A Systems Approach to Person-Centric Health Economics.

The economics of health and the economics of health care are not the same, and in fact can be competitors for resources in some cases. Using a traditional supply/demand framework can clarify the forces at work in person-centric health economics. Use of cost-effectiveness analysis, employing a broader systems perspective that incorporates sectors other than health care, and nudging individuals to better health habits are three strategies that can help to drive a shift from health care to health.

Radical prostatectomy innovation and outcomes at military and civilian institutions.

OBJECTIVES: Limited data are available regarding the impact of the type of healthcare delivery system on technology diffusion and associated clinical outcomes. We assessed the adoption of minimally invasive radical prostatectomy (MIRP), a recent clinical innovation, and whether this adoption altered surgical morbidity for prostate cancer surgery. STUDY DESIGN: Retrospective review of administrative data from TRICARE, the healthcare program of the United States Military Health System. Surgery occurred at military hospitals, supported by federal appropriations, or civilian hospitals, supported by hospital revenue. METHODS: We evaluated TRICARE beneficiaries with prostate cancer (International Classification of Disease, 9th Revision, Clinical Modification [ICD-9-CM] code: 185) who received a radical prostatectomy (60.5) between 2005 and 2009. MIRP was identified based on minimally invasive surgery codes (54.21, 17.42). We assessed yearly MIRP utilization, 30-day postoperative complications (Clavien classification system), length of stay, blood transfusion, and long-term urinary incontinence and erectile dysfunction. RESULTS: A total of 3366 men underwent radical prostatectomy at military hospitals compared with 1716 at civilian hospitals, with minimal clinic-demographic differences. MIRP adoption was 30% greater at civilian hospitals. There were fewer blood transfusions (odds ratio, 0.44; P <.0001) and shorter lengths of stay (incidence risk ratio, 0.85; P <.0001) among civilian hospitals, while 30-day postoperative complications, as well as long-term urinary incontinence and erectile dysfunction rates, were comparable. CONCLUSIONS: Compared with military hospitals, civilian hospitals had a greater MIRP adoption during this timeframe, but had comparable surgical morbidity.

Geographic variation within the military health system.

BACKGROUND: This study seeks to quantify variation in healthcare utilization and per capita costs using system-defined geographic regions based on enrollee residence within the Military Health System (MHS). METHODS: Data for fiscal years 2007 - 2010 were obtained from the Military Health System under a data sharing agreement with the Defense Health Agency (DHA). DHA manages all aspects of the Department of Defense Military Health System, including TRICARE. Adjusted rates were calculated for per capita costs and for two procedures with high interest to the MHS- back surgery and Cesarean sections for TRICARE Prime and Plus enrollees. Coefficients of variation (CoV) and interquartile ranges (IQR) were calculated and analyzed using residence catchment area as the geographic unit. Catchment areas anchored by a Military Treatment Facility (MTF) were compared to catchment areas not anchored by a MTF. RESULTS: Variation, as measured by CoV, was 0.37 for back surgery and 0.13 for C-sections in FY 2010- comparable to rates documented in other healthcare systems. The 2010 CoV (and average cost) for per capita costs was 0.26 ($3,479.51). Procedure rates were generally lower and CoVs higher in regions anchored by a MTF compared with regions not anchored by a MTF, based on both system-wide comparisons and comparisons of neighboring areas. CONCLUSIONS: In spite of its centrally managed system and relatively healthy beneficiaries with very robust health benefits, the MHS is not immune to unexplained variation in utilization and cost of healthcare.

Provider-Induced Demand in the Treatment of Carotid Artery Stenosis: Variation in Treatment Decisions Between Private Sector Fee-for-Service vs Salary-Based Military Physicians.

Importance: Although many factors influence the management of carotid artery stenosis, it is not well understood whether a preference toward procedural management exists when procedural volume and physician compensation are linked in the fee-for-service environment. Objective: To explore evidence for provider-induced demand in the management of carotid artery stenosis. Design, Setting, and Participants: The Department of Defense Military Health System Data Repository was queried for individuals diagnosed with carotid artery stenosis between October 1, 2006, and September 30, 2010. A hierarchical multivariable model evaluated the association of the treatment system (fee-for-service physicians in the private sector vs salary-based military physicians) with the odds of procedural intervention (carotid endarterectomy or carotid artery stenting) compared with medical management. Subanalysis was performed by symptom status at the time of presentation. The association of treatment system and of management strategy with clinical outcomes, including stroke and death, was also evaluated. Data analysis was conducted from August 15, 2015, to August 2, 2016. Main Outcomes and Measures: The odds of procedural intervention based on treatment system was the primary outcome used to indicate the presence and effect of provider-induced demand. Results: Of 10 579 individuals with a diagnosis of carotid artery stenosis (4615 women and 5964 men; mean [SD] age, 65.6 [11.4] years), 1307 (12.4%) underwent at least 1 procedure. After adjusting for demographic and clinical factors, the odds of undergoing procedural management were significantly higher for patients in the fee-for-service system compared with those in the salary-based setting (odds ratio, 1.629; 95% CI, 1.285-2.063; P < .001). This finding remained true when patients were stratified by symptom status at presentation (symptomatic: odds ratio, 2.074; 95% CI, 1.302-3.303; P = .002; and asymptomatic: odds ratio, 1.534; 95% CI, 1.186-1.984; P = .001). Conclusions and Relevance: Individuals treated in a fee-for-service system were significantly more likely to undergo procedural management for carotid stenosis compared with those in the salary-based setting. These findings remained consistent for individuals with and without symptomatic disease.