Jay Bhattacharya

All Publications

• Colorectal Cancer Screening in the Era of the Affordable Care Act JOURNAL OF GENERAL INTERNAL MEDICINE Richman, I., Asch, S. M., Bhattacharya, J., Owens, D. K. 2016; 31 (3): 315-320

  Abstract

  The Affordable Care Act (ACA) eliminated cost-sharing for evidence-based preventive services in an effort to encourage use.To evaluate use of colorectal cancer (CRC) screening in a national population-based sample before and after implementation of the ACA.Repeated cross-sectional analysis of the Medical Expenditure Panel Survey (MEPS) between 2009 and 2012 comparing CRC screening rates before and after implementation of the ACA.Adults 50-64 with private health insurance and adults 65-75 with Medicare.Self-reported receipt of screening colonoscopy, sigmoidoscopy, or fecal occult blood test (FOBT) within the past year among those eligible for screening.Our study included 8617 adults aged 50-64 and 3761 adults aged 65-75. MEPS response rates ranged from 58 to 63%. Among adults aged 50-64, 18.9-20.9% received a colonoscopy in the survey year, 0.59-2.1% received a sigmoidoscopy, and 7.9-10.4% received an FOBT. For adults aged 65-75, 23.6-27.7% received a colonoscopy, 1.3-3.2% a sigmoidoscopy, and 13.5-16.4% an FOBT. In adjusted analyses, among participants aged 50-64, there was no increase in yearly rates of colonoscopy (-0.28 percentage points, 95% CI -2.3 to 1.7, p?=?0.78), sigmoidoscopy (-1.1%, 95% CI -1.7 to -0.46, p?=?<0.001), or FOBT (-1.6%, 95% CI -3.2 to -0.03, p?=?0.046) post-ACA. For those aged 65-75, rates of colonoscopy (+2.3%, 95% CI -1.4 to 6.0, p?=?0.22), sigmoidoscopy (+0.34%, 95% CI 0.88 to 1.6, p?=?0.58) and FOBT (-0.65, 95% CI -4.1 to 2.8, p?=?0.72) did not increase. Among those aged 65-75 with Medicare and no additional insurance, the use of colonoscopy rose by 12.0% (95% CI 3.3 to 20.8, p?=?0.007). Among participants with Medicare living in poverty, colonoscopy use also increased (+5.7%, 95% CI 0.18 to 11.3, p?=?0.043).Eliminating cost-sharing for CRC screening has not resulted in changes in the use of CRC screening services for many Americans, although use may have increased in the post-ACA period among some Medicare beneficiaries.

  View details for DOI 10.1007/s11606-015-3504-2

  View details for Web of Science ID 000371162400012

  View details for PubMedID 26349953

• Physician spending and subsequent risk of malpractice claims: observational study BMJ-BRITISH MEDICAL JOURNAL Jena, A. B., Schoemaker, L., Bhattacharya, J., Seabury, S. A. 2015; 351

  View details for DOI 10.1136/bmj.h5516

  View details for Web of Science ID 000364390100005

• Out-of-pocket health expenditures and antimicrobial resistance in low-income and middle-income countries: an economic analysis LANCET INFECTIOUS DISEASES Alsan, M., Schoemaker, L., Eggleston, K., Kammili, N., Kolli, P., Bhattacharya, J. 2015; 15 (10): 1203-1210

  View details for DOI 10.1016/S1473-3099(15)00149-8

  View details for Web of Science ID 000361854300031

• Will Divestment from Employment-Based Health Insurance Save Employers Money? The Case of State and Local Governments JOURNAL OF EMPIRICAL LEGAL STUDIES Goldhaber-Fiebert, J. D., Studdert, D. M., Farid, M. S., Bhattacharya, J. 2015; 12 (3): 343-394

  View details for DOI 10.1111/jels.12076

  View details for Web of Science ID 000360209700001

• Health Outcomes in US Children with Abdominal Pain at Major Emergency Departments Associated with Race and Socioeconomic Status PLOS ONE Wang, L., Haberland, C., Thurm, C., Bhattacharya, J., Park, K. T. 2015; 10 (8)

  View details for DOI 10.1371/journal.pone.0132758

  View details for Web of Science ID 000359492300008

• Provider Visits and Early Vascular Access Placement in Maintenance Hemodialysis JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Erickson, K. F., Mell, M., Winkelmayer, W. C., Chertow, G. M., Bhattacharya, J. 2015; 26 (8): 1990-1997

  Abstract

  Medicare reimbursement policy encourages frequent provider visits for patients with ESRD undergoing hemodialysis. We hypothesize that patients seen more frequently by their nephrologist or advanced practitioner within the first 90 days of hemodialysis are more likely to undergo surgery to create an arteriovenous (AV) fistula or place an AV graft. We selected 35,959 patients aged ?67 years starting hemodialysis in the United States from a national registry. We used multivariable regression to evaluate the associations between mean visit frequency and AV fistula creation or graft placement in the first 90 days of hemodialysis. We conducted an instrumental variable analysis to test the sensitivity of our findings to potential bias from unobserved characteristics. One additional visit per month in the first 90 days of hemodialysis was associated with a 21% increase in the odds of AV fistula creation or graft placement during that period (95% confidence interval, 19% to 24%), corresponding to an average 4.5% increase in absolute probability. An instrumental variable analysis demonstrated similar findings. Excluding visits in months when patients were hospitalized, one additional visit per month was associated with a 10% increase in odds of vascular access surgery (95% confidence interval, 8% to 13%). In conclusion, patients seen more frequently by care providers in the first 90 days of hemodialysis undergo earlier AV fistula creation or graft placement. Payment policies that encourage more frequent visits to patients at key clinical time points may yield more favorable health outcomes than policies that operate irrespective of patients' health status.

  View details for DOI 10.1681/ASN.2014050464

  View details for Web of Science ID 000358895100023

  View details for PubMedID 25452668

• The Relationship between Commercial Health Care Prices and Medicare Spending and Utilization HEALTH SERVICES RESEARCH Romley, J. A., Axeen, S., Lakdawalla, D. N., Chernew, M. E., Bhattacharya, J., Goldman, D. P. 2015; 50 (3): 883-896

  Abstract

  To explore the relationship between commercial health care prices and Medicare spending/utilization across U.S. regions.Claims from large employers and Medicare Parts A/B/D over 2007-2009.We compared prices paid by commercial health plans to Medicare spending and utilization, adjusted for beneficiary health and the cost of care, across 301 hospital referral regions.A 10 percent lower commercial price (around the average level) is associated with 3.0 percent higher Medicare spending per member per year, and 4.3 percent more specialist visits (p < .01).Commercial health care prices are negatively associated with Medicare spending across regions. Providers may respond to low commercial prices by shifting service volume into Medicare. Further investigation is needed to establish causality.

  View details for DOI 10.1111/1475-6773.12262

  View details for Web of Science ID 000354878300015

  View details for PubMedID 25429755

• Provider Visit Frequency and Vascular Access Interventions in Hemodialysis CLINICAL JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Erickson, K. F., Mell, M. W., Winkelmayer, W. C., Chertow, G. M., Bhattacharya, J. 2015; 10 (2): 269-277

  Abstract

  Medicare reimbursement policy encourages frequent provider visits to patients with ESRD undergoing hemodialysis. This study sought to determine whether more frequent face-to-face provider (physician and advanced practitioner) visits lead to more procedures and therapeutic interventions aimed at preserving arteriovenous fistulas and grafts, improved vascular access outcomes, and fewer related hospitalizations.Multivariable regression was used to evaluate the association between provider (physician and advanced practitioner) visit frequency and interventions aimed at preserving vascular access, vascular access survival, hospitalization for vascular access infection, and outpatient antibiotic use in a cohort of 63,488 Medicare beneficiaries receiving hemodialysis in the United States. Medicare claims were used to identify the type of vascular access used, access-related events, and vascular access failure.One additional provider (physician and advanced practitioner) visit per month was associated with a 13% higher odds of receiving an intervention to preserve vascular access (95% confidence interval [95% CI], 12% to 14%) but was not associated with vascular access survival (hazard ratio, 1.01; 95% CI, 0.99 to 1.03). One additional provider visit was associated with a 9% (95% CI, 5% to 14%) lower odds of hospitalization for vascular access infection and a corresponding 9% (95% CI, 5% to 14%) higher odds of outpatient intravenous antibiotic administration. However, the associated changes in absolute probabilities of hospitalization and antibiotic administration were small.More frequent face-to-face provider (physician and advanced practitioner) visits were associated with more procedures and therapeutic interventions aimed at preserving vascular accesses, but not with prolonged vascular access survival and only a small decrease in hospitalization for vascular access.

  View details for DOI 10.2215/CJN.05540614

  View details for Web of Science ID 000348962400017

  View details for PubMedID 25587105

• Health outcomes in US children with abdominal pain at major emergency departments associated with race and socioeconomic status. PloS one Wang, L., Haberland, C., Thurm, C., Bhattacharya, J., Park, K. T. 2015; 10 (8)

  Abstract

  Over 9.6 million ED visits occur annually for abdominal pain in the US, but little is known about the medical outcomes of these patients based on demographics. We aimed to identify disparities in outcomes among children presenting to the ED with abdominal pain linked to race and SES.Data from 4.2 million pediatric encounters of abdominal pain were analyzed from 43 tertiary US children's hospitals, including 2.0 million encounters in the emergency department during 2004-2011. Abdominal pain was categorized as functional or organic abdominal pain. Appendicitis (with and without perforation) was used as a surrogate for abdominal pain requiring emergent care. Multivariate analysis estimated likelihood of hospitalizations, radiologic imaging, ICU admissions, appendicitis, appendicitis with perforation, and time to surgery and hospital discharge.Black and low income children had increased odds of perforated appendicitis (aOR, 1.42, 95% CI, 1.32- 1.53; aOR, 1.20, 95% CI 1.14 - 1.25). Blacks had increased odds of an ICU admission (aOR, 1.92, 95% CI 1.53 - 2.42) and longer lengths of stay (aHR, 0.91, 95% CI 0.86 - 0.96) than Whites. Minorities and low income also had lower rates of imaging for their appendicitis, including CT scans. The combined effect of race and income on perforated appendicitis, hospitalization, and time to surgery was greater than either separately.Based on race and SES, disparity of health outcomes exists in the acute ED setting among children presenting with abdominal pain, with differences in appendicitis with perforation, length of stay, and time until surgery.

  View details for DOI 10.1371/journal.pone.0132758

  View details for PubMedID 26267816

• Authors' reply to Barbieri and Kovarik, Mariani, and Waxman and Kanzaria. BMJ (Clinical research ed.) Jena, A. B., Schoemaker, L., Bhattacharya, J., Seabury, S. A. 2015; 351: h6774-?

  View details for DOI 10.1136/bmj.h6774

  View details for PubMedID 26668033

• Exposing Physicians To Reduced Residency Work Hours Did Not Adversely Affect Patient Outcomes After Residency HEALTH AFFAIRS Jena, A. B., Schoemaker, L., Bhattacharya, J. 2014; 33 (10): 1832-1840

  View details for DOI 10.1377/hlthaff.2014.0318

  View details for Web of Science ID 000343406500019

• Differences in healthcare expenditures for inflammatory bowel disease by insurance status, income, and clinical care setting PEERJ Park, M. D., Bhattacharya, J., Park, K. T. 2014; 2

  View details for DOI 10.7717/peerj.587

  View details for Web of Science ID 000347621300007

• Seasonal Patterns in Human A (H5N1) Virus Infection: Analysis of Global Cases PLOS ONE Mathur, M. B., Patel, R. B., Gould, M., Uyeki, T. M., Bhattacharya, J., Xiao, Y., Gillaspie, Y., Chae, C., Khazeni, N. 2014; 9 (9)

  View details for DOI 10.1371/journal.pone.0106171

  View details for Web of Science ID 000341774300008

• Physician Visits and 30-Day Hospital Readmissions in Patients Receiving Hemodialysis JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Erickson, K. F., Winkelmayer, W. C., Chertow, G. M., Bhattacharya, J. 2014; 25 (9): 2079-2087

  Abstract

  A focus of health care reform has been on reducing 30-day hospital readmissions. Patients with ESRD are at high risk for hospital readmission. It is unknown whether more monitoring by outpatient providers can reduce hospital readmissions in patients receiving hemodialysis. In nationally representative cohorts of patients in the United States receiving in-center hemodialysis between 2004 and 2009, we used a quasi-experimental (instrumental variable) approach to assess the relationship between frequency of visits to patients receiving hemodialysis following hospital discharge and the probability of rehospitalization. We then used a multivariable regression model and published hospitalization data to estimate the cost savings and number of hospitalizations that could be prevented annually with additional provider visits to patients in the month following hospitalization. In the main cohort (n=26,613), one additional provider visit in the month following hospital discharge was estimated to reduce the absolute probability of 30-day hospital readmission by 3.5% (95% confidence interval, 1.6% to 5.3%). The reduction in 30-day hospital readmission ranged from 0.5% to 4.9% in an additional four cohorts tested, depending on population density around facilities, facility profit status, and patient Medicaid eligibility. At current Medicare reimbursement rates, the effort to visit patients one additional time in the month following hospital discharge could lead to 31,370 fewer hospitalizations per year, and $240 million per year saved. In conclusion, more frequent physician visits following hospital discharge are estimated to reduce rehospitalizations in patients undergoing hemodialysis. Incentives for closer outpatient monitoring following hospital discharge could lead to substantial cost savings.

  View details for DOI 10.1681/ASN.2013080879

  View details for Web of Science ID 000341059200022

• Utilization Trends of Anti-TNF Agents and Health Outcomes in Adults and Children with Inflammatory Bowel Diseases: A Single-center Experience INFLAMMATORY BOWEL DISEASES Park, K. T., Sin, A., Wu, M., Bass, D., Bhattacharya, J. 2014; 20 (7): 1242-1249

  Abstract

  Utilization trends and health effects of infliximab and adalimumab in inflammatory bowel disease (IBD) are incompletely understood. We aimed to describe utilization trends of these 2 anti-tumor necrosis factor (TNF) agents, determine the correlation between utilization with rates of hospitalization and surgery and describe differences in use between adults and children.Longitudinal data were analyzed for drug utilization, hospitalization, and abdominal surgery. Descriptive statistics were used to show trends, and utilization quotients were compared for standardization. Multivariate logistic regression analysis assessed the association between drug use and rates of hospitalization and surgery.Four hundred thirty-eight pediatric and 2514 adult patients with IBD generated a total of 51,882 inpatient and outpatient encounters, representing 1185 Crohn's disease, 1531 ulcerative colitis, and 236 indeterminate colitis patients. From 2007 through 2012, utilization quotients declined for hospitalization but remained unchanged for surgery; adalimumab saw a 3-fold increase, despite continued dominance of infliximab. Median band and mean fitted plots showed downward hospitalization trends from 2006 to 2012. Utilization of infliximab peaked in 2008, Q4 with gradual decline to 2012, Q2; and adalimumab showed moderate increased utilization since 2007, Q1. Use of infliximab (odds ratio [OR], 0.76; 95% confidence interval [CI], 0.70-0.83) and adalimumab (OR, 0.79; 95% CI, 0.72-0.87) was associated with decreased hospitalization risk but not associated with reduced abdominal surgery risk. Children had increased hospitalization (OR, 2.68; 95% CI, 2.49-2.88) but decreased risk for abdominal surgery (OR, 0.57; 95% CI, 0.46-0.70).Current infliximab use remains substantially greater than adalimumab use, despite recent increased use of adalimumab. Although trends for hospitalization for IBD are decreasing, it is not reflected in abdominal surgery rates in a tertiary IBD referral center.

  View details for DOI 10.1097/MIB.0000000000000061

  View details for Web of Science ID 000337750000018

  View details for PubMedID 24846718

• Cleft palate surgery: an evaluation of length of stay, complications, and costs by hospital type. Cleft palate-craniofacial journal Nguyen, C., Hernandez-Boussard, T., Davies, S. M., Bhattacharya, J., Khosla, R. K., Curtin, C. M. 2014; 51 (4): 412-419

  Abstract

  Objective : The purpose of this study was to assess length of stay (LOS), complication rates, costs, and charges of cleft palate repair by various hospital types. We hypothesized that pediatric hospitals would have shorter LOS, fewer complications, and lower costs and charges. Methods : Patients were identified by ICD-9-CM code for cleft palate repair (27.62) using databases from the Agency for Health Research and Quality Healthcare Cost and Utilization Project Kids' Inpatient Database from 1997, 2000, 2003, and 2006. Patient characteristics (age, race, gender, insurer, comorbidities) and facility resources (hospital beds, cleft palate surgery volume, nurse-to-bed ratio, pediatric intensive care unit [PICU], PICU intensivist, burn unit) were examined. Hospitals types included pediatric hospitals, general hospitals, and nonaccredited children's hospital. For each hospital type, mean LOS, extended LOS (LOS > 2), and complications were assessed. Results : A total of 14,153 patients had cleft repair with a mean LOS of 2 days (SD, 0.04), mortality 0.01%, transfusion 0.3%, and complication <3%. Pediatric hospitals had fewer patients with extended hospital stays. Patients with an LOS >2 days were associated with fourfold higher complications. Comorbidities increased the relative rate of LOS >2 days by 90%. Pediatric hospitals had the highest comorbidities, yet 35% decreased the relative rate of LOS >2 days. Median total charges of $10,835 increased to $15,104 with LOS >2 days; median total costs of $4367 increased to $6148 with a LOS >2 days. Conclusion : Pediatric hospitals had higher comorbidities yet shorter LOS. Pediatric resources significantly decreased the relative rate of LOS >2 days. Median costs and charges increased by 41% with LOS >2 days. Further research is needed to understand additional aspects of pediatric hospitals associated with lower LOS.

  View details for DOI 10.1597/12-150

  View details for PubMedID 24063682

• Heterogeneity in Healthy Aging JOURNALS OF GERONTOLOGY SERIES A-BIOLOGICAL SCIENCES AND MEDICAL SCIENCES Lowsky, D. J., Olshansky, S. J., Bhattacharya, J., Goldman, D. P. 2014; 69 (6): 640-649

  Abstract

  For a surprisingly large segment of the older population, chronological age is not a relevant marker for understanding, measuring, or experiencing healthy aging. Using the 2003 Medical Expenditure Panel Survey and the 2004 Health and Retirement Study to examine the proportion of Americans exhibiting five markers of health and the variation in health-related quality of life across each of eight age groups, we find that a significant proportion of older Americans is healthy within every age group beginning at age 51, including among those aged 85+. For example, 48% of those aged 51-54 and 28% of those aged 85+ have excellent or very good self-reported health status; similarly, 89% of those aged 51-54 and 56% of those aged 85+ report no health-based limitations in work or housework. Also, health-related quality of life ranges widely within every age group, yet there is only a comparatively small variation in median quality of life across age groups, suggesting that older Americans today may be experiencing substantially different age-health trajectories than their predecessors. Patterns are similar for medical expenditures. Several policy implications are explored.

  View details for DOI 10.1093/gerona/glt162

  View details for Web of Science ID 000337128500003

  View details for PubMedID 24249734

• The Relationship of Health Aid to Population Health Improvements JAMA INTERNAL MEDICINE Bendavid, E., Bhattacharya, J. 2014; 174 (6)

  View details for DOI 10.1001/jamainternmed.2014.292

  View details for Web of Science ID 000336843500018

• Ending SNAP Subsidies For Sugar-Sweetened Beverages Could Reduce Obesity And Type 2 Diabetes HEALTH AFFAIRS Basu, S., Seligman, H. K., Gardner, C., Bhattacharya, J. 2014; 33 (6): 1032-1039

  Abstract

  To reduce obesity and type 2 diabetes rates, lawmakers have proposed modifying Supplemental Nutrition Assistance Program (SNAP) benefits to encourage healthier food choices. We examined the impact of two proposed policies: a ban on using SNAP dollars to buy sugar-sweetened beverages; and a subsidy in which for every SNAP dollar spent on fruit and vegetables, thirty cents is credited back to participants' SNAP benefit cards. We used nationally representative data and models describing obesity, type 2 diabetes, and determinants of food consumption among a sample of over 19,000 SNAP participants. We found that a ban on SNAP purchases of sugar-sweetened beverages would be expected to significantly reduce obesity prevalence and type 2 diabetes incidence, particularly among adults ages 18-65 and some racial and ethnic minorities. The subsidy policy would not be expected to have a significant effect on obesity and type 2 diabetes, given available data. Such a subsidy could, however, more than double the proportion of SNAP participants who meet federal vegetable and fruit consumption guidelines.

  View details for DOI 10.1377/hlthaff.2013.1246

  View details for Web of Science ID 000338187200015

• The relationship of health aid to population health improvements. JAMA internal medicine Bendavid, E., Bhattacharya, J. 2014; 174 (6): 881-887

  Abstract

  International aid to the health sector is an important component of all health spending in many developing countries. The relationship between health aid and changes in population health among aid recipients remains unknown.To quantify the relationship between health aid and changes in life expectancy and mortality in children younger than 5 years (under-5 mortality) among aid recipient nations.Cross-country panel data analysis of the relationship between measures of health aid, life expectancy, and under-5 mortality. Using difference models for longitudinal data with fixed effects for countries and years, we estimated the unique relationship between health aid and changes in life expectancy and under-5 mortality, controlling for gross domestic product per capita, urbanization, and total fertility rate.A total of 140 aid-recipient countries between 1974 and 2010.Annual amount of development assistance directed to the health sector in constant 2010 US dollars.Improvements in under-5 mortality and life expectancy in the period following aid receipt.Between 1974 and 2010, each 1% increase in health aid was associated with 0.24 months greater increase in life expectancy (95% CI, 0.02-0.46) (P?=?.03) and a 0.14 per 1000 live births faster decline in the probability of under-5 deaths per 1000 live births (95% CI, 0.02-0.26) (P?=?.02). The association between health aid and health improvements has strengthened over time, with the closest association occurring between 2000 and 2010. Health improvements associated with health aid are measurable for 3 to 5 years after aid disbursement. These findings imply that an increase of $1 billion in health aid could be associated with 364,800 fewer under-5 deaths (95% CI, 98,400-630,000).International aid to the health sector is related to increasing life expectancy and declining under-5 mortality. The benefits from aid appear to last for several years and have been greatest between 2000 and 2010, possibly because of improving health technologies or effective targeting of aid.

  View details for DOI 10.1001/jamainternmed.2014.292

  View details for PubMedID 24756557

• Demographic and Clinical Predictors of Mortality from Highly Pathogenic Avian Influenza A (H5N1) Virus Infection: CART Analysis of International Cases PLOS ONE Patel, R. B., Mathur, M. B., Gould, M., Uyeki, T. M., Bhattacharya, J., Xiao, Y., Khazeni, N. 2014; 9 (3)

  View details for DOI 10.1371/journal.pone.0091630

  View details for Web of Science ID 000333675600011

• Demographic and clinical predictors of mortality from highly pathogenic avian influenza A (H5N1) virus infection: CART analysis of international cases. PloS one Patel, R. B., Mathur, M. B., Gould, M., Uyeki, T. M., Bhattacharya, J., Xiao, Y., Khazeni, N. 2014; 9 (3)

  Abstract

  Human infections with highly pathogenic avian influenza (HPAI) A (H5N1) viruses have occurred in 15 countries, with high mortality to date. Determining risk factors for morbidity and mortality from HPAI H5N1 can inform preventive and therapeutic interventions.We included all cases of human HPAI H5N1 reported in World Health Organization Global Alert and Response updates and those identified through a systematic search of multiple databases (PubMed, Scopus, and Google Scholar), including articles in all languages. We abstracted predefined clinical and demographic predictors and mortality and used bivariate logistic regression analyses to examine the relationship of each candidate predictor with mortality. We developed and pruned a decision tree using nonparametric Classification and Regression Tree methods to create risk strata for mortality.We identified 617 human cases of HPAI H5N1 occurring between December 1997 and April 2013. The median age of subjects was 18 years (interquartile range 6-29 years) and 54% were female. HPAI H5N1 case-fatality proportion was 59%. The final decision tree for mortality included age, country, per capita government health expenditure, and delay from symptom onset to hospitalization, with an area under the receiver operator characteristic (ROC) curve of 0.81 (95% CI: 0.76-0.86).A model defined by four clinical and demographic predictors successfully estimated the probability of mortality from HPAI H5N1 illness. These parameters highlight the importance of early diagnosis and treatment and may enable early, targeted pharmaceutical therapy and supportive care for symptomatic patients with HPAI H5N1 virus infection.

  View details for DOI 10.1371/journal.pone.0091630

  View details for PubMedID 24667532

• Differences in healthcare expenditures for inflammatory bowel disease by insurance status, income, and clinical care setting. PeerJ Park, M. D., Bhattacharya, J., Park, K. 2014; 2

  Abstract

  Background. Socioeconomic factors and insurance status have not been correlated with differential use of healthcare services in inflammatory bowel disease (IBD). Aim. To describe IBD-related expenditures based on insurance and household income with the use of inpatient, outpatient, emergency, and office-based services, and prescribed medications in the United States (US). Methods. We evaluated the Medical Expenditure Panel Survey from 1996 to 2011 of individuals with Crohn's disease (CD) or ulcerative colitis (UC). Nationally weighted means, proportions, and multivariate regression models examined the relationships between income and insurance status with expenditures. Results. Annual per capita mean expenditures for CD, UC, and all IBD were $10,364 (N = 238), $7,827 (N = 95), and $9,528, respectively, significantly higher than non-IBD ($4,314, N = 276, 372, p < 0.05). Publicly insured patients incurred the highest costs ($18,067) over privately insured ($8,014, p < 0.05) or uninsured patients ($5,129, p < 0.05). Among all IBD patients, inpatient care composed the highest proportion of costs ($3,392, p < 0.05). Inpatient costs were disproportionately higher for publicly insured patients. Public insurance had higher odds of total costs than private (OR 2.13, CI [1.08-4.19]) or no insurance (OR 4.94, CI [1.26-19.47]), with increased odds for inpatient and emergency care. Private insurance had higher costs associated with outpatient care, office-based care, and prescribed medicines. Low-income patients had lower costs associated with outpatient (OR 0.38, CI [0.15-0.95]) and office-based care (OR 0.21, CI [0.07-0.62]). Conclusions. In the US, high inpatient utilization among publicly insured patients is a previously unrecognized driver of high IBD costs. Bridging this health services gap between SES strata for acute care services may curtail direct IBD-related costs.

  View details for DOI 10.7717/peerj.587

  View details for PubMedID 25279267

• Nutritional Policy Changes in the Supplemental Nutrition Assistance Program: A Microsimulation and Cost-Effectiveness Analysis MEDICAL DECISION MAKING Basu, S., Seligman, H., Bhattacharya, J. 2013; 33 (7): 937-948

  Abstract

  Some experts have proposed limiting the use of Supplemental Nutrition Assistance Program (SNAP) benefits, for calorie-dense foods or subsidizing SNAP purchases of healthier foods.To estimate health effects and cost-effectiveness of banning or taxing sugar-sweetened beverages (SSBs) or subsidizing fruits and vegetables purchased with SNAP.. Microsimulation. Data Sources. National Health and Nutrition Examination Survey, US Department of Agriculture Quarterly Food-at-Home Price Database, and SNAP program data. Target Population: US adults aged 25 to 64 y. Time Horizon. 10 y. Perspective. Governmental. Outcome MEASURES: Incremental costs, quality-adjusted life-years (QALYs), body mass index, Alternative Healthy Eating Index, Food Security Score, diabetes person-years, and deaths from myocardial infarctions (MIs) and strokes.of Base-Case Analysis. Banning SSB purchases using SNAP benefits would be expected to avert 510,000 diabetes person-years and 52,000 deaths from MIs and strokes over the next decade, with a savings of $2900 per QALY saved. A penny-per-ounce tax on SSBs purchased with SNAP dollars would produce higher cost savings due to tax revenues but avert fewer chronic disease deaths. However, some SNAP participants are likely to preferentially purchase SSBs through their disposable income, indirectly reducing their food security. A 30% produce subsidy would be expected to avert 39,000 diabetes person-years and 4600 cardiovascular deaths over 10 y without effects on food security. Results of Sensitivity Analysis. Results are sensitive to the intake elasticities of SSBs and produce. Limitations. Input data did not provide information on heterogeneity in response to price changes within the SNAP-using POPULATION: CONCLUSIONS: SNAP restrictions on SSBs could lower chronic disease mortality, but further testing should examine indirect effects on disposable income and food security. Subsidizing produce could confer fewer benefits or risks but at higher cost.

  View details for DOI 10.1177/0272989X13493971

  View details for Web of Science ID 000324535200005

  View details for PubMedID 23811757

• The effect of trauma center care on pediatric injury mortality in California, 1999 to 2011. journal of trauma and acute care surgery Wang, N. E., Saynina, O., Vogel, L. D., Newgard, C. D., Bhattacharya, J., Phibbs, C. S. 2013; 75 (4): 704-716

  Abstract

  Trauma centers (TCs) have been shown to decrease mortality in adults, but this has not been demonstrated at a population level in all children. We hypothesized that seriously injured children would have increased survival in a TC versus nontrauma center (nTC), but there would be no increased benefit from pediatric-designated versus adult TC care.This was a retrospective study of the unmasked California Office of Statewide Health and Planning Department patient discharge database (1999-2011). DRG International Classification of Diseases-9th Rev. (ICD-9) diagnostic codes indicating trauma were identified for children (0-18 years), and injury severity was calculated from ICD-9 codes using validated algorithms. To adjust for hospital case mix, we selected patients with ICD-9 codes that were capable of causing death and which appeared at both TCs and nTCs. Instrumental variable (IV) analysis using differential distance between the child's residence to a TC and to the nearest hospital was applied to further adjust for unobservable differences in TC and nTC populations. Instrumental variable regression models analyzed the association between mortality and TC versus nTC care as well as for pediatric versus adult TC designations, adjusting for demographic and clinical variables.Unadjusted mortality for the entire population of children with nontrivial trauma (n = 445,236) was 1.2%. In the final study population (n = 77,874), mortality was 5.3%, 3.8% in nTCs and 6.1% in TCs. IV regression analysis demonstrated a 0.79 percentage point (95% confidence interval, -0.80 to -0.30; p = 0.044) decrease in mortality for children cared for in TC versus nTC. No decrease in mortality was demonstrated for children cared for in pediatric versus adult TCs.Our IV TC outcome models use improved injury severity and case mix adjustment to demonstrate decreased mortality for seriously injured California children treated in TCs. These results can be used to take evidence-based steps to decrease disparities in pediatric access to, and subsequent outcomes for, trauma care.Therapeutic/care management, level III.

  View details for DOI 10.1097/TA.0b013e31829a0a65

  View details for PubMedID 24064887

• The effect of trauma center care on pediatric injury mortality in California, 1999 to 2011. journal of trauma and acute care surgery Wang, N. E., Saynina, O., Vogel, L. D., Newgard, C. D., Bhattacharya, J., Phibbs, C. S. 2013; 75 (4): 704-716

  Abstract

  Trauma centers (TCs) have been shown to decrease mortality in adults, but this has not been demonstrated at a population level in all children. We hypothesized that seriously injured children would have increased survival in a TC versus nontrauma center (nTC), but there would be no increased benefit from pediatric-designated versus adult TC care.This was a retrospective study of the unmasked California Office of Statewide Health and Planning Department patient discharge database (1999-2011). DRG International Classification of Diseases-9th Rev. (ICD-9) diagnostic codes indicating trauma were identified for children (0-18 years), and injury severity was calculated from ICD-9 codes using validated algorithms. To adjust for hospital case mix, we selected patients with ICD-9 codes that were capable of causing death and which appeared at both TCs and nTCs. Instrumental variable (IV) analysis using differential distance between the child's residence to a TC and to the nearest hospital was applied to further adjust for unobservable differences in TC and nTC populations. Instrumental variable regression models analyzed the association between mortality and TC versus nTC care as well as for pediatric versus adult TC designations, adjusting for demographic and clinical variables.Unadjusted mortality for the entire population of children with nontrivial trauma (n = 445,236) was 1.2%. In the final study population (n = 77,874), mortality was 5.3%, 3.8% in nTCs and 6.1% in TCs. IV regression analysis demonstrated a 0.79 percentage point (95% confidence interval, -0.80 to -0.30; p = 0.044) decrease in mortality for children cared for in TC versus nTC. No decrease in mortality was demonstrated for children cared for in pediatric versus adult TCs.Our IV TC outcome models use improved injury severity and case mix adjustment to demonstrate decreased mortality for seriously injured California children treated in TCs. These results can be used to take evidence-based steps to decrease disparities in pediatric access to, and subsequent outcomes for, trauma care.Therapeutic/care management, level III.

  View details for DOI 10.1097/TA.0b013e31829a0a65

  View details for PubMedID 24064887

• 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

• Small Increases To Employer Premiums Could Shift Millions Of People To The Exchanges And Add Billions To Federal Outlays HEALTH AFFAIRS Austin, D. R., Luan, A., Wang, L. L., Bhattacharya, J. 2013; 32 (9): 1531-1537

  Abstract

  The Affordable Care Act will expand insurance coverage to more than twenty-five million Americans, partly through subsidized private insurance available from newly created health insurance exchanges for people with incomes of 133-400 percent of the federal poverty level. The act will alter the financial incentive structure for employers and influence their decisions on whether or not to offer their employees coverage. These decisions, in turn, will affect federal outlays and revenues through several mechanisms. We model the sensitivity of federal costs for the insurance exchange coverage provision of the Affordable Care Act using the nationally representative Medical Expenditure Panel Survey data set. We assess revenues and subsidy outlays for premiums and cost sharing for individuals purchasing private insurance through exchanges. Our findings show that changing theoretical premium contribution levels by just $100 could induce 2.25 million individuals to transition to exchanges and increase federal outlays by $6.7 billion. Policy makers and analysts should pay especially careful attention to participation rates as the act's implementation continues.

  View details for DOI 10.1377/hlthaff.2013.0522

  View details for Web of Science ID 000324681500004

  View details for PubMedID 24019356

• Variation in Nephrologist Visits to Patients on Hemodialysis across Dialysis Facilities and Geographic Locations CLINICAL JOURNAL OF THE AMERICAN SOCIETY OF NEPHROLOGY Erickson, K. F., Tan, K. B., Winkelmayer, W. C., Chertow, G. M., Bhattacharya, J. 2013; 8 (6): 987-994

  Abstract

  BACKGROUND AND OBJECTIVES: Geographic and other variations in medical practices lead to differences in medical costs, often without a clear link to health outcomes. This work examined variation in the frequency of physician visits to patients receiving hemodialysis to measure the relative importance of provider practice patterns (including those patterns linked to geographic region) and patient health in determining visit frequency. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This work analyzed a nationally representative 2006 database of patients receiving hemodialysis in the United States. A variation decomposition analysis of the relative importance of facility, geographic region, and patient characteristics-including demographics, socioeconomic status, and indicators of health status-in explaining physician visit frequency variation was conducted. Finally, the associations between facility, geographic and patient characteristics, and provider visit frequency were measured using multivariable regression. RESULTS: Patient characteristics accounted for only 0.9% of the total visit frequency variation. Accounting for case-mix differences, patients' hemodialysis facilities explained about 24.9% of visit frequency variation, of which 9.3% was explained by geographic region. Visit frequency was more closely associated with many facility and geographic characteristics than indicators of health status. More recent dialysis initiation and recent hospitalization were associated with decreased visit frequency. CONCLUSIONS: In hemodialysis, provider visit frequency depends more on geography and facility location and characteristics than patients' health status or acuity of illness. The magnitude of variation unrelated to patient health suggests that provider visit frequency practices do not reflect optimal management of patients on dialysis.

  View details for DOI 10.2215/CJN.10171012

  View details for Web of Science ID 000320149900015

  View details for PubMedID 23430207

• The Gorbachev Anti-Alcohol Campaign and Russia's Mortality Crisis AMERICAN ECONOMIC JOURNAL-APPLIED ECONOMICS Bhattacharya, J., Gathmann, C., Miller, G. 2013; 5 (2): 232-260

  View details for DOI 10.1257/app.5.2.232

  View details for Web of Science ID 000316732800009

• The Utility of Childhood and Adolescent Obesity Assessment in Relation to Adult MEDICAL DECISION MAKING Goldhaber-Fiebert, J. D., Rubinfeld, R. E., Bhattacharya, J., Robinson, T. N., Wise, P. H. 2013; 33 (2): 163-175

  Abstract

  High childhood obesity prevalence has raised concerns about future adult health, generating calls for obesity screening of young children.To estimate how well childhood obesity predicts adult obesity and to forecast obesity-related health of future US adults.Longitudinal statistical analyses; microsimulations combining multiple data sets.National Longitudinal Survey of Youth, Population Study of Income Dynamics, and National Health and Nutrition Evaluation Surveys.The authors estimated test characteristics and predictive values of childhood body mass index to identify 2-, 5-, 10-, and 15 year-olds who will become obese adults. The authors constructed models relating childhood body mass index to obesity-related diseases through middle age stratified by sex and race.Twelve percent of 18-year-olds were obese. While screening at age 5 would miss 50% of those who become obese adults, screening at age 15 would miss 9%. The predictive value of obesity screening below age 10 was low even when maternal obesity was included as a predictor. Obesity at age 5 was a substantially worse predictor of health in middle age than was obesity at age 15. For example, the relative risk of developing diabetes as adults for obese white male 15-year-olds was 4.5 versus otherwise similar nonobese 15-year-olds. For obese 5-year-olds, the relative risk was 1.6.Main results do not include Hispanics due to sample size. Past relationships between childhood and adult obesity and health may change in the future.Early childhood obesity assessment adds limited information to later childhood assessment. Targeted later childhood approaches or universal strategies to prevent unhealthy weight gain should be considered.

  View details for DOI 10.1177/0272989X12447240

  View details for Web of Science ID 000316684200006

• An economic analysis of conservative management versus active treatment for men with localized prostate cancer. Journal of the National Cancer Institute. Monographs Perlroth, D. J., Bhattacharya, J., Goldman, D. P., Garber, A. M. 2012; 2012 (45): 250-257

  Abstract

  Comparative effectiveness research suggests that conservative management (CM) strategies are no less effective than active initial treatment for many men with localized prostate cancer. We estimate longer-term costs of initial management strategies and potential US health expenditure savings by increased use of conservative management for men with localized prostate cancer. Five-year total health expenditures attributed to initial management strategies for localized prostate cancer were calculated using commercial claims data from 1998 to 2006, and savings were estimated from a US population health-care expenditure model. Our analysis finds that patients receiving combinations of active treatments have the highest additional costs over conservative management at $63 500, followed by $48 550 for intensity-modulated radiation therapy, $37 500 for primary androgen deprivation therapy, and $28 600 for brachytherapy. Radical prostatectomy ($15 200) and external beam radiation therapy ($18 900) were associated with the lowest costs. The population model estimated that US health expenditures could be lowered by 1) use of initial CM over all active treatment ($2.9-3.25 billion annual savings), 2) shifting patients receiving intensity-modulated radiation therapy to CM ($680-930 million), 3) foregoing primary androgen deprivation therapy($555 million), 4) reducing the use of adjuvant androgen deprivation in addition to local therapies ($630 million), and 5) using single treatments rather than combination local treatment ($620-655 million). In conclusion, we find that all active treatments are associated with higher longer-term costs than CM. Substantial savings, representing up to 30% of total costs, could be realized by adopting CM strategies, including active surveillance, for initial management of men with localized prostate cancer.

  View details for DOI 10.1093/jncimonographs/lgs037

  View details for PubMedID 23271781

• Treatment effect bounds: An application to Swan-Ganz catheterization JOURNAL OF ECONOMETRICS Bhattacharya, J., Shaikh, A. M., Vytlacil, E. 2012; 168 (2): 223-243

  View details for DOI 10.1016/j.jeconom.2012.01.001

  View details for Web of Science ID 000304634800004

• HIV Development Assistance and Adult Mortality in Africa JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Bendavid, E., Holmes, C. B., Bhattacharya, J., Miller, G. 2012; 307 (19): 2060-2067

  Abstract

  The effect of global health initiatives on population health is uncertain. Between 2003 and 2008, the US President's Emergency Plan for AIDS Relief (PEPFAR), the largest initiative ever devoted to a single disease, operated intensively in 12 African focus countries. The initiative's effect on all-cause adult mortality is unknown.To determine whether PEPFAR was associated with relative changes in adult mortality in the countries and districts where it operated most intensively.Using person-level data from the Demographic and Health Surveys, we conducted cross-country and within-country analyses of adult mortality (annual probability of death per 1000 adults between 15 and 59 years old) and PEPFAR's activities. Across countries, we compared adult mortality in 9 African focus countries (Ethiopia, Kenya, Mozambique, Namibia, Nigeria, Rwanda, Tanzania, Uganda, and Zambia) with 18 African nonfocus countries from 1998 to 2008. We performed subnational analyses using information on PEPFAR's programmatic intensity in Tanzania and Rwanda. We employed difference-in-difference analyses with fixed effects for countries and years as well as personal and time-varying area characteristics.Adult all-cause mortality.We analyzed information on 1 538 612 adults, including 60 303 deaths, from 41 surveys in 27 countries, 9 of them focus countries. In 2003, age-adjusted adult mortality was 8.3 per 1000 adults in the focus countries (95% CI, 8.0-8.6) and 8.5 per 1000 adults (95% CI, 8.3-8.7) in the nonfocus countries. In 2008, mortality was 4.1 per 1000 (95% CI, 3.6-4.6) in the focus countries and 6.9 per 1000 (95% CI, 6.3-7.5) in the nonfocus countries. The adjusted odds ratio of mortality among adults living in focus countries compared with nonfocus countries between 2004 and 2008 was 0.84 (95% CI, 0.72-0.99; P = .03). Within Tanzania and Rwanda, the adjusted odds ratio of mortality for adults living in districts where PEPFAR operated more intensively was 0.83 (95% CI, 0.72-0.97; P = .02) and 0.75 (95% CI, 0.56-0.99; P = .04), respectively, compared with districts where it operated less intensively.Between 2004 and 2008, all-cause adult mortality declined more in PEPFAR focus countries relative to nonfocus countries. It was not possible to determine whether PEPFAR was associated with mortality effects separate from reductions in HIV-specific deaths.

  View details for Web of Science ID 000304048200025

  View details for PubMedID 22665105

• The Association Between Insurance Status and Emergency Department Disposition of Injured California Children ACADEMIC EMERGENCY MEDICINE Arroyo, A. C., Wang, N. E., Saynina, O., Bhattacharya, J., Wise, P. H. 2012; 19 (5): 541-551

  Abstract

  This study examined the relationship between insurance status and emergency department (ED) disposition of injured California children.Multivariate regression models were built using data obtained from the 2005 through 2009 California Office of Statewide Health Planning and Development (OSHPD) data sets for all ED visits by injured children younger than 19 years of age.Of 3,519,530 injury-related ED visits, 52% were insured by private, and 36% were insured by public insurance, while 11% of visits were not insured. After adjustment for injury characteristics and demographic variables, publicly insured children had a higher likelihood of admission for mild, moderate, and severe injuries compared to privately insured children (mild injury adjusted odds ratio [AOR] = 1.36, 95% confidence interval [CI] = 1.34 to 1.39; moderate and severe injury AOR = 1.34, 95% CI = 1.28 to 1.41). However, uninsured children were less likely to be admitted for mild, moderate, and severe injuries compared to privately insured children (mild injury AOR = 0.63, 95% CI = 0.61 to 0.66; moderate and severe injury AOR = 0.50, 95% CI = 0.46 to 0.55). While publicly insured children with moderate and severe injuries were as likely as privately insured children to experience an ED death (AOR = 0.91, 95% CI = 0.70 to 1.18), uninsured children with moderate and severe injuries were more likely to die in the ED compared to privately insured children (AOR = 3.11, 95% CI = 2.38 to 4.06).Privately insured, publicly insured, and uninsured injured children have disparate patterns of ED disposition. Policy and clinical efforts are needed to ensure that all injured children receive equitable emergency care.

  View details for DOI 10.1111/j.1553-2712.2012.01356.x

  View details for Web of Science ID 000304133300009

• Pharmaceutical Price Controls and Minimum Efficacy Regulation: Evidence from the United States and Italy HEALTH SERVICES RESEARCH Atella, V., Bhattacharya, J., Carbonari, L. 2012; 47 (1): 293-308

  Abstract

  This article examines the relationship between drug price and drug quality and how it varies across two of the most common regulatory regimes in the pharmaceutical market: minimum efficacy standards (MES) and a mix of MES and price control mechanisms (MES + PC).Our primary data source is the Tufts-New England Medical Center-Cost Effectiveness Analysis Registry which have been merged with price data taken from MEPS (for the United States) and AIFA (for Italy).Through a simple model of adverse selection we model the interaction between firms, heterogeneous buyers, and the regulator.The theoretical analysis provides two results. First, an MES regime provides greater incentives to produce high-quality drugs. Second, an MES + PC mix reduces the difference in price between the highest and lowest quality drugs on the market.The empirical analysis based on United States and Italian data corroborates these results.

  View details for DOI 10.1111/j.1475-6773.2011.01333.x

  View details for Web of Science ID 000299040600018

  View details for PubMedID 22091623

• Diabetes, Its Treatment, and Catastrophic Medical Spending in 35 Developing Countries DIABETES CARE Smith-Spangler, C. M., Bhattacharya, J., Goldhaber-Fiebert, J. D. 2012; 35 (2): 319-326

  Abstract

  To assess the individual financial impact of having diabetes in developing countries, whether diabetic individuals possess appropriate medications, and the extent to which health insurance may protect diabetic individuals by increasing medication possession or decreasing the risk of catastrophic spending.Using 2002-2003 World Health Survey data (n = 121,051 individuals; 35 low- and middle-income countries), we examined possession of medications to treat diabetes and estimated the relationship between out-of-pocket medical spending (2005 international dollars), catastrophic medical spending, and diabetes. We assessed whether health insurance modified these relationships.Diabetic individuals experience differentially higher out-of-pocket medical spending, particularly among individuals with high levels of spending (excess spending of $157 per year [95% CI 130-184] at the 95th percentile), and a greater chance of incurring catastrophic medical spending (17.8 vs. 13.9%; difference 3.9% [95% CI 0.2-7.7]) compared with otherwise similar individuals without diabetes. Diabetic individuals with insurance do not have significantly lower risks of catastrophic medical spending (18.6 vs. 17.7%; difference not significant), nor were they significantly more likely to possess diabetes medications (22.8 vs. 20.6%; difference not significant) than those who were otherwise similar but without insurance. These effects were more pronounced and significant in lower-income countries.In low-income countries, despite insurance, diabetic individuals are more likely to experience catastrophic medical spending and often do not possess appropriate medications to treat diabetes. Research into why policies in these countries may not adequately protect people from catastrophic spending or enhance possession of critical medications is urgently needed.

  View details for DOI 10.2337/dc11-1770

  View details for Web of Science ID 000299856000024

  View details for PubMedID 22238276

• The other ex ante moral hazard in health JOURNAL OF HEALTH ECONOMICS Bhattacharya, J., Packalen, M. 2012; 31 (1): 135-146

  Abstract

  It is well-known that pooled insurance coverage can induce people to make inefficiently low investments in self-protective activities. We identify another ex ante moral hazard that runs in the opposite direction. Lower levels of self-protection and the associated chronic conditions and behavioral patterns such as obesity, smoking, and malnutrition increase the incidence of many diseases and consumption of treatments to those diseases. This increases the reward for innovation and thus benefits the innovator. It also increases treatment innovation which benefits all consumers. As individuals do not take these positive externalities into account, their investments in self-protection are inefficiently high. We quantify the lower bound of this externality for obesity. The lower bound is independent of how much additional innovation is generated. The results show that the externality we identify offsets the negative Medicare-induced insurance externality of obesity. The Medicare-induced obesity subsidy is thus not a sufficient rationale for "soda taxes", "fat taxes" or other penalties on obesity. The quantitative finding also implies that the other ex ante moral hazard that we identify can be as important as the ex ante moral hazard that has been a central concept in health economics for decades.

  View details for DOI 10.1016/j.jhealeco.2011.09.001

  View details for Web of Science ID 000302972200012

  View details for PubMedID 21993331

• Opportunities and benefits as determinants of the direction of scientific research JOURNAL OF HEALTH ECONOMICS Bhattacharya, J., Packalen, M. 2011; 30 (4): 603-615

  Abstract

  Scientific research and private-sector technological innovation differ in objectives, constraints, and organizational forms. Scientific research may thus not be driven by the direct practical benefit to others in the way that private-sector innovation is. Alternatively, some - yet largely unexplored - mechanisms drive the direction of scientific research to respond to the expected public benefit. We test these two competing hypotheses of scientific research. This is important because any coherent specification of what constitutes the socially optimal allocation of research requires that scientists take the public practical benefit of their work into account in setting their agenda. We examine whether the composition of medical research responds to changes in disease prevalence, while accounting for the quality of available research opportunities. We match biomedical publications data with disease prevalence data and develop new methods for estimating the quality of research opportunities from textual information and structural productivity parameters.

  View details for DOI 10.1016/j.jhealeco.2011.05.007

  View details for Web of Science ID 000294393500001

  View details for PubMedID 21683461

• Persistent Racial Disparities in Survival After Heart Transplantation CIRCULATION Liu, V., Bhattacharya, J., Weill, D., Hlatky, M. A. 2011; 123 (15): 1642-1649

  Abstract

  Racial and ethnic disparities are well documented in many areas of health care, but have not been comprehensively evaluated among recipients of heart transplants.We performed a retrospective cohort study of 39075 adult primary heart transplant recipients from 1987 to 2009 using national data from the United Network of Organ Sharing and compared mortality for nonwhite and white patients using the Cox proportional hazards model. During the study period, 8082 nonwhite and 30 993 white patients underwent heart transplantation. Nonwhite heart transplant recipients increased over time, comprising nearly 30% of transplantations since 2005. Nonwhite recipients had a higher clinical risk profile than white recipients at the time of transplantation, but had significantly higher posttransplantation mortality even after adjustment for baseline risk. Among the nonwhite group, only black recipients had an increased risk of death compared with white recipients after multivariable adjustment for recipient, transplant, and socioeconomic factors (hazard ratio, 1.34; 95% confidence interval, 1.21 to 1.47; P<0.001). Five-year mortality was 35.7% (95% confidence interval, 35.2 to 38.3) among black and 26.5% (95% confidence interval, 26.0 to 27.0) among white recipients. Black patients were more likely to die of graft failure or a cardiovascular cause than white patients, but less likely to die of infection or malignancy. Although mortality decreased over time for all transplant recipients, the disparity in mortality between blacks and whites remained essentially unchanged.Black heart transplant recipients have had persistently higher mortality than whites recipients over the past 2 decades, perhaps because of a higher rate of graft failure.

  View details for DOI 10.1161/CIRCULATIONAHA.110.976811

  View details for Web of Science ID 000289620600017

  View details for PubMedID 21464049

• Racial Disparities in Survival After Lung Transplantation ARCHIVES OF SURGERY Liu, V., Weill, D., Bhattacharya, J. 2011; 146 (3): 286-293

  Abstract

  Racial disparities have not been comprehensively evaluated among recipients of lung transplantation.To describe the association between race and lung transplant survival and to determine whether racial disparities have changed in the modern (2001-2009) compared with the historical (1987-2000) transplant eras. Design, Setting, andA retrospective cohort study of 16 875 adults who received primary lung transplants from October 16, 1987, to February 19, 2009, was conducted using data from the United Network of Organ Sharing.We measured the risk of death after lung transplant for nonwhites compared with whites using time-to-event analysis.During the study period, 14 858 white and 2017 nonwhite patients underwent a lung transplant; they differed significantly at baseline. The percentage of nonwhite transplant recipients increased from 8.8% (before 1996) to 15.0% (2005-2009). In the historical era, 5-year survival was lower for nonwhites than whites (40.9% vs 46.9%). Nonwhites were at an increased risk of death independent of age, health and socioeconomic status, diagnosis, geographic region, donor organ characteristics, and operative factors (hazard ratio, 1.15; 95% confidence interval, 1.01-1.30). In subgroup analysis of the historical era, blacks had worsened 5-year survival compared with whites (39.0% vs 46.9%) and black women had worsened survival compared with white women (36.9% vs 48.9%). In the modern transplant era, survival improved for all patients. However, a greater improvement among nonwhites has eliminated the disparities in survival between the races (5-year survival, 52.5% vs 51.6%).In contrast to the historical era, there was no significant difference in lung transplant survival in the modern era between whites and nonwhites.

  View details for Web of Science ID 000288611300009

  View details for PubMedID 21422359

• Who Pays for Obesity? JOURNAL OF ECONOMIC PERSPECTIVES Bhattacharya, J., Sood, N. 2011; 25 (1): 139-157

  Abstract

  Adult obesity is a growing problem. From 1962 to 2006, obesity prevalence nearly tripled to 35.1 percent of adults. The rising prevalence of obesity is not limited to a particular socioeconomic group and is not unique to the United States. Should this widespread obesity epidemic be a cause for alarm? From a personal health perspective, the answer is an emphatic "yes." But when it comes to justifications of public policy for reducing obesity, the analysis becomes more complex. A common starting point is the assertion that those who are obese impose higher health costs on the rest of the population?a statement which is then taken to justify public policy interventions. But the question of who pays for obesity is an empirical one, and it involves analysis of how obese people fare in labor markets and health insurance markets. We will argue that the existing literature on these topics suggests that obese people on average do bear the costs and benefits of their eating and exercise habits. We begin by estimating the lifetime costs of obesity. We then discuss the extent to which private health insurance pools together obese and thin, whether health insurance causes obesity, and whether being fat might actually cause positive externalities for those who are not obese. If public policy to reduce obesity is not justified on the grounds of external costs imposed on others, then the remaining potential justification would need to be on the basis of helping people to address problems of ignorance or self-control that lead to obesity. In the conclusion, we offer a few thoughts about some complexities of such a justification.

  View details for DOI 10.1257/jep.25.1.139

  View details for Web of Science ID 000287303900007

  View details for PubMedID 21598459

• Changes in U.S. Hospitalization and Mortality Rates Following Smoking Bans JOURNAL OF POLICY ANALYSIS AND MANAGEMENT Shetty, K. D., DeLeire, T., White, C., Bhattacharya, J. 2011; 30 (1): 6-28

  Abstract

  U.S. state and local governments have increasingly adopted restrictions on smoking in public places. This paper analyzes nationally representative databases, including the Nationwide Inpatient Sample, to compare short-term changes in mortality and hospitalization rates in smoking-restricted regions with control regions. In contrast with smaller regional studies, we find that smoking bans are not associated with statistically significant short-term declines in mortality or hospital admissions for myocardial infarction or other diseases. An analysis simulating smaller studies using subsamples reveals that large short-term increases in myocardial infarction incidence following a smoking ban are as common as the large decreases reported in the published literature.

  View details for DOI 10.1002/pam.20548

  View details for Web of Science ID 000285447200002

  View details for PubMedID 21465828

• The relation of price of antiretroviral drugs and foreign assistance with coverage of HIV treatment in Africa: retrospective study BRITISH MEDICAL JOURNAL Bendavid, E., Leroux, E., Bhattacharya, J., Smith, N., Miller, G. 2010; 341

  Abstract

  To determine the association of reductions in price of antiretroviral drugs and foreign assistance for HIV with coverage of antiretroviral treatment.Retrospective study.Africa.13 African countries, 2003-8.A price index of first line antiretroviral therapy with data on foreign assistance for HIV was used to estimate the associations of prices and foreign assistance with antiretroviral coverage (percentage of people with advanced HIV infection receiving antiretroviral therapy), controlling for national public health spending, HIV prevalence, governance, and fixed effects for countries and years.Between 2003 and 2008 the annual price of first line antiretroviral therapy decreased from $1177 (£733; ?844) to $96 and foreign assistance for HIV per capita increased from $0.4 to $13.8. At an annual price of $100, a $10 decrease was associated with a 0.16% adjusted increase in coverage (95% confidence interval 0.11% to 0.20%; 0.19% unadjusted, 0.14% to 0.24%). Each additional $1 per capita in foreign assistance for HIV was associated with a 1.0% adjusted increase in coverage (0.7% to 1.2%; 1.4% unadjusted, 1.1% to 1.6%). If the annual price of antiretroviral therapy stayed at $100, foreign assistance would need to quadruple to $64 per capita to be associated with universal coverage. Government effectiveness and national public health expenditures were also positively associated with increasing coverage.Reductions in price of antiretroviral drugs were important in broadening coverage of HIV treatment in Africa from 2003 to 2008, but their future role may be limited. Foreign assistance and national public health expenditures for HIV seem more important in expanding future coverage.

  View details for DOI 10.1136/bmj.c6218

  View details for Web of Science ID 000284586600002

  View details for PubMedID 21088074

• Effects of Mass Media Coverage on Timing and Annual Receipt of Influenza Vaccination among Medicare Elderly HEALTH SERVICES RESEARCH Yoo, B., Holland, M. L., Bhattacharya, J., Phelps, C. E., Szilagyi, P. G. 2010; 45 (5): 1287-1309

  Abstract

  To measure the association between mass media coverage on flu-related topics and influenza vaccination, regarding timing and annual vaccination rates, among the nationally representative community-dwelling elderly.Years 1999, 2000, and 2001 Medicare Current Beneficiary Survey.Cross-sectional survival analyses during each of three influenza vaccination seasons between September 1999 and December 2001. The outcome variable was daily vaccine receipt. We measured daily media coverage by counting the number of television program transcripts and newspaper/wire service articles, including keywords of influenza/flu and vaccine/shot shortage/delay. All models' covariates included three types of media, vaccine supply, and regional/individual factors.Influenza-related reports in all three media sources had a positive association with earlier vaccination timing and annual vaccination rate. Four television networks' reports had most consistent positive effects in all models, for example, shifting the mean vaccination timing earlier by 1.8-4.1 days (p<.001) or increasing the annual vaccination rate by 2.3-7.9 percentage points (p<.001). These effects tended to be greater when reported in a headline rather than in text only and if including additional keywords, for example, vaccine shortage/delay.Timing and annual receipt of influenza vaccination appear to be influenced by media coverage, particularly by headlines and specific reports on shortage/delay.

  View details for DOI 10.1111/j.1475-6773.2010.01127.x

  View details for Web of Science ID 000281712400009

  View details for PubMedID 20579128

• AIDS and declining support for dependent elderly people in Africa: retrospective analysis using demographic and health surveys BRITISH MEDICAL JOURNAL Kautz, T., Bendavid, E., Bhattacharya, J., Miller, G. 2010; 340

  Abstract

  To determine the relation between the HIV/AIDS epidemic and support for dependent elderly people in Africa.Retrospective analysis using data from Demographic and Health Surveys.22 African countries between 1991 and 2006.123,176 individuals over the age of 60.We investigated how three measures of the living arrangements of older people have been affected by the HIV/AIDS epidemic: the number of older individuals living alone (that is, the number of unattended elderly people); the number of older individuals living with only dependent children under the age of 10 (that is, in missing generation households); and the number of adults age 18-59 (that is, prime age adults) per household where an older person lives.An increase in annual AIDS mortality of one death per 1000 people was associated with a 1.5% increase in the proportion of older individuals living alone (95% CI 1.2% to 1.9%) and a 0.4% increase in the number of older individuals living in missing generation households (95% CI 0.3% to 0.6%). Increases in AIDS mortality were also associated with fewer prime age adults in households with at least one older person and at least one prime age adult (P<0.001). These findings suggest that in our study countries, which encompass 70% of the sub-Saharan population, the HIV/AIDS epidemic could be responsible for 582,200-917,000 older individuals living alone without prime age adults and 141,000-323,100 older individuals being the sole caregivers for young children.Africa's HIV/AIDS epidemic might be responsible for a large number of older people losing their support and having to care for young children. This population has previously been under-recognised. Efforts to reduce HIV/AIDS deaths could have large "spillover" benefits for elderly people in Africa.

  View details for DOI 10.1136/bmj.c2841

  View details for Web of Science ID 000279051900002

  View details for PubMedID 20554660

• An Environment-Wide Association Study (EWAS) on Type 2 Diabetes Mellitus PLOS ONE Patel, C. J., Bhattacharya, J., Butte, A. J. 2010; 5 (5)

  Abstract

  Type 2 Diabetes (T2D) and other chronic diseases are caused by a complex combination of many genetic and environmental factors. Few methods are available to comprehensively associate specific physical environmental factors with disease. We conducted a pilot Environmental-Wide Association Study (EWAS), in which epidemiological data are comprehensively and systematically interpreted in a manner analogous to a Genome Wide Association Study (GWAS).We performed multiple cross-sectional analyses associating 266 unique environmental factors with clinical status for T2D defined by fasting blood sugar (FBG) concentration > or =126 mg/dL. We utilized available Centers for Disease Control (CDC) National Health and Nutrition Examination Survey (NHANES) cohorts from years 1999 to 2006. Within cohort sample numbers ranged from 503 to 3,318. Logistic regression models were adjusted for age, sex, body mass index (BMI), ethnicity, and an estimate of socioeconomic status (SES). As in GWAS, multiple comparisons were controlled and significant findings were validated with other cohorts. We discovered significant associations for the pesticide-derivative heptachlor epoxide (adjusted OR in three combined cohorts of 1.7 for a 1 SD change in exposure amount; p<0.001), and the vitamin gamma-tocopherol (adjusted OR 1.5; p<0.001). Higher concentrations of polychlorinated biphenyls (PCBs) such as PCB170 (adjusted OR 2.2; p<0.001) were also found. Protective factors associated with T2D included beta-carotenes (adjusted OR 0.6; p<0.001).Despite difficulty in ascertaining causality, the potential for novel factors of large effect associated with T2D justify the use of EWAS to create hypotheses regarding the broad contribution of the environment to disease. Even in this study based on prior collected epidemiological measures, environmental factors can be found with effect sizes comparable to the best loci yet found by GWAS.

  View details for DOI 10.1371/journal.pone.0010746

  View details for Web of Science ID 000278017300017

  View details for PubMedID 20505766

• Evaluating Permanent Disability Ratings Using Empirical Data on Earnings Losses JOURNAL OF RISK AND INSURANCE Bhattacharya, J., Neuhauser, F., Reville, R. T., Seabury, S. A. 2010; 77 (1): 231-260

  View details for DOI 10.1111/j.1539-6975.2009.01343.x

  View details for Web of Science ID 000274321700012

• Insuring the Near-Elderly: How Much Would Medicare Save? ANNALS OF INTERNAL MEDICINE Bhattacharya, J. 2009; 151 (11): 816-817

  View details for Web of Science ID 000272727900008

  View details for PubMedID 19949148

• Market evidence of misperceived mortality risk JOURNAL OF ECONOMIC BEHAVIOR & ORGANIZATION Bhattacharya, J., Goldman, D., Sood, N. 2009; 72 (1): 451-462

  View details for DOI 10.1016/j.jebo.2008.10.014

  View details for Web of Science ID 000271110900032

• Cost Implications of Reduced Work Hours and Workloads for Resident Physicians NEW ENGLAND JOURNAL OF MEDICINE Nuckols, T. K., Bhattacharya, J., Wolman, D. M., Ulmer, C., Escarce, J. J. 2009; 360 (21): 2202-2215

  Abstract

  Although the Accreditation Council for Graduate Medical Education (ACGME) limits the work hours of residents, concerns about fatigue persist. A new Institute of Medicine (IOM) report recommends, among other changes, improved adherence to the 2003 ACGME limits, naps during extended shifts, a 16-hour limit for shifts without naps, and reduced workloads.We used published data to estimate labor costs associated with transferring excess work from residents to substitute providers, and we examined the effects of our assumptions in sensitivity analyses. Next, using a probability model to represent labor costs as well as mortality and costs associated with preventable adverse events, we determined the net costs to major teaching hospitals and cost-effectiveness across a range of hypothetical changes in the rate of preventable adverse events.Annual labor costs from implementing the IOM recommendations were estimated to be $1.6 billion (in 2006 U.S. dollars) across all ACGME-accredited programs ($1.1 billion to $2.5 billion in sensitivity analyses). From a 10% decrease to a 10% increase in preventable adverse events, net costs per admission ranged from $99 to $183 for major teaching hospitals and from $17 to $266 for society. With 2.5% to 11.3% decreases in preventable adverse events, costs to society per averted death ranged from $3.4 million to $0.Implementing the four IOM recommendations would be costly, and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high.

  View details for Web of Science ID 000266206000007

  View details for PubMedID 19458365

• The President's Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes ANNALS OF INTERNAL MEDICINE Bendavid, E., Bhattacharya, J. 2009; 150 (10): 688-U5

  Abstract

  Since 2003, the President's Emergency Plan for AIDS Relief (PEPFAR) has been the most ambitious initiative to address the global HIV epidemic. However, the effect of PEPFAR on HIV-related outcomes is unknown.To assess the effect of PEPFAR on HIV-related deaths, the number of people living with HIV, and HIV prevalence in sub-Saharan Africa.Comparison of trends before and after the initiation of PEPFAR's activities.12 African focus countries and 29 control countries with a generalized HIV epidemic from 1997 to 2007 (451 country-year observations).A 5-year, $15 billion program for HIV treatment, prevention, and care that started in late 2003.HIV-related deaths, the number of people living with HIV, and HIV prevalence.Between 2004 and 2007, the difference in the annual change in the number of HIV-related deaths was 10.5% lower in the focus countries than in the control countries (P = 0.001). The difference in trends between the groups before 2003 was not significant. The annual growth in the number of people living with HIV was 3.7% slower in the focus countries than in the control countries from 1997 to 2002 (P = 0.05), but during PEPFAR's activities, the difference was no longer significant. The difference in the change in HIV prevalence did not significantly differ throughout the study period. These estimates were stable after sensitivity analysis.The selection of the focus countries was not random, which limits the generalizability of the results.After 4 years of PEPFAR activity, HIV-related deaths decreased in sub-Saharan African focus countries compared with control countries, but trends in adult prevalence did not differ. Assessment of epidemiologic effectiveness should be part of PEPFAR's evaluation programs.Agency for Healthcare Research and Quality.

  View details for Web of Science ID 000266285300004

  View details for PubMedID 19349625

• Hormone Replacement Therapy and Cardiovascular Health in the United States MEDICAL CARE Shetty, K. D., Vogt, W. B., Bhattacharya, J. 2009; 47 (5): 600-605

  Abstract

  Hormone replacement therapy (HRT) was widely used among postmenopausal women until 2002 because observational studies suggested that HRT reduced cardiovascular risk. The Women's Health Initiative randomized trial reported opposite results in 2002, which caused HRT use to drop sharply.We examine the relationship between HRT use and cardiovascular outcomes (deaths and nonfatal hospitalizations) in the entire US population, which has not been studied in prior clinical trials or observational studies.We use an instrumental variables regression design to analyze the relationship between medication use, cardiovascular risk factors, and acute stroke and myocardial infarction event rates in women aged 40 to 79 years. The natural experiment of the 2002 decline in HRT usage mitigates confounding factors. We use US death records, hospital discharge data obtained from the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, and nationally representative surveys of medication usage, and behavioral risk factors.Decreases in HRT use were not associated with statistically significant changes in hospitalizations or deaths due to acute stroke (0.000002, P = 0.999, 95% CI: -0.0027 to 0.0027). Decreased HRT use was associated with a decrease in the incidence of acute myocardial infarction (-0.0025 or -25 events/10,000 person-years, P = 0.021, 95% CI: -0.0047 to -0.0004). The results were similar in a sensitivity analysis using alternate data sources.Decreased HRT use was not associated with reduced acute stroke rate but was associated with a decreased acute myocardial infarction rate among women. Our results suggest that observational data can provide correct inferences on clinical outcomes in the overall population if a suitable natural experiment is identified.

  View details for Web of Science ID 000265563500014

  View details for PubMedID 19319001

• 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

• Treatment effect bounds under monotonicity assumptions: An application to Swan-Ganz catheterization AMERICAN ECONOMIC REVIEW Bhattacharya, J., Shaikh, A. M., Vytlacil, E. 2008; 98 (2): 351-356

  View details for DOI 10.1257/aer.98.2.351

  View details for Web of Science ID 000256370300059

• Chronic disease and severe disability among working-age populations MEDICAL CARE Bhattacharya, J., Choudhry, K., Lakdawalla, D. 2008; 46 (1): 92-100

  Abstract

  Recent work has shown that rates of severe disability, measured by the inability to perform basic activities of daily living, have been rising in working age populations. At the same time, the prevalence of important chronic diseases has been rising, while others falling, among working age populations. Chronically ill individuals are more likely than others to have activity of daily living limitations.We examine the extent to which chronic disease trends can explain these disability trends.We use nationally representative survey data from the 1984-1996 National Interview Survey, which posed a consistent set of questions regarding limitations in activities of daily living over that period.We decompose trends in disability into 2 parts-1 part due to trends in the prevalence of chronic disease and the other due to trends in disability prevalence among those with chronic disease.: Our primary findings are that for working age populations between 1984 and 1996: (1) disability prevalence fell dramatically among the nonchronically ill; (2) rising obesity prevalence explains about 40% of the rise in disability attributable to trends chronic illness; and (3) rising disability prevalence among the chronically ill explains about 60% of the rise in disability attributable to trends in chronic illness.Disability prevention efforts in working age populations should focus on reductions in obesity prevalence and limiting disability among chronically ill populations. Given the rise in disability among these population subgroups, it is unclear whether further substantial declines in elderly disability can be expected.

  View details for Web of Science ID 000252234200014

  View details for PubMedID 18162861

• Changes in hospital mortality associated with residency work-hour regulations ANNALS OF INTERNAL MEDICINE Shetty, K. D., Bhattacharya, J. 2007; 147 (2): 73-80

  Abstract

  In 2002, the Accreditation Council on Graduate Medical Education enacted regulations, effective 1 July 2003, that limited work hours for all residency programs in the United States.To determine whether work-hour regulations were associated with changes in mortality in hospitalized patients.Comparison of mortality rates in high-risk teaching service patients hospitalized before and after July 2003, with nonteaching service patients used as a control group.551 U.S. community hospitals included in the Healthcare Cost and Utilization Project's Nationwide Inpatient Survey between January 2001 and December 2004.1,511,945 adult patients admitted for 20 medical and 15 surgical diagnoses. Measurement: Inpatient mortality.In 1,268,738 medical patients examined, the regulations were associated with a 0.25% reduction in the absolute mortality rate (P = 0.043) and a 3.75% reduction in the relative risk for death. In subgroup analyses, particularly large improvements in mortality were observed among patients admitted for infectious diseases (change, -0.66%; P = 0.007) and in medical patients older than 80 years of age (change, -0.71%; P = 0.005). By contrast, in 243,207 surgical patients, regulations were not associated with statistically significant changes (change, 0.13%; P = 0.54).Teaching status was assigned according to hospital characteristics because direct information on each patient's provider was not available. Results reflect changes associated with the sum of regulations, not specifically with caps on work hours.The work-hour regulations were associated with decreased short-term mortality among high-risk medical patients in teaching hospitals but were not associated with statistically significant changes among surgical patients in teaching hospitals.

  View details for Web of Science ID 000248179300001

  View details for PubMedID 17548403

• Health insurance and the obesity externality. Advances in health economics and health services research Bhattacharya, J., Sood, N. 2007; 17: 279-318

  Abstract

  If rational individuals pay the full costs of their decisions about food intake and exercise, economists, policy makers, and public health officials should treat the obesity epidemic as a matter of indifference. In this paper, we show that, as long as insurance premiums are not risk rated for obesity, health insurance coverage systematically shields those covered from the full costs of physical inactivity and overeating. Since the obese consume significantly more medical resources than the non-obese, but pay the same health insurance premiums, they impose a negative externality on normal weight individuals in their insurance pool. To estimate the size of this externality, we develop a model of weight loss and health insurance under two regimes--(1) underwriting on weight is allowed and (2) underwriting on weight is not allowed. We show that under regime (1), there is no obesity externality. Under regime (2), where there is an obesity externality, all plan participants face inefficient incentives to undertake unpleasant dieting and exercise. These reduced incentives lead to inefficient increases in bodyweight, and reduced social welfare. Using data on medical expenditures and bodyweight from the National Health and Interview Survey and the Medical Expenditure Panel Survey, we estimate that, in a health plan with a coinsurance rate of 17.5%, the obesity externality imposes a welfare cost of about $150 per capita. Our results also indicate that the welfare loss can be reduced by technological change that lowers the pecuniary and non-pecuniary costs of losing weight, and also by increasing the coinsurance rate.

  View details for PubMedID 19548556

• Breakfast of champions? The school breakfast program and the nutrition of children and families JOURNAL OF HUMAN RESOURCES Bhattacharya, J., Currie, J., Haider, S. J. 2006; 41 (3): 445-466

  View details for Web of Science ID 000239846500001

• Estimating probit models with self-selected treatments STATISTICS IN MEDICINE Bhattacharya, J., Goldman, D., McCaffrey, D. 2006; 25 (3): 389-413

  Abstract

  Outcomes research often requires estimating the impact of a binary treatment on a binary outcome in a non-randomized setting, such as the effect of taking a drug on mortality. The data often come from self-selected samples, leading to a spurious correlation between the treatment and outcome when standard binary dependent variable techniques, like logit or probit, are used. Intuition suggests that a two-step procedure (analogous to two-stage least squares) might be sufficient to deal with this problem if variables are available that are correlated with the treatment choice but not the outcome. This paper demonstrates the limitations of such a two-step procedure. We show that such estimators will not generally be consistent. We conduct a Monte Carlo exercise to compare the performance of the two-step probit estimator, the two-stage least squares linear probability model estimator, and the multivariate probit. The results from this exercise argue in favour of using the multivariate probit rather than the two-step or linear probability model estimators, especially when there is more than one treatment, when the average probability of the dependent variable is close to 0 or 1, or when the data generating process is not normal. We demonstrate how these different methods perform in an empirical example examining the effect of private and public insurance coverage on the mortality of HIV+ patients.

  View details for DOI 10.1002/sim.2226

  View details for Web of Science ID 000235092100003

  View details for PubMedID 16382420

• Does Medicare benefit the poor? JOURNAL OF PUBLIC ECONOMICS Bhattacharya, J., Lakdawalla, D. 2006; 90 (1-2): 277-292

  View details for DOI 10.1016/j.jpubeco.2005.01.001

  View details for Web of Science ID 000235118900013

• Technological advances in cancer and future spending by the elderly HEALTH AFFAIRS Bhattacharya, J., Shang, B. P., Su, C. K., Goldman, D. P. 2005; 24 (6): W5R53-W5R66

  Abstract

  This paper forecasts the consequences of scientific progress in cancer for total Medicare spending between 2005 and 2030. Because technological advance is uncertain, widely varying scenarios are modeled. A baseline scenario assumes that year 2000 technology stays frozen. A second scenario incorporates recent cancer treatment advances and their attendant discomfort. Optimistic scenarios analyzed include the discovery of an inexpensive cure, a vaccine that prevents cancer, and vastly improved screening techniques. Applying the Future Elderly Model, we find that no scenario holds major promise for guaranteeing the future financial health of Medicare.

  View details for DOI 10.1377/hlthaff.W5.R53

  View details for Web of Science ID 000235033500057

  View details for PubMedID 16186151

• Welfare-enhancing technological change and the growth of obesity AMERICAN ECONOMIC REVIEW Lakdawalla, D., Philipson, T., Bhattacharya, J. 2005; 95 (2): 253-257

  View details for Web of Science ID 000233172500047

• Specialty Selection and Lifetime Returns to Specialization Within Medicine Journal of Human Resources Bhattacharya J 2005; 40 (1): 115-143
• Specialty selection and lifetime returns to specialization within medicine JOURNAL OF HUMAN RESOURCES Bhattacharya, J. 2005; 40 (1): 115-143

  View details for Web of Science ID 000227254100006

• Impacts of informal caregiver availability on long-term care expenditures in OECD countries HEALTH SERVICES RESEARCH Yoo, B. K., Bhattacharya, J., McDonald, K. M., Garber, A. M. 2004; 39 (6): 1971-1995

  Abstract

  To quantify the effects of informal caregiver availability and public funding on formal long-term care (LTC) expenditures in developed countries.Secondary data were acquired for 15 Organization for Economic Cooperation and Development (OECD) countries from 1970 to 2000.Secondary data analysis, applying fixed- and random-effects models to time-series cross-sectional data. Outcome variables are inpatient or home heath LTC expenditures. Key explanatory variables are measures of the availability of informal caregivers, generosity in public funding for formal LTC, and the proportion of the elderly population in the total population.Aggregated macro data were obtained from OECD Health Data, United Nations Demographic Yearbooks, and U.S. Census Bureau International Data Base.Most of the 15 OECD countries experienced growth in LTC expenditures over the study period. The availability of a spouse caregiver, measured by male-to-female ratio among the elderly, is associated with a $28,840 (1995 U.S. dollars) annual reduction in formal LTC expenditure per additional elderly male. Availability of an adult child caregiver, measured by female labor force participation and full-time/part-time status shift, is associated with a reduction of $310 to $3,830 in LTC expenditures. These impacts on LTC expenditure vary across countries and across time within a country.The availability of an informal caregiver, particularly a spouse caregiver, is among the most important factors explaining variation in LTC expenditure growth. Long-term care policies should take into account behavioral responses: decreased public funding in LTC may lead working women to leave the labor force to provide more informal care.

  View details for Web of Science ID 000226743500004

  View details for PubMedID 15544640

• Price regulation in secondary insurance markets JOURNAL OF RISK AND INSURANCE Bhattacharya, J., Goldman, D., Sood, N. 2004; 71 (4): 643-675

  View details for Web of Science ID 000225847900004

• Poverty, food insecurity, and nutritional outcomes in children and adults JOURNAL OF HEALTH ECONOMICS Bhattacharya, J., Currie, J., Haider, S. 2004; 23 (4): 839-862

  Abstract

  Using data from the National Health and Nutrition Examination Survey, we examine the relationship between nutritional status, poverty, and food insecurity for household members of various ages. Our most striking result is that, while poverty is predictive of poor nutrition among preschool children, food insecurity does not provide any additional predictive power for this age group. Among school age children, neither poverty nor food insecurity is associated with nutritional outcomes, while among adults and the elderly, both food insecurity and poverty are predictive. These results suggest that researchers should be cautious about assuming connections between food insecurity and nutritional outcomes, particularly among children.

  View details for DOI 10.1016/j.jhealeco.2003.12.008

  View details for Web of Science ID 000223878600013

  View details for PubMedID 15587700

• Trends - Are the young becoming more disabled. HEALTH AFFAIRS Lakdawalla, D. N., Bhattacharya, J., Goldman, D. P. 2004; 23 (1): 168-176

  Abstract

  This paper investigates trends in disability in the U.S. population, particularly among people under age fifty. Even as the elderly have become less disabled, reported disability has risen for younger Americans, especially those ages 30-49. We suggest some possible explanations for rising disability levels, such as obesity, technological advances in medicine, and changing disability insurance laws. Obesity and its attendant disorders seem particularly associated with these trends, although the data are not definitive. Whatever its sources, rising disability among the young could have adverse consequences for public programs such as disability insurance, Medicare, and Medicaid.

  View details for DOI 10.1377/hlthaff.23.1.168

  View details for Web of Science ID 000187907600021

  View details for PubMedID 15002639

• Price Regulation in Secondary Insurance Markets Journal of Risk and Insurance Bhattacharya J, Goldman D, Sood N 2004; 71 (4): 643-75
• Disability Forecasts and Future Medicare Costs FRONTIERS IN HEALTH POLICY RESEARCH, VOLUME 7 Bhattacharya, J., Cutler, D. M., Goldman, D. P., Hurd, M. D., Joyce, G. F., Lakdawalla, D. N., Panis, C. W., Shang, B. 2004: 75-94

  Abstract

  The traditional focus of disability research has been on the elderly, with good reason. Chronic disability is much more prevalent among the elderly, and it has a more direct impact on the demand for medical care. It is also important to understand trends in disability among the young, however, particularly if these trends diverge from those among the elderly. These trends could have serious implications for future health care spending because more disability at younger ages almost certainly translates into more disability among tomorrow's elderly, and disability is a key predictor of health care spending. Using data from the Medicare Current Beneficiary Survey (MCBS) and the National Health Interview Study (NHIS), we forecast that per-capita Medicare costs will decline for the next fifteen to twenty years, in accordance with recent projections of declining disability among the elderly. By 2020, however, the trend reverses. Per-capita costs begin to rise due to growth in disability among the younger elderly. Total costs may well remain relatively flat until 2010 and then begin to rise because per-capita costs will cease to decline rapidly enough to offset the influx of new elderly people. Overall, cost forecasts for the elderly that incorporate information about disability among today's younger generations yield more pessimistic scenarios than those based solely on elderly data sets, and this information should be incorporated into official Medicare forecasts.

  View details for Web of Science ID 000284042100004

  View details for PubMedID 15612336

• The link between public and private insurance and HIV-related mortality JOURNAL OF HEALTH ECONOMICS Bhattacharya, J., Goldman, D., Sood, N. 2003; 22 (6): 1105-1122

  Abstract

  As policymakers consider expanding insurance coverage for the human immunodeficiency virus (HIV+) population, it is useful to ask whether insurance has any effect on health outcomes, and, if so, whether public insurance is as efficacious as private insurance in preventing premature death. Using data from a nationally representative cohort of HIV-infected persons receiving regular medical care, we estimate the impact of different types of insurance on mortality in this population. Our main findings are that (1) ignoring observed and unobserved health status misleads one to conclude that insurance may not be protective for HIV patients, (2) after accounting for observed and unobserved heterogeneity, insurance does protect against premature death, and (3) private insurance is more effective than public insurance. The better performance of private insurance can be explained in part by more restrictive Medicaid prescription drug policies that limit access to highly efficacious treatment.

  View details for DOI 10.1016/j.jhealeco.2003.07.001

  View details for Web of Science ID 000186669200012

  View details for PubMedID 14604563

• A simple model of pharmaceutical price dynamics JOURNAL OF LAW & ECONOMICS Bhattacharya, J., Vogt, W. B. 2003; 46 (2): 599-626

  View details for Web of Science ID 000187746500010

• Heat or eat? Cold-weather shocks and nutrition in poor American families AMERICAN JOURNAL OF PUBLIC HEALTH Bhattacharya, J., DeLeire, T., Haider, S., Currie, J. 2003; 93 (7): 1149-1154

  Abstract

  The authors sought to determine the effects of cold-weather periods on budgets and nutritional outcomes among poor American families.The Consumer Expenditure Survey was used to track expenditures on food and home fuels, and the Third National Health and Nutrition Examination Survey was used to track calorie consumption, dietary quality, vitamin deficiencies, and anemia.Both poor and richer families increased fuel expenditures in response to unusually cold weather. Poor families reduced food expenditures by roughly the same amount as their increase in fuel expenditures, whereas richer families increased food expenditures.Poor parents and their children spend less on and eat less food during cold-weather budgetary shocks. Existing social programs fail to buffer against these shocks.

  View details for Web of Science ID 000183827200041

  View details for PubMedID 12835201

• A Simple Model of Pharmaceutical Price Dynamics Journal of Law and Economics Bhattacharya J, Vogt WB 2003; 46 (2): 599-626
• A response to the points by Manton and Williamson MEDICAL CARE Lakdawalla, D., Bhattacharya, J., Goldman, D. P. 2003; 41 (1): 28-31

  View details for Web of Science ID 000180243000006

  View details for PubMedID 12544541

• Forecasting the nursing home population MEDICAL CARE Lakdawalla, D., Goldman, D. P., Bhattacharya, J., Hurd, M. D., Joyce, G. F., Panis, C. W. 2003; 41 (1): 8-20

  Abstract

  To forecast growth in the US nursing home population, as a function of trends in disability and marriage.Nursing home residence is modeled as a function of disability status, marital status, and other demographic covariates. Our predictions for nursing home residence are built upon joint forecasts of marriage and disability. We use data from the 1992 to 1996 Medicare Current Beneficiary Surveys, which are individual-level data sets designed to be representative of the US population older than the age of 65.Today's young cohorts will have higher rates and levels of institutionalization than their older counterparts. This will reverse several decades of decline in rates of disability and institutionalization. The nursing home population is likely to be 10-25% higher than would be suggested by a simple extrapolation of past declines in disability.In recent years, the rate of institutionalization among the elderly has been falling. It is predicted that this trend will reverse itself within the next decade, and that we will see substantial increases in the incidence of institutionalization among the elderly. This result is generated by our prediction of rising disability among the younger cohorts that are beginning to approach old age.

  View details for Web of Science ID 000180243000003

  View details for PubMedID 12544538

• Comparing severity of impairment for different permanent upper extremity musculoskeletal injuries JOURNAL OF OCCUPATIONAL REHABILITATION Reville, R. T., Neuhauser, F. W., Bhattacharya, J., Martin, C. 2002; 12 (3): 205-221

  Abstract

  The labor market impact of upper extremity musculoskeletal injuries that result in permanent disability was estimated using data from the State of California. Administrative data on disability evaluations and resulting ratings was matched to data on the earnings of over 7000 injured workers. Using these data, labor market experience pre- and postinjury was tracked. Each injured worker was matched to a set of control workers who worked at the same firm, had the same tenure at the firm, and earned the same income at the time of injury. By comparing the injured and uninjured workers, lost earnings and the impact of injury on return to work was estimated. Evidence of considerable lost earnings resulting from injury was found. The results are compared to "disability ratings" that are used to set compensation under California's workers' compensation program. The disability rating was also found to predict poorly differences across upper extremity injuries in losses. In particular, those with shoulder injuries have larger losses than those with elbow or wrist injuries, despite receiving the same disability ratings.

  View details for Web of Science ID 000177380400009

  View details for PubMedID 12228950

• Optimal contributions to flexible spending accounts ECONOMICS LETTERS Bhattacharya, J., Schoenbaum, M., Sood, N. 2002; 76 (1): 129-135

  View details for Web of Science ID 000175987200018

• Personal choices of health plans by managed care experts MEDICAL CARE Studdert, D. M., Bhattacharya, J., Schoenbaum, M., Warren, B., Escarce, J. J. 2002; 40 (5): 375-386

  Abstract

  Expert opinion has not been used as a basis for comparing different forms of health insurance, in part because this perspective may not be appropriately sensitive to aspects of care that consumers value.Using a case-control design, managed care experts were surveyed at 17 academic institutions in the United States to determine the type of health plan they chose (fee-for-service, HMO, POS, PPO, or catastrophic). Controls consisted of academicians from other disciplines at these institutions who ostensibly faced the same insurance options. We then compared the choices of physician experts, nonphysician experts and controls using a multinomial logit model that was sensitive to the choice set available at each institution. We also examined the choice behavior of respondents within moderate (< $150,000) and high (> or =$150,000) income levels.Four hundred thirty-seven experts and 465 controls were surveyed and responses were received from 73.7% and 52.7%, respectively. Physician experts were approximately half as likely (14.9%) as controls (26.6%) or nonphysician experts (27.6%) to enroll in HMO plans. In moderate-income households, both physicians (Relative Risk [RR] = 0.42; P <0.01) and nonphysician experts (RR = 0.71; P <0.1) were less likely than controls to opt for an HMO. Experts' propensity to choose HMO coverage varied little with income, whereas controls' propensity changed dramatically between moderate (39.1% in HMOs) and high (14.0% in HMOs) income categories.The aversion of physician experts, and nonphysician experts with moderate income, to HMO plans may be caused by their stronger distaste for the constraints on choice and access that typically accompany HMO coverage. Alternatively, it may be explained by their superior ability to absorb, understand, and use information about available insurance options. Insights into quality in managed care may also play a role.

  View details for Web of Science ID 000175375400003

  View details for PubMedID 11961472

• Role of neck surgery in conjunction with radiation in regional control of node-positive cancer of the oropharynx AMERICAN JOURNAL OF CLINICAL ONCOLOGY-CANCER CLINICAL TRIALS Su, C. K., Bhattacharya, J., Wang, C. C. 2002; 25 (2): 109-116

  Abstract

  For patients with clinically node-positive oropharynx cancer treated with radiotherapy, planned neck dissection is controversial. We investigated whether neck surgery after radiation reduces nodal recurrence. Between 1970 and 1995, 263 patients at Massachusetts General Hospital received radiotherapy for clinically node-positive base of tongue or tonsil carcinomas. Patients received three different types of treatment: neck surgery followed by radiation (SR)-50 patients; radiation alone (RT)-160 patients; and radiation followed by surgery (RS)-53 patients. Median patient follow-up was 28 months. SR patients have an 84% complete response (CR) rate, RT patients 76%, and RS patients 13%. In multivariate analysis, among patients with a CR, the three treatment groups have the same regional control rates. Among patients with an incomplete response, the RS treatment group is 67% (p < 0.01) and 86% (p < 0.01) less likely to have recurrence than the RT and SR groups, respectively. Neck dissection after radiation therapy improves regional control for patients without a complete clinical response to radiation therapy but not for those with a CR. Despite higher CR rates, neck dissection before radiation confers no regional control benefit. We therefore recommend that primary radiotherapy with neck dissection be reserved for those without a complete clinical response.

  View details for Web of Science ID 000174906300002

  View details for PubMedID 11943885

• Optimal Contributions to Flexible Spending Accounts Economics Letters Bhattacharya J, Schoenbaum M, Sood N 2002; 76 (1): 129-35
• Comparing Measures of Overtime across BLS Surveys Industrial Relations Deleire T, Bhattacharya J, MaCurdy T 2002; 41 (2): 362-69
• New methods and data sources for measuring economic consequences of workplace injuries Reville, R. T., Bhattacharya, J., Weinstein, L. R. WILEY-LISS. 2001: 452-463

  Abstract

  Evaluation of programs and policies to reduce the incidence of workplace injuries require that the consequences of injury are estimated correctly. Because workplace injuries are complex events, the availability of data that reflects this complexity is the largest obstacle to this estimation.We review the literature on the consequences of workplace injuries for both workers and employers, focusing on data sources, particularly linked administrative data from different public agencies. We also review other approaches to obtaining data to examine workplace injuries, including public-use longitudinal survey data, primary data collection, and linked employee-employer databases. We make suggestions for future research.Recent advances in the literature on the economic consequences of workplace injuries for workers have been driven to a great extent by the availability of new data sources. Much remains unexplored. We find longitudinal survey databases including the National Longitudinal Survey of Youth, and the Health and Retirement Survey, to be very promising though largely untapped sources of data on workplace injuries. We also find that linked employee-employer databases are well suited for the study of consequences for employers.We expect that new data sources should lead to rapid advances in our understanding of the economic consequences of workplace injuries for both workers and employers.

  View details for Web of Science ID 000171326500012

  View details for PubMedID 11598994

• Effect of insurance on mortality in an HIV-positive population in care JOURNAL OF THE AMERICAN STATISTICAL ASSOCIATION Goldman, D. R., Bhattacharya, J., McCaffrey, D. F., Duan, N., Leibowitz, A. A., Joyce, G. F., Morton, S. C. 2001; 96 (455): 883-894

  View details for Web of Science ID 000170729300010

• Health plan choice and information about out-of-pocket costs: An experimental analysis INQUIRY-THE JOURNAL OF HEALTH CARE ORGANIZATION PROVISION AND FINANCING Schoenbaum, M., Spranca, M., Elliott, M., Bhattacharya, J., Short, P. F. 2001; 38 (1): 35-48

  Abstract

  Many consumers are offered two or more employer-sponsored health insurance plans, and competition among health plans for subscribers is promoted as a mechanism for balancing health care costs and quality. Yet consumers may not receive the information necessary to make informed health plan choices. This study tests the effects on health plan choice of providing supplemental decision-support materials to inform consumers about expected health plan costs. Our main finding is that such information induces consumers to bear more risk, especially those in relatively good health. Thus our results suggest that working-age, privately insured consumers currently may be over-insuring for medical care.

  View details for Web of Science ID 000168845100004

  View details for PubMedID 11381720

• The impact of state policy on the costs of HIV infection MEDICAL CARE RESEARCH AND REVIEW Goldman, D. P., Leibowitz, A. A., Joyce, G. F., Shapiro, M. F., Bozzette, S. A. 2001; 58 (1): 31-53

  Abstract

  There is substantial variation in the generosity of public assistance programs that affect HIV+ patients, and these differences should affect the economic outcomes associated with HIV infection. This article uses data from a nationally representative sample of HIV+ patients to assess how differences across states in Medicaid and AIDS Drug Assistance Programs (ADAP) affect costs and labor market outcomes for HIV+ patients in care in that state. Making ADAP programs more generous in terms of drug coverage would reduce per patient total monthly costs, mainly through a reduction in hospitalization costs. In contrast, expanding ADAP eligibility by increasing the income threshold would increase the total cost of care. Expanding eligibility for Medicaid through the medically needy program would increase per patient total costs, but full-time employment would increase and so would monthly earnings. The authors conclude that more generous state policies toward HIV+ patients--especially those designed to provide access to efficacious treatment--could improve the economic outcomes associated with HIV.

  View details for Web of Science ID 000166858000002

  View details for PubMedID 11236232

• The Effect of Insurance on Mortality in an HIV+ Population in Care Journal of the American Statistical Association Goldman D, Bhattacharya J, McCaffrey D, Duan N, Leibowitz A, Morton S. 2001; 96 (455): 883-894
• The design of healthcare for communities: A study of health care delivery for alcohol, drug abuse, and mental health conditions INQUIRY-THE JOURNAL OF HEALTH CARE ORGANIZATION PROVISION AND FINANCING Sturm, R., Gresenz, C., Sherbourne, C., Minnium, K., Klap, R., Bhattacharya, J., Farley, D., Young, A. S., Burnam, M. A., Wells, K. B. 1999; 36 (2): 221-233

  Abstract

  There is a shortage of data to inform policy debates about the quickly changing health care system. This paper describes Healthcare for Communities (HCC), a component of the Robert Wood Johnson Foundation's Health Tracking Initiative that was designed to fill this gap for alcohol, drug abuse, and mental health care. HCC bridges clinical perspectives and economic/policy research approaches, links data at market, service delivery, and individual levels, and features a household survey of nearly 9,600 individuals with an employer follow-back survey. Public use files will be available in late 1999.

  View details for Web of Science ID 000082104700010

  View details for PubMedID 10459376

• Cause-Specific Mortality among Medicare Enrollees Inquiries in the economics of aging Bhattacharya J, Garber A, MaCurdy T 1998: 311-24
• Cause-specific mortality among Medicare enrollees INQUIRIES IN THE ECONOMICS OF AGING Bhattacharya, J., Garger, A. M., McCurdy, T. E. 1998: 311-325

  View details for Web of Science ID 000079936000011

• The utilization of outpatient medical services in Japan JOURNAL OF HUMAN RESOURCES Bhattacharya, J., Vogt, W. B., Yoshikawa, A., Nakahara, T. 1996; 31 (2): 450-476

  View details for Web of Science ID A1996UH41200008

• The Utilization of Outpatient Medical Services in Japan Journal of Human Resources Bhattacharya J, Vogt WB, Yoshikawa A, Nakahara T 1996; 31 (2): 450-76
• THE ROLE OF DIAGNOSTIC TECHNOLOGY IN COMPETITION AMONG JAPANESE HOSPITALS INTERNATIONAL JOURNAL OF TECHNOLOGY MANAGEMENT Vogt, W. B., Bhattacharya, J., KUPOR, S., Yoshikawa, A., Nakahara, T. 1995: 93-105

  View details for Web of Science ID A1995TB34000009