.76]; P<.001), fewer hospitalizations (mean [SD], 0.05 [0.22] vs 0.50 [0.62]; P<.001), and lower costs (median [interquartile range], $1048 [$331-$8522] vs $23 482 [$9708-$55 648]; P<.001) than patients in the control group.Conclusions and Relevance: Incorporating an LHW into cancer care increases goals-of-care documentation and patient satisfaction and reduces health care use and costs at the end of life.Trial Registration: ClinicalTrials.gov Identifier: NCT02966509.

View details for DOI 10.1001/jamaoncol.2018.2446

View details for PubMedID 30054634
Health Care System Factors Associated with Transition Preparation in Youth with Special Health Care Needs. Population health management McKenzie, R. B., Sanders, L., Bhattacharya, J., Bundorf, M. K. 2018
Abstract

The aim of this study was to assess: (1) the proportion of youth with special health care needs (YSHCN) with adequate transition preparation, (2) whether transition preparation differs by individual, condition-related and health care system-related factors, and (3) whether specific components of the medical home are associated with adequate transition preparation. The authors conducted a cross-sectional analysis of the 2009-2010 National Survey of Children with Special Health Care Needs, which surveyed a nationally representative sample of 17,114 parents of YSHCN ages 12 to 18 years. Adequate transition preparation was based on positive responses to questions about transition to an adult provider, changing health care needs, maintaining insurance coverage, and if providers encouraged YSHCN to take responsibility for health care needs. Weighted descriptive, bivariate and multivariate analyses were conducted to determine the association between patient and health care system factors and adequate transition preparation. Overall, 32.1% of YSHCN had adequate transition preparation. Older age, female sex, income ≤400% of the poverty level, lack of medical complexity, and having shared decision making, family-centered care, and effective care coordination were associated with increased odds of transition preparation. The majority of YSHCN do not receive adequate transition preparation and younger, male adolescents with medical complexity were less likely to receive transition preparation. Different patterns of disparities were identified for each subcomponent measure of transition preparation, which may help target at-risk populations for specific services. Efforts to improve transition preparation should leverage specific components of the medical home including care coordination, shared decision making, and family-centered care.

View details for DOI 10.1089/pop.2018.0027

View details for PubMedID 29957127
Contrasting Effectiveness and Cost-Effectiveness of Colorectal Cancer Screening Under Commercial Insurance vs. Medicare. The American journal of gastroenterology Ladabaum, U., Mannalithara, A., Brill, J. V., Levin, Z., Bundorf, M. K. 2018
Abstract

OBJECTIVES: Most cost-effectiveness analyses of colorectal cancer (CRC) screening assume Medicare payment rates and a lifetime horizon. Our aims were to examine the implications of differential payment levels and time horizons for commercial insurers vs. Medicare on the cost-effectiveness of CRC screening.METHODS: We used our validated Markov cohort simulation of CRC screening in the average risk US population to examine CRC screening at ages 50-64 under commercial insurance, and at ages 65-80 under Medicare, using a health-care sector perspective. Model outcomes included discounted quality-adjusted life-years (QALYs) and costs per person, and incremental cost/QALY gained.RESULTS: Lifetime costs/person were 20-44% higher when assuming commercial payment rates rather than Medicare rates for people under 65. Most of the substantial clinical benefit of screening at ages 50-64 was realized at ages ≥65. For commercial payers with a time horizon of ages 50-64, fecal occult blood testing (FOBT) and fecal immunochemical testing (FIT) were cost-effective (<$61,000/QALY gained), but colonoscopy was costly (>$185,000/QALY gained). Medicare experienced substantial clinical benefits and cost-savings from screening done at ages <65, even if screening was not continued. Among those previously screened, continuing FOBT and FIT under Medicare was cost-saving and continuing colonoscopy was highly cost-effective (<$30,000/QALY gained), and initiating any screening in those previously unscreened was highly effective and cost-saving.CONCLUSIONS: Modeling suggests that CRC screening is highly cost-effective over a lifetime even when considering higher payment rates by commercial payers vs. Medicare. Screening may appear relatively costly for commercial payers if only a time horizon of ages 50-64 is considered, but it is predicted to yield substantial clinical and economic benefits that accrue primarily at ages ≥65 under Medicare.

View details for DOI 10.1038/s41395-018-0106-8

View details for PubMedID 29904156
ACA Marketplace Premiums and Competition Among Hospitals and Physician Practices AMERICAN JOURNAL OF MANAGED CARE Polyakova, M., Bundorf, M., Kessler, D. P., Baker, L. C. 2018; 24 (2): 85-+
Abstract

To examine the association between annual premiums for health plans available in Federally Facilitated Marketplaces (FFMs) and the extent of competition and integration among physicians and hospitals, as well as the number of insurers.We used observational data from the Center for Consumer Information and Insurance Oversight on the annual premiums and other characteristics of plans, matched to measures of physician, hospital, and insurer market competitiveness and other characteristics of 411 rating areas in the 37 FFMs.We estimated multivariate models of the relationship between annual premiums and Herfindahl-Hirschman indices of hospitals and physician practices, controlling for the number of insurers, the extent of physician-hospital integration, and other plan and rating area characteristics.Premiums for Marketplace plans were higher in rating areas in which physician, hospital, and insurance markets were less competitive. An increase from the 10th to the 90th percentile of physician concentration and hospital concentration was associated with increases of $393 and $189, respectively, in annual premiums for the Silver plan with the second lowest cost. A similar increase in the number of insurers was associated with a $421 decrease in premiums. Physician-hospital integration was not significantly associated with premiums.Premiums for FFM plans were higher in markets with greater concentrations of hospitals and physicians but fewer insurers. Higher premiums make health insurance less affordable for people purchasing unsubsidized coverage and raise the cost of Marketplace premium tax credits to the government.

View details for Web of Science ID 000425326700008

View details for PubMedID 29461855
Marketplace Plans Provide Risk Protection, But Actuarial Values Overstate Realized Coverage For Most Enrollees HEALTH AFFAIRS Polyakova, M., Hua, L., Bundorf, M. 2017; 36 (12): 2078–84
View details for DOI 10.1377/hlthaff.2017.0660

View details for Web of Science ID 000417164000008
An Analysis of Medicare Reimbursement to Ophthalmologists: Years 2012 to 2013 AMERICAN JOURNAL OF OPHTHALMOLOGY Han, E., Baisiwala, S., Jain, A., Bundorf, M., Pershing, S. 2017; 182: 133–40
Abstract

To analyze trends in utilization and payment of ophthalmic services in the Medicare population for years 2012 and 2013.Retrospective, cross-sectional study.A retrospective cross-sectional observational analysis was performed using publicly available Medicare Physician and Other Supplier aggregate file and the Physician and Other Supplier Public Use File. Variables analyzed included aggregate beneficiary demographics, Medicare payments to ophthalmologists, ophthalmic medical services provided, and the most common Medicare-reimbursed ophthalmic services.In 2013, total Medicare Part B reimbursement for ophthalmology was $5.8 billion, an increase of 3.6% from the previous year. From 2012 to 2013, the total number of ophthalmology services rendered increased by 2.2%, while average dollar amount reimbursed per ophthalmic service decreased by 5.4%. The top 5 highest reimbursed services accounted for 85% of total ophthalmic Medicare payments in 2013, an 11% increase from 2012. During 2013, drug reimbursement represented 32.8% of the total Medicare payments to ophthalmologists. Ranibizumab and aflibercept alone accounted for 95% of the entire $1.9 billion in drug reimbursements ophthalmologists in 2013.Medicare Part B reimbursement for ophthalmologists was primarily driven by use of anti-vascular endothelial growth factor (anti-VEGF) injections from 2012 to 2013. Of the total drug payments to ophthalmologists, biologic anti-VEGF agents ranibizumab and aflibercept accounted for 95% of all drug reimbursement. This is in contrast to other specialties, in which drug reimbursement represented only a small portion of Medicare reimbursement.

View details for DOI 10.1016/j.ajo.2017.07.022

View details for Web of Science ID 000411920900017

View details for PubMedID 28784553
Mortality In Rural China Declined As Health Insurance Coverage Increased, But No Evidence The Two Are Linked HEALTH AFFAIRS Zhou, M., Liu, S., Bundorf, M., Eggleston, K., Zhou, S. 2017; 36 (9): 1672–78
Abstract

Health insurance holds the promise of improving population health and survival and protecting people from catastrophic health spending. Yet evidence from lower- and middle-income countries on the impact of health insurance is limited. We investigated whether insurance expansion reduced adult mortality in rural China, taking advantage of differences across Chinese counties in the timing of the introduction of the New Cooperative Medical Scheme (NCMS). We assembled and analyzed newly collected data on NCMS implementation, linked to data from the Chinese Center for Disease Control and Prevention on cause-specific, age-standardized death rates and variables specific to county-year combinations for seventy-two counties in the period 2004-12. While mortality rates declined among rural residents during this period, we found little evidence that the expansion of health insurance through the NCMS contributed to this decline. However, our relatively large standard errors leave open the possibility that the NCMS had effects on mortality that we could not detect. Moreover, mortality benefits might arise only after many years of accumulated coverage.

View details for DOI 10.1377/hlthaff.2017.0135

View details for Web of Science ID 000409213200022

View details for PubMedID 28874497
As Infliximab Use for Ulcerative Colitis Has Increased, so Has the Rate of Surgical Resection. Journal of gastrointestinal surgery Kin, C., Kate Bundorf, M. 2017
Abstract

Infliximab was approved for ulcerative colitis in 2005 after randomized trials showed it reduced the risk of colectomy. Its effect on population-level surgery rates is unknown. Our aim is to assess the impact of infliximab approval for ulcerative colitis on surgical intervention.Retrospective review of a private insurance claims database (2002 to 2013) was performed of patients aged 18-64 diagnosed with ulcerative colitis and with 2 years of follow-up. Outcome measures were infliximab treatment and surgical resection. Multivariable logistic regression used independent variables of time period of diagnosis, age, gender, comorbidities, and insurance type.The cohort included 58,681 patients. Age, gender, and comorbidities were comparable across time periods. Patients diagnosed in the post-infliximab period had greater odds of undergoing infliximab treatment within the first year of diagnosis than those in the pre-infliximab era (OR = 2.88, p < 0.001). However, the odds of undergoing total colectomy or total proctocolectomy were also higher in patients diagnosed in the post-infliximab period (OR 1.5, p < 0.001).The use of infliximab for ulcerative colitis has, as expected, increased since its approval, but so has the risk of surgery. Thus, the introduction of biologic therapy has not decreased the risk for surgery for this patient population.

View details for DOI 10.1007/s11605-017-3431-0

View details for PubMedID 28484890
Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients With Chest Pain. JAMA internal medicine Sandhu, A. T., Heidenreich, P. A., Bhattacharya, J., Bundorf, M. K. 2017
Abstract

Noninvasive testing and coronary angiography are used to evaluate patients who present to the emergency department (ED) with chest pain, but their effects on outcomes are uncertain.To determine whether cardiovascular testing-noninvasive imaging or coronary angiography-is associated with changes in the rates of coronary revascularization or acute myocardial infarction (AMI) admission in patients who present to the ED with chest pain without initial findings of ischemia.This retrospective cohort analysis used weekday (Monday-Thursday) vs weekend (Friday-Sunday) presentation as an instrument to adjust for unobserved case-mix variation (selection bias) between 2011 and 2012. National claims data (Truven MarketScan) was used. The data included a total of 926 633 privately insured patients ages 18 to 64 years who presented to the ED with chest pain without initial diagnosis consistent with acute ischemia.Noninvasive testing or coronary angiography within 2 days or 30 days of presentation.The primary end points were coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and AMI admission at 7, 30, 180, and 365 days. The secondary end points were coronary angiography and coronary artery bypass grafting in those who underwent angiography.The patients were ages 18 to 64 years with an average age of 44.4 years. A total of 536 197 patients (57.9%) were women. Patients who received testing (224 973) had increased risk at baseline and had greater risk of AMI admission than those who did not receive testing (701 660) (0.35% vs 0.14% at 30 days). Weekday patients (571 988) had similar baseline comorbidities to weekend patients (354 645) but were more likely to receive testing. After risk factor adjustment, testing within 30 days was associated with a significant increase in coronary angiography (36.5 per 1000 patients tested; 95% CI, 21.0-52.0) and revascularization (22.8 per 1000 patients tested; 95% CI, 10.6-35.0) at 1 year but no significant change in AMI admissions (7.8 per 1000 patients tested; 95% CI, -1.4 to 17.0). Testing within 2 days was also associated with a significant increase in coronary revascularization but no difference in AMI admissions.Cardiac testing in patients with chest pain was associated with increased downstream testing and treatment without a reduction in AMI admissions, suggesting that routine testing may not be warranted. Further research into whether specific high-risk subgroups benefit from testing is needed.

View details for DOI 10.1001/jamainternmed.2017.2432

View details for PubMedID 28654959
The effect of hospital/physician integration on hospital choice JOURNAL OF HEALTH ECONOMICS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2016; 50: 1-8
Abstract

In this paper, we estimate how hospital ownership of physicians' practices affects their patients' hospital choices. We match data on the hospital admissions of Medicare beneficiaries, including the identity of their physician, with data on the identity of the owner of their physician's practice. We find that a hospital's ownership of a physician dramatically increases the probability that the physician's patients will choose the owning hospital. We also find that patients are more likely to choose a high-cost, low-quality hospital when their physician is owned by that hospital.

View details for DOI 10.1016/j.jhealeco.2016.08.006

View details for Web of Science ID 000390500800001

View details for PubMedID 27639202
Hospital Ownership of Physicians: Hospital Versus Physician Perspectives. Medical care research and review Baker, L. C., Bundorf, M. K., Devlin, A. M., Kessler, D. P. 2016
Abstract

Although there has been significant interest from health services researchers and policy makers about recent trends in hospitals' ownership of physician practices, few studies have investigated the strengths and weaknesses of available data sources. In this article, we compare results from two national surveys that have been used to assess ownership patterns, one of hospitals (the American Hospital Association survey) and one of physicians (the SK&A survey). We find some areas of agreement, but also some disagreement, between the two surveys. We conclude that full understanding of the causes and consequences of hospital ownership of physicians requires data collected at the both the hospital and the physician level. The appropriate measure of integration depends on the research question being investigated.

View details for PubMedID 27811140
Cost of Ulcerative Colitis Care has Increased in the Biologic Era Kin, C. J., Bundorf, M. ELSEVIER SCIENCE INC. 2016: E174
View details for DOI 10.1016/j.jamcollsurg.2016.08.442

View details for Web of Science ID 000395825100385
Medicare Advantage Plans Pay Hospitals Less Than Traditional Medicare Pays. Health affairs Baker, L. C., Bundorf, M. K., Devlin, A. M., Kessler, D. P. 2016; 35 (8): 1444-1451
Abstract

There is ongoing debate about how prices paid to providers by Medicare Advantage plans compare to prices paid by fee-for-service Medicare. We used data from Medicare and the Health Care Cost Institute to identify the prices paid for hospital services by fee-for-service (FFS) Medicare, Medicare Advantage plans, and commercial insurers in 2009 and 2012. We calculated the average price per admission, and its trend over time, in each of the three types of insurance for fixed baskets of hospital admissions across metropolitan areas. After accounting for differences in hospital networks, geographic areas, and case-mix between Medicare Advantage and FFS Medicare, we found that Medicare Advantage plans paid 5.6 percent less for hospital services than FFS Medicare did. Without taking into account the narrower networks of Medicare Advantage, the program paid 8.0 percent less than FFS Medicare. We also found that the rates paid by commercial plans were much higher than those of either Medicare Advantage or FFS Medicare, and growing. At least some of this difference comes from the much higher prices that commercial plans pay for profitable service lines.

View details for DOI 10.1377/hlthaff.2015.1553

View details for PubMedID 27503970
Physician Utilization Patterns for VEGF-Inhibitor Drugs in the 2012 United States Medicare Population: Bevacizumab, Ranibizumab, and Aflibercept OPHTHALMIC SURGERY LASERS & IMAGING RETINA Baisiwala, S., Bundorf, M. K., Pershing, S. 2016; 47 (6): 555-562
Abstract

To evaluate variation in physician use of vascular endothelial growth factor (VEGF) inhibitors.Population-based analysis of comprehensive, publicly available 2012 Medicare claims, aggregated by physician specialty and service type - including intravitreal injections of bevacizumab (Avastin; Genentech, South San Francisco, CA), ranibizumab (Lucentis; Genetech, South San Francisco, CA), and aflibercept (Eylea; Regeneron, Tarrytown, NY). Physicians were characterized by total patients treated, proportion treated with each drug, total intravitreal injection payments, and proportion of total payments for each drug.The authors identified 2,869 ophthalmologists. On average, each treated 203 patients with VEGF-inhibitors, 75.9% of which were treated with bevacizumab. Using all three agents was the most common practice (1,121 physicians), closely followed by using bevacizumab only (1,061 physicians). Ranibizumab accounted for most payments, but bevacizumab was the largest payment source for a sizeable proportion of physicians who used only/mostly bevacizumab.Most ophthalmologists use multiple VEGF inhibitors, but vary in their relative use. A subset of ophthalmologists predominantly use ranibizumab, but ophthalmologists overall use more bevacizumab despite financial incentives favoring ranibizumab. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:555-562.].

View details for DOI 10.3928/23258160-20160601-07

View details for Web of Science ID 000393095900008

View details for PubMedID 27327285
CONSUMER-DIRECTED HEALTH PLANS: A REVIEW OF THE EVIDENCE JOURNAL OF RISK AND INSURANCE Bundorf, M. K. 2016; 83 (1): 9-42
View details for DOI 10.1111/jori.12141

View details for Web of Science ID 000370663200002
Does health plan generosity enhance hospital market power? JOURNAL OF HEALTH ECONOMICS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2015; 44: 54-62
Abstract

We test whether the generosity of employer-sponsored health insurance facilitates the exercise of market power by hospitals. We construct indices of health plan generosity and the price and volume of hospital services using data from Truven MarketScan for 601 counties from 2001 to 2007. We use variation in the industry and union status of covered workers within a county over time to identify the causal effects of generosity. Although OLS estimates fail to reject the hypothesis that generosity facilitates the exercise of hospital market power, IV estimates show a statistically significant and economically important positive effect of plan generosity on hospital prices in uncompetitive markets, but not in competitive markets. Our results suggest that most of the aggregate effect of hospital market structure on prices found in previous work may be coming from areas with generous plans.

View details for DOI 10.1016/j.jhealeco.2015.08.007

View details for Web of Science ID 000367408200005
ANTITRUST FOR ACCOUNTABLE CARE ORGANIZATIONS JOURNAL OF COMPETITION LAW & ECONOMICS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2015; 11 (2): 317-329
View details for DOI 10.1093/joclec/nhv002

View details for Web of Science ID 000356238300002
Survey on patient safety climate in public hospitals in China BMC HEALTH SERVICES RESEARCH Zhou, P., Bundorf, M. K., Gu, J., He, X., Xue, D. 2015; 15
Abstract

Patient safety climate has been recognized as a core determinant for improving safety in hospitals. Describing workforce perceptions of patient safety climate is an important part of safety climate management. This study aimed to describe staff's perceptions of patient safety climate in public hospitals in Shanghai, China and to determine how perceptions of patient safety climate differ between different types of workers in the U.S. and China.Survey of employees of 6 secondary, general public hospitals in Shanghai conducted during 2013 using a modified version of the U.S. Patient Safety Climate in Health Care Organizations (PSCHO) tool. The percentage of "problematic responses" (PPRs) was used to measure safety climate, and the PPRs were compared among employees with different job types, using χ (2) tests and multivariate regression models.Perceptions of patient safety climate were relatively positive among hospital employees and similar to those of employees in U.S. hospitals along most dimensions. For workers in Chinese hospitals, the scales of "fear of blame" and "fear of shame" had the highest PPRs, whereas in the United States the scale of "fear of shame" had among the lowest PPRs. As in the United States, hospital managers in China perceived a more positive patient safety climate overall than other types of personnel."Fear of shame" and "fear of blame" may be important barriers to improvement of patient safety in Chinese hospitals. Research on the effect of patient safety climate on outcomes is necessary to implement effective polices to improve patient safety and quality outcomes in China.

View details for DOI 10.1186/s12913-015-0710-x

View details for Web of Science ID 000349640800001

View details for PubMedCentralID PMC4326494
Treating age-related macular degeneration: comparing the use of two drugs among medicare and veterans affairs populations. Health affairs Pershing, S., Pal Chee, C., Asch, S. M., Baker, L. C., Boothroyd, D., Wagner, T. H., Bundorf, M. K. 2015; 34 (2): 229-238
Abstract

While new biologics have revolutionized the treatment of age-related macular degeneration-the leading cause of severe vision loss among older adults-these new drugs have also raised concerns over the economic impact of medical innovation. The two leading agents are similar in effectiveness but vary greatly in price-up to $2,000 per injection for ranibizumab compared to $50 for bevacizumab. We examined the diffusion of these drugs in fee-for-service Medicare and Veterans Affairs (VA) systems during 2005-11, in part to assess the impact that differing financial incentives had on prescribing. Physicians treating Medicare patients have a direct financial incentive to prescribe the more expensive agent (ranibizumab), while VA physicians do not. Medicare injections of the more expensive ranibizumab peaked in 2007 at 47 percent. Beginning in 2009 the less expensive bevacizumab became the predominant therapy for Medicare patients, accounting for more than 60 percent of injections. For VA patients, the distribution of injections across the two drugs was relatively equal, particularly from 2009 to 2011. Our analysis indicates that there are opportunities in both the VA and Medicare to adopt more value-conscious treatment patterns and that multiple mechanisms exist to influence utilization.

View details for DOI 10.1377/hlthaff.2014.1032

View details for PubMedID 25646102
Survey on patient safety climate in public hospitals in China. BMC health services research Zhou, P., Bundorf, M. K., Gu, J., He, X., Xue, D. 2015; 15: 53-?
Abstract

Patient safety climate has been recognized as a core determinant for improving safety in hospitals. Describing workforce perceptions of patient safety climate is an important part of safety climate management. This study aimed to describe staff's perceptions of patient safety climate in public hospitals in Shanghai, China and to determine how perceptions of patient safety climate differ between different types of workers in the U.S. and China.Survey of employees of 6 secondary, general public hospitals in Shanghai conducted during 2013 using a modified version of the U.S. Patient Safety Climate in Health Care Organizations (PSCHO) tool. The percentage of "problematic responses" (PPRs) was used to measure safety climate, and the PPRs were compared among employees with different job types, using χ (2) tests and multivariate regression models.Perceptions of patient safety climate were relatively positive among hospital employees and similar to those of employees in U.S. hospitals along most dimensions. For workers in Chinese hospitals, the scales of "fear of blame" and "fear of shame" had the highest PPRs, whereas in the United States the scale of "fear of shame" had among the lowest PPRs. As in the United States, hospital managers in China perceived a more positive patient safety climate overall than other types of personnel."Fear of shame" and "fear of blame" may be important barriers to improvement of patient safety in Chinese hospitals. Research on the effect of patient safety climate on outcomes is necessary to implement effective polices to improve patient safety and quality outcomes in China.

View details for DOI 10.1186/s12913-015-0710-x

View details for PubMedID 25890169
EXPANDING PATIENTS' PROPERTY RIGHTS IN THEIR MEDICAL RECORDS AMERICAN JOURNAL OF HEALTH ECONOMICS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2015; 1 (1): 82-100
View details for DOI 10.1162/ajhe_a_00004

View details for Web of Science ID 000380366300006
Compliance with clinical pathways for inpatient care in Chinese public hospitals. BMC health services research He, X. Y., Bundorf, M. K., Gu, J. J., Zhou, P., Xue, D. 2015; 15: 459-?
Abstract

The National Health and Family Planning Commission of China has issued more than 400 clinical pathways to improve the effectiveness and efficiency of medical care delivered by public hospitals in China. The aim of our study is to determine whether patient care is compliant with national clinical pathways in public general hospitals of Pudong New Area in Shanghai.We identified the clinical pathways established by the National Health and Family Planning Commission of China for 5 common conditions (community-acquired pneumonia, acute myocardial infarction (AMI), heart failure, cesarean section, type-2 diabetes). We randomly selected patients with each condition admitted to one of 7 public general hospitals in Pudong New Area in China in January, 2013. We identified key process indicators (KPIs) for each pathway and, based on chart review for each patient, determined whether the patient's care was compliant for each indicator. We calculated the proportion of care which was compliant with clinical pathways for each indicator, the average proportion of indicators that were met for each patient, and the proportion of patients whose care was compliant for all measures. For selected indicators, we compared compliance rates among hospitals in our study with those from other countries.Average compliance rates across the KPIs for each condition ranged from 61 % for AMI to 89 % for pneumonia. The percent of patient receiving fully compliant care ranged from 0 for AMI and heart failure to 39 % for pneumonia. Compared to the compliance rate for process indicators in the hospitals of other countries, some rates in the hospitals that we audited were higher, but some were lower.Few patients received care that complied with all the pathways for each condition. The reasons for low compliance with national clinical pathways and how to improve clinical quality in public hospitals of China need to be further explored.

View details for DOI 10.1186/s12913-015-1121-8

View details for PubMedID 26445427

View details for PubMedCentralID PMC4595105
Physician Practice Competition and Prices Paid by Private Insurers for Office Visits JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Baker, L. C., Bundorf, M. K., Royalty, A. B., Levin, Z. 2014; 312 (16): 1653-1662
Abstract

Physician practice consolidation could promote higher-quality care but may also create greater economic market power that could lead to higher prices for physician services.To assess the relationship between physician competition and prices paid by private preferred provider organizations (PPOs) for 10 types of office visits in 10 prominent specialties.Retrospective study in 1058 US counties in urbanized areas, representing all 50 states, examining the relationship between measured physician competition and prices paid for office visits in 2010 and the relationship between changes in competition and prices between 2003 and 2010, using regression analysis to control for possible confounding factors.Variation in the mean Hirschman-Herfindahl Index (HHI) of physician practices within a county by specialty (HHIs range from 0, representing maximally competitive markets, to 10,000 in markets served by a single [monopoly] practice).Mean price paid by county to physicians in each specialty by private PPOs for intermediate office visits with established patients (Current Procedural Terminology [CPT] code 99213) and a price index measuring the county-weighted mean price for 10 types of office visits with new and established patients (CPT codes 99201-99205, 99211-99215) relative to national mean prices.In 2010, across all specialties studied, HHIs were 3 to 4 times higher in the 90th-percentile county than the 10th-percentile county (eg, for family practice: 10th percentile HHI = 1023 and 90th percentile HHI = 3629). Depending on specialty, mean price for a CPT code 99213 visit was between $70 and $75. After adjustment for potential confounders, depending on specialty, prices at the 90th-percentile HHI were between $5.85 (orthopedics; 95% CI, $3.46-$8.24) and $11.67 (internal medicine; 95% CI, $9.13-$14.21) higher than at the 10th percentile. Including all types of office visits, price indexes at the 90th-percentile HHI were 8.3% (orthopedics; 95% CI, 5.0%-11.6%) to 16.1% (internal medicine; 95% CI, 12.8%-19.5%) higher. Between 2003 and 2010, there were larger price increases in areas that were less competitive in 2002 than in initially more competitive areas.More competition among physicians is related to lower prices paid by private PPOs for office visits. These results may inform work on policies that influence practice competition.

View details for DOI 10.1001/jama.2014.10921

View details for Web of Science ID 000343301400022
Colorectal Testing Utilization and Payments in a Large Cohort of Commercially Insured US Adults AMERICAN JOURNAL OF GASTROENTEROLOGY Ladabaum, U., Levin, Z., Mannalithara, A., Brill, J. V., Bundorf, M. K. 2014; 109 (10): 1513-1525
Abstract

Screening decreases colorectal cancer (CRC) mortality. The national press has scrutinized colonoscopy charges. Little systematic evidence exists on colorectal testing and payments among commercially insured persons. Our aim was to characterize outpatient colorectal testing utilization and payments among commercially insured US adults.We conducted an observational cohort study of outpatient colorectal test utilization rates, indications, and payments among 21 million 18-64-year-old employees and dependants with noncapitated group health insurance provided by 160 self-insured employers in the 2009 Truven MarketScan Databases.Colonoscopy was the predominant colorectal test. Among 50-64-year olds, 12% underwent colonoscopy in 1 year. Most fecal tests and colonoscopies were associated with screening/surveillance indications. Testing rates were higher in women, and increased with age. Mean payments for fecal occult blood and immunochemical tests were $5 and $21, respectively. Colonoscopy payments varied between and within sites of service. Mean payments for diagnostic colonoscopy in an office, outpatient hospital facility, and ambulatory surgical center were $586 (s.d. $259), $1,400 (s.d. $681), and $1,074 (s.d. $549), respectively. Anesthesia and pathology services accompanied 35 and 52% of colonoscopies, with mean payments of $494 (s.d. $354) and $272 (s.d. $284), respectively. Mean payments for the most prevalent colonoscopy codes were 1.4- to 1.9-fold the average Medicare payments.Most outpatient colorectal testing among commercially insured adults was associated with screening or surveillance. Payments varied widely across sites of service, and payments for anesthesia and pathology services contributed substantially to total payments. Cost-effectiveness analyses of CRC screening have relied on Medicare payments as proxies for costs, but cost-effectiveness may differ when analyzed from the perspectives of Medicare or commercial insurers.

View details for DOI 10.1038/ajg.2014.64

View details for Web of Science ID 000344460100002
Patients' Preferences Explain A Small But Significant Share Of Regional Variation In Medicare Spending HEALTH AFFAIRS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2014; 33 (6): 957-963
Abstract

This study assessed the extent to which differences in patients' preferences across geographic areas explained differences in traditional fee-for-service Medicare spending across Dartmouth Atlas of Health Care Hospital Referral Regions (HRRs). Preference measures were based on results of a survey that asked patients questions about their physicians, their own health status, and the care they would want in their last six months of life. We found that patients' preferences explained 5 percent of the variation across HRRs in total Medicare spending. In comparison, supply factors, such as the number of physicians, specialists, and hospital beds, explained 23 percent, and patients' health and income explained 12 percent. We also explored the relative importance of preferences in determining three components of total spending: spending at the end of life, inpatient spending, and spending on physician services. Relative to supply factors, health, and income, patients' preferences explained the largest share of variation in end-of-life spending and the smallest share of variation in spending on physician services. We conclude that variation in preferences contributes to differences across areas in Medicare spending. Medicare policy must consider both supply factors and patients' preferences in deciding how much to accommodate area variation in spending and the extent to which that variation should be subsidized by taxpayers.

View details for DOI 10.1377/hlthaff.2013.1184

View details for Web of Science ID 000338187200006
Vertical Integration: Hospital Ownership Of Physician Practices Is Associated With Higher Prices And Spending HEALTH AFFAIRS Baker, L. C., Bundorf, M. K., Kessler, D. P. 2014; 33 (5): 756-763
Abstract

We examined the consequences of contractual or ownership relationships between hospitals and physician practices, often described as vertical integration. Such integration can reduce health spending and increase the quality of care by improving communication across care settings, but it can also increase providers' market power and facilitate the payment of what are effectively kickbacks for inappropriate referrals. We investigated the impact of vertical integration on hospital prices, volumes (admissions), and spending for privately insured patients. Using hospital claims from Truven Analytics MarketScan for the nonelderly privately insured in the period 2001-07, we constructed county-level indices of prices, volumes, and spending and adjusted them for enrollees' age and sex. We measured hospital-physician integration using information from the American Hospital Association on the types of relationships hospitals have with physicians. We found that an increase in the market share of hospitals with the tightest vertically integrated relationship with physicians--ownership of physician practices--was associated with higher hospital prices and spending. We found that an increase in contractual integration reduced the frequency of hospital admissions, but this effect was relatively small. Taken together, our results provide a mixed, although somewhat negative, picture of vertical integration from the perspective of the privately insured.

View details for DOI 10.1377/hlthaff.2013.1279

View details for Web of Science ID 000336666500006
Enrollment in prescription drug insurance: The interaction of numeracy and choice set size. Health psychology Szrek, H., Bundorf, M. K. 2014; 33 (4): 340-348
Abstract

Objective: To determine how choice set size affects decision quality among individuals of different levels of numeracy choosing prescription drug plans. Method: Members of an Internet-enabled panel age 65 and over were randomly assigned to sets of prescription drug plans varying in size from 2 to 16 plans from which they made a hypothetical choice. They answered questions about enrollment likelihood and the costs and benefits of their choice. The measure of decision quality was enrollment likelihood among those for whom enrollment was beneficial. Enrollment likelihood by numeracy and choice set size was calculated. A model of moderated mediation was analyzed to understand the role of numeracy as a moderator of the relationship between the number of plans and the quality of the enrollment decision and the roles of the costs and benefits in mediating that relationship. Results: More numerate adults made better decisions than less numerate adults when choosing among a small number of alternatives but not when choice sets were larger. Choice set size had little effect on decision making of less numerate adults. Differences in decision making costs between more and less numerate adults helped explain the effect of choice set size on decision quality. Conclusions: Interventions to improve decision making in the context of Medicare Part D may differentially affect lower and higher numeracy adults. The conflicting results on choice overload in the psychology literature may be explained in part by differences amongst individuals in how they respond to choice set size. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

View details for DOI 10.1037/a0032738

View details for PubMedID 23795708
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
Abstract

To investigate the source of the weak correlation across geographic areas between Medicare and private insurance spending.Retrospective, descriptive analysis.We obtained Medicare spending data at the hospital referral region (HRR) level for 2007 from the Dartmouth Atlas, and commercial claims from large employers for 2007 from the Truven MarketScan Database. We constructed county-level data on hospital market structure from Medicare patient flows and obtained county-level data on the Medicare wage index from the Centers for Medicare & Medicaid Services website. We aggregated these sources to the HRR level. We decomposed Medicare and private spending into 2 components: price and volume. We also decomposed Medicare and private prices into 2 components: a common measure of cost and a sector-specific markup. We computed correlations between Medicare and private prices and volumes, and the correlation of each sector’s price and volume with cost and markup.We found that Medicare and private prices are strongly positively correlated, largely because both are keyed off of common costs. Consistent with previous work, we found that Medicare and private volumes are strongly positively correlated as well.The weak correlation between Medicare and private spending is consistent with these 2 empirical regularities. It is mathematically due to negative correlations between each sector’s price and the other sector’s volume. In particular, we found that private prices have important spillover effects on Medicare volume. Future research on the effects of competition should take account of this phenomenon.

View details for Web of Science ID 000330599000009
Are Prescription Drug Insurance Choices Consistent With Expected Utility Theory? HEALTH PSYCHOLOGY Bundorf, M. K., Mata, R., Schoenbaum, M., Bhattacharya, J. 2013; 32 (9): 986-994
Abstract

Objective: To determine the extent to which people make choices inconsistent with expected utility theory when choosing among prescription drug insurance plans and whether tabular or graphical presentation format influences the consistency of their choices. Method: Members of an Internet-enabled panel chose between two Medicare prescription drug plans. The "low variance" plan required higher out-of-pocket payments for the drugs respondents usually took but lower out-of-pocket payments for the drugs they might need if they developed a new health condition than the "high variance" plan. The probability of a change in health varied within subjects and the presentation format (text vs. graphical) and the affective salience of the clinical condition (abstract vs. risk related to specific clinical condition) varied between subjects. Respondents were classified based on whether they consistently chose either the low or high variance plan. Logistic regression models were estimated to examine the relationship between decision outcomes and task characteristics. Results: The majority of respondents consistently chose either the low or high variance plan, consistent with expected utility theory. Half of respondents consistently chose the low variance plan. Respondents were less likely to make discrepant choices when information was presented in graphical format. Conclusions: Many people, although not all, make choices consistent with expected utility theory when they have information on differences among plans in the variance of out-of-pocket spending. Medicare beneficiaries would benefit from information on the extent to which prescription drug plans provide risk protection. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

View details for DOI 10.1037/a0033517

View details for Web of Science ID 000323799300008

View details for PubMedID 24001249
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
The association of strategic group and organizational culture with hospital performance in China HEALTH CARE MANAGEMENT REVIEW Xue, D., Zhou, P., Bundorf, M. K., Huang, J. X., Chang, J. L. 2013; 38 (3): 258-270
Abstract

BACKGROUND:: The policy environment in China is rapidly changing. Strategic planning may enable hospitals to respond more effectively to changes in their external environment, little evidence exists on the extent to which public hospitals in China adopt different strategies and the relationship between strategic decision-making and hospital performance. PURPOSES:: The purposes of our study were to determine the extent to which different hospitals adopt different strategies, whether strategies are associated with organizational culture and whether hospital strategies are associated with hospital performance. METHODOLOGY:: Presidents (or vice presidents), employees, and patients from 87 public hospitals were surveyed during 2009. Measures of strategic group were developed using cluster analysis based on the three dimensions of product position, competitive posture, and market position. Culture was measured using a tool developed by the investigators. Performance was measured based on profitability, patient satisfaction, and employee satisfaction with overall hospital development in the recent 5 years. The association of strategic group and organizational culture with hospital performance was analyzed using multivariate models. FINDINGS:: Chinese public general hospitals were classified into five strategic groups that had significant differences in product positioning, competitive posture, and market position. Hospitals of similar types based on regulation adopted different strategies. Organizational culture was not strongly associated with hospital strategic group. Although strategic group was associated with hospital profitability and patient satisfaction in the models with or without control for hospital location, these effects did not persist after controlling for organizational culture, hospital level, and hospital location. PRACTICE IMPLICATIONS:: It is important for public hospitals in China to make effective strategic planning and align their organizational culture with the strategies for better execution and therefore better performance. Moreover, the method of hospital strategic grouping in the study provides a new way to analyze management issues within a strategic group and between strategic groups.

View details for DOI 10.1097/HMR.0b013e3182678f9a

View details for Web of Science ID 000320698400008

View details for PubMedID 22872139
Pricing and Welfare in Health Plan Choice AMERICAN ECONOMIC REVIEW Bundorf, M. K., Levin, J., Mahoney, N. 2012; 102 (7): 3214-3248
Abstract

Premiums in health insurance markets frequently do not reflect individual differences in costs, either because consumers have private information or because prices are not risk rated. This creates inefficiencies when consumers self-select into plans. We develop a simple econometric model to study this problem and estimate it using data on small employers. We find a welfare loss of 2-11 percent of coverage costs compared to what is feasible with risk rating. Only about one-quarter of this is due to inefficiently chosen uniform contribution levels. We also investigate the reclassification risk created by risk rating individual incremental premiums, finding only a modest welfare cost.

View details for DOI 10.1257/aer.102.7.3214

View details for Web of Science ID 000312093000004
Organizational Culture and Its Relationship with Hospital Performance in Public Hospitals in China HEALTH SERVICES RESEARCH Zhou, P., Bundorf, K., Chang, J. L., Huang, J. X., Xue, D. 2011; 46 (6): 2139-2160
Abstract

To measure perceptions of organizational culture among employees of public hospitals in China and to determine whether perceptions are associated with hospital performance.Hospital, employee, and patient surveys from 87 Chinese public hospitals conducted during 2009.Developed and administered a tool to assess organizational culture in Chinese public hospitals. Used factor analysis to create measures of organizational culture. Analyzed the relationships between employee type and perceptions of culture and between perceptions of culture and hospital performance using multivariate models.Employees perceived the culture of Chinese public hospitals as stronger in internal rules and regulations, and weaker in empowerment. Hospitals in which employees perceived that the culture emphasized cost control were more profitable and had higher rates of outpatient visits and bed days per physician per day but also had lower levels of patient satisfaction. Hospitals with cultures perceived as customer-focused had longer length of stay but lower patient satisfaction.Managers in Chinese public hospitals should consider whether the culture of their organization will enable them to respond effectively to their changing environment.

View details for DOI 10.1111/j.1475-6773.2011.01336.x

View details for Web of Science ID 000297244200007

View details for PubMedID 22092228
Age and the Purchase of Prescription Drug Insurance by Older Adults PSYCHOLOGY AND AGING Szrek, H., Bundorf, M. K. 2011; 26 (2): 308-320
Abstract

The Medicare Part D Prescription Drug Program places an unprecedented degree of choice in the hands of older adults despite concerns over their ability to make effective decisions and desire to have extensive choice in this context. While previous research has compared older adults to younger adults along these dimensions, our study, in contrast, examines how likelihood to delay decision making and preferences for choice differ by age among older age cohorts. Our analysis is based on responses of older adults to a simulation of enrollment in Medicare Part D. We examine how age, numeracy, cognitive reflection, and the interaction between age and performance on these instruments are related to the decision to enroll in a Medicare prescription drug plan and preference for choice in this context. We find that numeracy and cognitive reflection are positively associated with enrollment likelihood and that they are more important determinants of enrollment than age. We also find that greater numeracy is associated with a lower willingness to pay for choice. Hence, our findings raise concern that older adults, and, in particular, those with poorer numerical processing skills, may need extra support in enrolling in the program: they are less likely to enroll than those with stronger numerical processing skills, even though they show greater willingness to pay for choice.

View details for DOI 10.1037/a0023169

View details for Web of Science ID 000291668800007

View details for PubMedID 21534689

View details for PubMedCentralID PMC3115506
Insurance mandates, embryo transfer, outcomes-the link is tenuous FERTILITY AND STERILITY Banks, N. K., Norian, J. M., Bundorf, M. K., Henne, M. B. 2010; 94 (7): 2776-2779
Abstract

To examine the relationship between state insurance mandate status and the number of embryos transferred in assisted reproductive technology cycles, we conducted a retrospective analysis of clinics reporting to the publicly available national Society for Assisted Reproductive Technology registry. We found that clinics in states with comprehensive mandates transferred between 0.210 and 0.288 fewer embryos per cycle depending upon patient age, and were more likely to transfer fewer embryos than recommended for older women; however, the relationship between state mandate status and clinic birth and multiple birth rates varied by age group.

View details for DOI 10.1016/j.fertnstert.2010.05.037

View details for Web of Science ID 000284573700067

View details for PubMedID 20579988
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

View details for PubMedCentralID PMC3195432
Choice Set Size and Decision Making: The Case of Medicare Part D Prescription Drug Plans MEDICAL DECISION MAKING Bundorf, M. K., Szrek, H. 2010; 30 (5): 582-593
Abstract

The impact of choice on consumer decision making is controversial in US health policy.The authors' objective was to determine how choice set size influences decision making among Medicare beneficiaries choosing prescription drug plans.The authors randomly assigned members of an Internet-enabled panel age 65 and older to sets of prescription drug plans of varying sizes (2, 5, 10, and 16) and asked them to choose a plan. Respondents answered questions about the plan they chose, the choice set, and the decision process. The authors used ordered probit models to estimate the effect of choice set size on the study outcomes.Both the benefits of choice, measured by whether the chosen plan is close to the ideal plan, and the costs, measured by whether the respondent found decision making difficult, increased with choice set size. Choice set size was not associated with the probability of enrolling in any plan.Medicare beneficiaries face a tension between not wanting to choose from too many options and feeling happier with an outcome when they have more alternatives. Interventions that reduce cognitive costs when choice sets are large may make this program more attractive to beneficiaries.

View details for DOI 10.1177/0272989X09357793

View details for Web of Science ID 000283174800011

View details for PubMedID 20228281
The effects of competition on assisted reproductive technology outcomes FERTILITY AND STERILITY Henne, M. B., Bundorf, M. K. 2010; 93 (6): 1820-1830
Abstract

To evaluate the relationship between competition among fertility clinics and assisted reproductive technology (ART) treatment outcomes, particularly multiple births.Using clinic-level data from 1995 to 2001, we examined the relationship between competition and clinic-level ART outcomes and practice patterns.National database registry.Clinics performing ART.The number of clinics within a 20-mile (32.19-km) radius of a given clinic.Clinic-level births, singleton births, and multiple births per ART cycle; multiple births per ART birth; average number of embryos transferred per cycle; and the proportion of cycles for women under age 35 years.The number of competing clinics is not strongly associated with ART birth and multiple birth rates. Relative to clinics with no competitors, the rate of multiple births per cycle is lower (-0.03 percentage points) only for clinics with more than 15 competitors. Embryo transfer practices are not statistically significantly associated with the number of competitors. Clinic-level competition is strongly associated with patient mix. The proportion of cycles for patients under 35 years old is 6.4 percentage points lower for clinics with more than 15 competitors than for those with no competitors.Competition among fertility clinics does not appear to increase rates of multiple births from ART by promoting more aggressive embryo transfer decisions.

View details for DOI 10.1016/j.fertnstert.2008.02.159

View details for Web of Science ID 000276678100014

View details for PubMedID 18442821
The Effects of Offering Health Plan Choice Within Employment-Based Purchasing Groups JOURNAL OF RISK AND INSURANCE Bundorf, M. K. 2010; 77 (1): 105-127
View details for DOI 10.1111/j.1539-6975.2009.01338.x

View details for Web of Science ID 000274321700005
Health Risk, Income, and Employment-Based Health Insurance Forum for Health Economics and Policy M. Kate Bundorf 2010; 13 (2)
United States GLOBAL MARKETPLACE FOR PRIVATE HEALTH INSURANCE: STRENGTH IN NUMBERS Bundorf, M., Pauly, M. V., Preker, A. S., Zweifel, P., Schellekens, O. P. 2010: 253–60
View details for Web of Science ID 000306573700011
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
The incidence of the healthcare costs of obesity JOURNAL OF HEALTH ECONOMICS Bhattacharya, J., Bundorf, M. K. 2009; 28 (3): 649-658
Abstract

Who pays the healthcare costs associated with obesity? Among workers, this is largely a question of the incidence of the costs of employer-sponsored coverage. Using data from the National Longitudinal Survey of Youth and the Medical Expenditure Panel Survey, we find that the incremental healthcare costs associated with obesity are passed on to obese workers with employer-sponsored health insurance in the form of lower cash wages. Obese workers without employer-sponsored insurance do not have a wage offset relative to their non-obese counterparts. A substantial part of the lower wages among obese women attributed to labor market discrimination can be explained by their higher health insurance premiums.

View details for DOI 10.1016/j.jhealeco.2009.02.009

View details for Web of Science ID 000266648500011

View details for PubMedID 19433210
Do markets respond to quality information? The case of fertility clinics JOURNAL OF HEALTH ECONOMICS Bundorf, M. K., Chun, N., Goda, G. S., Kessler, D. P. 2009; 28 (3): 718-727
Abstract

Although policymakers have increasingly turned to provider report cards as a tool to improve health care quality, existing studies provide mixed evidence on whether they influence consumer choices. We examine the effects of providing consumers with quality information in the context of fertility clinics providing Assisted Reproductive Therapies (ART). We report three main findings. First, clinics with higher birth rates had larger market shares after the adoption of report cards relative to before. Second, clinics with a disproportionate share of young, relatively easy-to-treat patients had lower market shares after adoption versus before. This suggests that consumers take into account information on patient mix when evaluating clinic outcomes. Third, report cards had larger effects on consumers and clinics from states with ART insurance coverage mandates. We conclude that consumers respond to quality report cards when choosing among providers of ART.

View details for DOI 10.1016/j.jhealeco.2009.01.001

View details for Web of Science ID 000266648500016

View details for PubMedID 19328568
The Effects of Offering Health Plan Choice within Employment-Based Purchasing Groups The Journal of Risk and Insurance M. Kate Bundorf 2009; 77 (1): 105
Reply to Ralph Bradley, "Comment - Defining health insurance affordability: Unobserved heterogeneity matters" JOURNAL OF HEALTH ECONOMICS Bundorf, M., Pauly, M. V. 2009; 28 (1): 251–54
View details for DOI 10.1016/j.jhealeco.2008.10.008

View details for Web of Science ID 000263190800018
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
Public Support for National Health Insurance: The Roles of Forum for Health Economics and Health Policy M. Kate Bundorf, Victor R. Fuchs 2008; 10 (1)
Insurance mandates and trends in infertility treatments FERTILITY AND STERILITY Henne, M. B., Bundorf, M. K. 2008; 89 (1): 66-73
Abstract

To examine the relationship between insurance mandates and the utilization and outcomes of assisted reproductive technologies (ART).Using clinic-level data from 1990 to 2001, we examined differences between states with and without insurance mandates in rates of utilization and outcomes of ART using multivariable least squares regression.National clinic registry data.Clinics performing ART, no patient-level data.The type of insurance mandate in each state during each year of the study.Cycles per 1,000 women aged 25-44 years, live births per 1,000 cycles, and multiple births per live ART birth.Use of ART grew rapidly during the 1990 s and grew most quickly in states that adopted comprehensive insurance mandates. Compared with states without mandates, births per cycle were 4% lower and multiples per ART birth were 2% lower in states with comprehensive mandates.Comprehensive insurance mandates are associated with greater utilization of ART and lower rates of births per cycle and multiple births per ART birth. Whether the differences in outcomes are due to differences in embryo transfer practices or to patient characteristics is unclear.

View details for DOI 10.1016/j.fertnstert.2007.01.167

View details for Web of Science ID 000252498700010

View details for PubMedID 17482603
Use and outcomes of intracytoplasmic sperm injection for non-male factor infertility 101st Annual Meeting of the American-Urological-Association Kim, H. H., Bundorf, M. K., Behr, B., McCallum, S. W. ELSEVIER SCIENCE INC. 2007: 622–28
Abstract

To determine whether intracytoplasmic sperm injection (ICSI) is associated with improved outcomes for non-male factor infertility.We examined the patient characteristics associated with treatment choice-ICSI and conventional in vitro fertilization (IVF)-among patients without a diagnosis of male factor infertility and compared outcomes between the two groups, adjusting for patient characteristics using multivariate regression models.Academic fertility center.We evaluated 696 consecutive assisted reproductive technology (ART) cycles performed for couples with normal semen analysis at the Stanford Reproductive Endocrinology and Infertility Center between 2002 and 2003. We compared patient characteristics, cycle details, and outcomes for ICSI and IVF.Fertilization, pregnancy, and live birth rates.Patient characteristics were similar between the two groups, except the proportion of patients with unexplained infertility (IVF 15.1% vs. ICSI 23.5%), previous fertility (IVF 62.6% vs. ICSI 45.5%), and previous ART cycle (IVF 41.2% vs. ICSI 67.7%). More oocytes were fertilized per cycle for the IVF group (6.6 oocytes versus 5.1 oocytes). Fertilization failure, pregnancy, and live birth rates did not differ between IVF and ICSI. Using logistic regressions, having had previous ART was found to be positively associated with ICSI. Treatment choice of ICSI was not associated with fertilization, pregnancy, or live birth rates.No clear evidence of improved outcomes with ICSI was demonstrated for non-male factor infertility.

View details for DOI 10.1016/j.fertnstert.2006.12.013

View details for Web of Science ID 000249751900014

View details for PubMedID 17445809
Is health insurance affordable for the uninsured? JOURNAL OF HEALTH ECONOMICS Bundorf, M. K., Pauly, M. V. 2006; 25 (4): 650-673
Abstract

In this paper, we investigate the meaning of "affordability" in the context of health insurance. Assessing the relationship between the affordability of coverage and the large number of uninsured in the U.S. is important for understanding the barriers to purchasing coverage and evaluating the role of policy in reducing the number of uninsured. We propose several definitions of affordability and examine the implications of alternative definitions for estimates of the proportion of uninsured who are unable to afford coverage. We find that, depending on the definition, health insurance was affordable to between one-quarter and three-quarters of the uninsured in the United States in 2000.

View details for DOI 10.1016/j.jhealeco.2005.11.003

View details for Web of Science ID 000239366600003

View details for PubMedID 16806543
Who searches the internet for health information? 4th World Conference of the International-Health-Economics-Association (iHEA) Bundorf, M. K., Wagner, T. H., Singer, S. J., Baker, L. C. WILEY-BLACKWELL PUBLISHING, INC. 2006: 819–36
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

View details for PubMedCentralID PMC1713205
The effects of rate regulation on demand for supplemental health insurance 118th Annual Meeting of the American-Economic-Association Bundorf, M. K., Simon, K. I. AMER ECONOMIC ASSOC. 2006: 67–71
View details for Web of Science ID 000237855200013
Employer health insurance offerings and employee enrollment decisions HEALTH SERVICES RESEARCH Polsky, D., Stein, R., Nicholson, S., Bundorf, M. K. 2005; 40 (5): 1259-1278
Abstract

To determine how the characteristics of the health benefits offered by employers affect worker insurance coverage decisions.The 1996-1997 and the 1998-1999 rounds of the nationally representative Community Tracking Study Household Survey.We use multinomial logistic regression to analyze the choice between own-employer coverage, alternative source coverage, and no coverage among employees offered health insurance by their employer. The key explanatory variables are the types of health plans offered and the net premium offered. The models include controls for personal, health plan, and job characteristics.When an employer offers only a health maintenance organization married employees are more likely to decline coverage from their employer and take-up another offer (odds ratio (OR)=1.27, p<.001), while singles are more likely to accept the coverage offered by their employer and less likely to be uninsured (OR=0.650, p<.001). Higher net premiums increase the odds of declining the coverage offered by an employer and remaining uninsured for both married (OR=1.023, p<.01) and single (OR=1.035, p<.001) workers.The type of health plan coverage an employer offers affects whether its employees take-up insurance, but has a smaller effect on overall coverage rates for workers and their families because of the availability of alternative sources of coverage. Relative to offering only a non-HMO plan, employers offering only an HMO may reduce take-up among those with alternative sources of coverage, but increase take-up among those who would otherwise go uninsured. By modeling the possibility of take-up through the health insurance offers from the employer of the spouse, the decline in coverage rates from higher net premiums is less than previous estimates.

View details for DOI 10.1111/j.1475-6773.2005.00415.x

View details for Web of Science ID 000231708000002

View details for PubMedID 16174133

View details for PubMedCentralID PMC1361201
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
The magnitude and nature of risk selection in employer-sponsored health plans HEALTH SERVICES RESEARCH Nicholson, S., Bundorf, K., Stein, R. M., Polsky, D. 2004; 39 (6): 1817-U1
Abstract

To determine whether health maintenance organizations (HMOs) attract enrollees who use relatively few medical resources and whether a simple risk-adjustment system could mitigate or eliminate the inefficiency associated with risk selection.The first and second rounds of the Community Tracking Study Household Survey (CTSHS), a national panel data set of households in 60 different markets in the United States.We use regression analysis to examine medical expenditures in the first round of the survey between enrollees who switched plan types (i.e., from a non-HMO plan to an HMO plan, or vice versa) between the first and second rounds of the survey versus enrollees who remained in their original plan. The dependent variable is an enrollee's medical resource use, measured in dollars, and the independent variables include gender, age, self-reported health status, and other demographic variables.We restrict our analysis to the 6,235 non-elderly persons who were surveyed in both rounds of the CTSHS, received health insurance from their employer or the employer of a household member in both years of the survey, and were offered a choice of an HMO and a non-HMO plan in both years.We find that people who switched from a non-HMO to an HMO plan used 11 percent fewer medical services in the period prior to switching than people who remained in a non-HMO plan, and that this relatively low use persisted once they enrolled in an HMO. Furthermore, people who switched from an HMO to a non-HMO plan used 18 percent more medical services in the period prior to switching than those who remained in an HMO plan.HMOs are experiencing favorable risk selection and would most likely continue to do so even if employers adjusted health plan payments based on enrollees' gender and age because the selection is based on enrollee characteristics that are difficult to observe, such as preferences for medical care and health status.

View details for Web of Science ID 000226743200012

View details for PubMedID 15533189
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
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
Impact of managed care on the treatment, costs, and outcomes of fee-for-service medicare patients with acute myocardial infarction HEALTH SERVICES RESEARCH Bundorf, M. K., Schulman, K. A., Stafford, J. A., Gaskin, D., Jollis, J. G., Escarce, J. J. 2004; 39 (1): 131-152
Abstract

To examine the effects of market-level managed care activity on the treatment, cost, and outcomes of care for Medicare fee-for-service acute myocardial infarction (AMI) patients.Patients from the Cooperative Cardiovascular Project (CCP), a sample of Medicare beneficiaries discharged from nonfederal acute-care hospitals with a primary discharge diagnosis of AMI from January 1994 to February 1996.We estimated models of patient treatment, costs, and outcomes using ordinary least squares and logistic regression. The independent variables of primary interest were market-area managed care penetration and competition. The models included controls for patient, hospital, and other market area characteristics.We merged the CCP data with Medicare claims and other data sources. The study sample included CCP patients aged 65 and older who were admitted during 1994 and 1995 with a confirmed AMI to a nonrural hospital.Rates of revascularization and cardiac catheterization for Medicare fee-for-service patients with AMI are lower in high-HMO penetration markets than in low-penetration ones. Patients admitted in high-HMO-competition markets, in contrast, are more likely to receive cardiac catheterization for treatment of their AMI and had higher treatment costs than those admitted in low-competition markets.The level of managed care activity in the health care market affects the process of care for Medicare fee-for-service AMI patients. Spillovers from managed care activity to patients with other types of insurance are more likely when managed care organizations have greater market power.

View details for Web of Science ID 000188758000010

View details for PubMedID 14965081
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
Employee demand for health insurance and employer health plan choices JOURNAL OF HEALTH ECONOMICS Bundorf, M. K. 2002; 21 (1): 65-88
Abstract

Although most private health insurance in US is employment-based, little is known about how employers choose health plans for their employees. In this paper, I examine the relationship between employee preferences for health insurance and the health plans offered by employers. I find evidence that employee characteristics affect the generosity of the health plans offered by employers and the likelihood that employers offer a choice of plans. Although the results suggest that employers do respond to employee preferences in choosing health benefits, the effects of worker characteristics on plan offerings are quantitatively small.

View details for Web of Science ID 000173616800004

View details for PubMedID 11845926
Consumer protection and the HMO backlash: Are HMOs to blame for drive-through deliveries? Association-for-Public-Policy-and-Management Meeting Volpp, K. G., Bundorf, M. K. BLUE CROSS BLUE SHIELD ASSOC. 1999: 101–9
Abstract

This study used patient discharge data from New Jersey to examine differences in length of stay for normal, uncomplicated deliveries between patients in health maintenance organizations (HMOs) and those not in HMOs. The percentage of one-day stays increased from less than 4% for all payers in 1990 to 48.1% for HMO patients, and 31.5% for non-HMO patients in 1994. Controlling for other factors, the odds of an HMO patient staying one day were nearly twice as great as a non-HMO patient by 1994; for all patients, regardless of payer, the odds of a one-day stay in 1994 were more than 18 times the odds of a one-day stay in 1990. The strong secular trend suggests that legislation and regulations should be targeted at particular policies rather than insurers.

View details for Web of Science ID 000080272700011

View details for PubMedID 10335315

Associate Professor of Health Research and Policy (Health Services Research) and Senior Fellow at the Stanford Institute for Economic Policy Research and, by courtesy, at the Hoover Institution

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