Relationship Between Patient-Centered Primary Care Provider Communication and Emergency Room Visits in the Medicaid Population in North Carolina, United States.

INTRODUCTION: Medicaid, a joint federal-state program, finances health care for eligible low-income individuals and families in the United States. Medicaid patients use disproportionately more emergency room (ER) services than other patients in the United States. Inadequate provider communication during primary care visits might be one reason for this well-documented phenomenon. The goal of the study was to examine how patient-centered provider communication related to ER use by Medicaid patients in North Carolina. METHODS: A 2015 state-wide cross-sectional telephone survey of NC adult Medicaid patients (n = 2652) was based on the CAHPS methodology. Predictors were 4 patient-centered provider communication characteristics assessed by patients. The outcome was the number of ER visits during 6 months prior to the survey. We used negative binomial regression to examine the relationship. RESULTS: Effective patient-centered provider communication index was associated with 19% fewer ER visits (P < .05). Provider's respect for patients had the biggest impact on the number of visits (37% fewer ER visits, P < .001). Easy to understand provider explanations were associated with 18% fewer ER visits (P < .05). Longer (>1 year) patient continuity with the current primary care provider was associated with 36% to 38% fewer ER visits (P < .001). CONCLUSIONS: Health care quality improvement should focus on training providers how to show respect, give easily understood explanations, and maintain good interpersonal relationships with patients. Relevant agencies should emphasize training and accreditation with a specific emphasis on communication of providers delivering care to Medicaid patients.

Cost Analysis of Ceramic Heads in Primary Total Hip Arthroplasty.

BACKGROUND: The advent of adverse local tissue reactions seen in metal-on-metal bearings, and the recent recognition of trunnionosis, have led many surgeons to recommend ceramic-on-polyethylene articulations for primary total hip arthroplasty. However, to our knowledge, there has been little research that has considered whether the increased cost of ceramic provides enough benefit over cobalt-chromium to justify its use. The primary purpose of this study was to compare the cost-effectiveness of ceramic-on-polyethylene implants and metal-on-polyethylene implants in patients undergoing total hip arthroplasty. METHODS: Markov decision modeling was used to determine the ceramic-on-polyethylene implant revision rate necessary to be cost-effective compared with the revision rate of metal-on-polyethylene implants across a range of patient ages and implant costs. A different set of Markov models was used to estimate the national cost burden of choosing ceramic-on-polyethylene implants over metal-on-polyethylene implants for primary total hip arthroplasties. The Premier Research Database was used to identify 20,398 patients who in 2012 were ≥45 years of age and underwent a total hip arthroplasty with either a ceramic-on-polyethylene implant or a metal-on-polyethylene implant. RESULTS: The cost-effectiveness of ceramic heads is highly dependent on the cost differential between ceramic and metal femoral heads and the age of the patient. At a cost differential of $325, ceramic-on-polyethylene bearings are cost-effective for patients <85 years of age. At a cost differential of $600, it is cost-effective to utilize ceramic-on-polyethylene bearings in patients <65 years of age, and, at a differential of $1,003, ceramic-on-polyethylene bearings are not cost-effective at any age. CONCLUSIONS: The ability to recoup the initial increased expenditure of ceramic heads through a diminished lifetime revision cost is dependent on the price premium for ceramic and the age of the patient. A wholesale switch to ceramic bearings regardless of age or cost differential may result in an economic burden to the health system. LEVEL OF EVIDENCE: Economic and decision analysis, Level III. See Instructions for Authors for a complete description of levels of evidence.

Federal health insurance reform and "exchanges": recent history.

The major national innovation of the Affordable Care Act (ACA) is the insurance exchange or health insurance marketplace (HIM). We begin by briefly reviewing the ACA's chief features and detailing its HIM provisions. Section two explores the policy history of exchanges, beginning with Clinton's proposals and Massachusetts' Connector and concluding by contrasting the House-passed bill with one national exchange and the Senate bill with state-based exchanges. The Senate bill became the ACA. The evolution of policy ideas about exchanges suggests three critical conditions for a successful exchange: commodification (of insurance products), competition (between insurers), and communication (to potential buyers and the public about insurance). The penultimate section compares the rollout of the state-run Kentucky exchange and the federally facilitated exchange in North Carolina in light of what we will call the 3 Cs. The conclusion reflects more widely upon the unique form that the pro-competition or deregulatory strategy has taken in health policy.