Impact of the Affordable Care Act's Physician Payments Sunshine Act on branded statin prescribing.

OBJECTIVE: To evaluate the impact of the Affordable Care Act's Physician Payments Sunshine Act (PPSA), which mandates disclosure of industry payments to physicians, on physician prescribing of branded statins. DATA SOURCES: Administrative claims data from 2011 to 2015 from three large national commercial insurers were provided by the Health Care Cost Institute. STUDY DESIGN: We adopted a difference-in-differences and event study design, leveraging the control group of physicians in two states, MA and VT, which implemented state laws on disclosure of industry payments prior to the national PPSA. To further address potential confounding caused by differences in prescribing patterns across states, our analytical sample includes physicians practicing in border counties between the treatment (NH, NY, and RI) and control (MA and VT) states. DATA COLLECTION: We restricted our sample to physicians who had at least 50 new-fill prescription claims for statins during the five-year study period, with at least one new-fill prescription claim each year. PRINCIPAL FINDINGS: We found that the PPSA led to a 7% (p < 0.001) reduction in monthly new prescriptions of brand-name statin over the study period, with little change in generic prescribing. The reduction in branded prescriptions was concentrated among physicians with the highest tercile of drug spending pre-PPSA, with a decrease of 15% (p < 0.001) in new branded statin prescriptions. The decline was most prominent after mandated reporting of industry payments began before the payment data was published. CONCLUSIONS: The PPSA may have achieved its intended effect of reducing branded prescriptions at least in the short run, particularly among physicians most likely to have engaged in excessive or low-value prescribing of branded drugs.

Information, relative skill, and technology abandonment.

We study the role of relative task-specific skill in explaining the heterogeneity in physicians' technology abandonment decisions in response to negative information shocks. We show that after an unexpected FDA safety warning on the use of minimally invasive hysterectomies, physicians alter their procedural mix towards open procedures and away from the minimally invasive procedures. This effect is less pronounced for physicians more skilled in performing minimally invasive procedures relative to open procedures, highlighting relative skill as an explanation for differential technology abandonment. Since physicians with higher relative skill are more likely to use minimally invasive procedures before the FDA safety communication, we find that the FDA intervention led to a substantial increase in practice variation across physicians with different relative skill levels. These findings are consistent with a theoretical model that predicts physicians' response to new information regarding the effectiveness of medical technology.

The economics of medical procedure innovation.

This paper explores the economic incentives for medical procedure innovation. Using a proprietary dataset on billing code applications for emerging medical procedures, we highlight two mechanisms that could hinder innovation. First, the administrative hurdle of securing permanent, reimbursable billing codes substantially delays innovation diffusion. We find that Medicare utilization of innovative procedures increases nearly nine-fold after the billing codes are promoted to permanent (reimbursable) from provisional (non-reimbursable). However, only 29 percent of the provisional codes are promoted within the five-year probation period. Second, medical procedures lack intellectual property rights, especially those without patented devices. When appropriability is limited, specialty medical societies lead the applications for billing codes. We indicate that the ad hoc process for securing billing codes for procedure innovations creates uncertainty about both the development process and the allocation and enforceability of property rights. This stands in stark contrast to the more deliberate regulatory oversight for pharmaceutical innovations.

Provider networks and health plan premium variation.

OBJECTIVE: To examine how plan premiums are associated with physician network breadth, hospital network breadth, and hospital network quality on the Affordable Care Act's Health Insurance Marketplaces in all 50 states and the DC in 2016. DATA SOURCES: Data on plan premiums and characteristics came from 2016 Robert Wood Johnson Foundation Health Insurance Exchange (HIX) Compare. Provider network information was obtained from Vericred. Hospital characteristics were obtained from CMS Hospital Compare and the American Hospital Association (AHA) survey. STUDY DESIGN: We analyzed how plan premiums were associated with variations in physician network breadth, hospital network breadth, and hospital network quality using ordinary least square regressions with state-rating area fixed effects and carrier fixed effects. PRINCIPAL FINDINGS: Plan premiums were positively associated with physician network breadth and hospital network breadth. We find the following statistically significant results: a one standard deviation increase in physician network breadth was linked to a premium increase of 2.8 percent or $101 per year; a one standard deviation increase in hospital network breadth was linked to a premium increase of 2.4 percent or $86 per year. There was no significant association between premiums and hospital network quality, as measured by hospital star ratings and the inclusion of teaching hospitals or the top-20 hospitals nationwide. CONCLUSIONS: Physician network breadth and hospital network breadth contributed positively to plan premiums. The roles of the two types of provider network breadth are quantitatively similar. Premiums appear to be insensitive to hospital network quality.

Information presentation and consumer choice: Evidence from Assisted Reproductive Technology (ART) Success Rate Reports.

How does the presentation of multidimensional quality information in public reporting affect consumer responsiveness? This paper addresses this question exploiting an exogenous change of reporting format in the Assisted Reproductive Technology (ART) reports by the Centers for Disease Control and Prevention. Compared with the first version of the ART report, the second version highlights the "singleton-birth rate" measure, which is complementary to the "multiple-birth rate" measure reported in the first version. We find that consumers are more likely to choose clinics with a lower multiple-birth rate after the format change, indicating more sensitivity to the highlighted measure. This finding implies that information presentation plays an important role in affecting the effectiveness of public reporting.

Entry regulation and the effect of public reporting: Evidence from Home Health Compare.

Economic theory suggests that competition and information are complementary tools for promoting health care quality. The existing empirical literature has documented this effect only in the context of competition among existing firms. Extending this literature, we examine competition driven by the entry of new firms into the home health care industry. In particular, we use the certificate of need (CON) law as a proxy for the entry of firms to avoid potential endogeneity of entry. We find that home health agencies in non-CON states improved quality under public reporting significantly more than agencies in CON states. Because home health care is a labor-intensive and capital-light industry, the state CON law is a major barrier for new firms to enter. Our findings suggest that policymakers may jointly consider information disclosure and entry regulation to achieve better quality in home health care.

Biodegradation of di-n-butyl phthalate (DBP) by a novel endophytic Bacillus megaterium strain YJB3.

Phthalic acid esters (PAEs) are a group of recalcitrant and hazardous organic compounds that pose a great threat to both ecosystem and human beings. A novel endophytic strain YJB3 that could utilize a wide range of PAEs as the sole carbon and energy sources for cell growth was isolated from Canna indica root tissue. It was identified as Bacillus megaterium based on morphological characteristics and 16S rDNA sequence homology analysis. The degradation capability of the strain YJB3 was investigated by incubation in mineral salt medium containing di-n-butyl-phthalate (DBP), one of important PAEs under different environmental conditions, showing 82.5% of the DBP removal in 5days of incubation under the optimum conditions (acetate 1.2g·L-1, inocula 1.8%, and temperature 34.2°C) achieved by two-step sequential optimization technologies. The DBP metabolites including mono-butyl phthalate (MBP), phthalic acid (PA), protocatechuic acid (PCA), etc. were determined by GC-MS. The PCA catabolic genes responsible for the aromatic ring cleavage of PCA in the strain YJB3 were excavated by whole-genome sequencing. Thus, a degradation pathway of DBP by the strain YJB3 was proposed that MBP was formed, followed by PA, and then the intermediates were further utilized till complete degradation. To our knowledge, this is the first study to show the biodegradation of PAEs using endophyte. The results in the present study suggest that the strain YJB3 is greatly promising to act as a competent inoculum in removal of PAEs in both soils and crops.

Health Information Technologies: Which Nursing Homes Adopted Them?

PURPOSE: Long-term care facilities have lagged heavily behind other health providers in adopting health information technology (IT). This article examines the facility characteristics that are associated with health IT adoption. DESIGN AND METHODS: This study is a secondary data analysis of information gathered between 2005 and 2011 about nursing facility characteristics contained in the Online Certification & Reporting (OSCAR) files and information about health IT adoption in each nursing home contained in the Healthcare Information and Management Systems Society (HIMSS) Analytics Database. Multivariate regression analysis is conducted. RESULTS: Nursing homes with licensed nursing staff levels above the state average were 20% more likely to adopt computer-provided order entry (CPOE) than homes with licensed nursing staff below average. Resident resources (more Medicare-paid patients and fewer Medicaid patients) were positively correlated to health IT adoption, particularly to a clinical data repository (CDR), clinical decision support systems (CDSS), and an order entry (OE) system. Other characteristics, including chain affiliation, ownership, and market competition, are also related to some health IT adoption within nursing homes. IMPLICATION: Nursing homes with more personnel or resident resources are more likely to adopt health IT. Other factors such as market competition are also important predictors. Future research is needed to examine what factors motivate nursing homes to adopt health IT.

The Effect of Publicized Quality Information on Home Health Agency Choice.

We examine consumers' use of publicized quality information in Medicare home health care markets, where consumer cost sharing and travel costs are absent. We report two findings. First, agencies with high quality scores are more likely to be preferred by consumers after the introduction of a public reporting program than before. Second, consumers' use of publicized quality information differs by patient group. Community-based patients have slightly larger responses to public reporting than hospital-discharged patients. Patients with functional limitations at the start of their care, at least among hospital-discharged patients, have a larger response to the reported functional outcome measure than those without functional limitations. In all cases of significant marginal effects, magnitudes are small. We conclude that the current public reporting approach is unlikely to have critical impacts on home health agency choice. Identifying and releasing quality information that is meaningful to consumers may help increase consumers' use of public reports.