Variation In Treatment Intensity Research Articles

The Affordable Care Act's Coverage Impacts in the Trump Era.

The 2016 US presidential election created uncertainty about the future of the Affordable Care Act (ACA) and led to postponed implementation of certain provisions, reduced funding for outreach, and the removal of the individual mandate tax penalty. In this article, we estimate how the causal impact of the ACA on insurance coverage changed during 2017 through 2019, the first 3 years of the Trump administration, compared to 2016. Data come from the 2011–2019 waves of the American Community Survey (ACS), with the sample restricted to non-elderly adults. Our model leverages variation in treatment intensity from state Medicaid expansion decisions and pre-ACA uninsured rates. We find that the coverage gains from the components of the law that took effect nationally—such as the individual mandate and regulations and subsidies in the private non-group market—fell from 5 percentage points in 2016 to 3.6 percentage points in 2019. In contrast, the coverage gains from the Medicaid expansion increased in 2017 (7.0 percentage points) before returning to the 2016 level of coverage gains in 2019 (5.9 percentage points). The net effect of the ACA in expansion states is a combination of these trends, with coverage gains falling from 10.8 percentage points in 2016 to 9.6 percentage points in 2019.

The Differential Effects of Insurance Mandates on Health Care Spending for Children's Autism Spectrum Disorder.

There is substantial variation in treatment intensity among children with autism spectrum disorder (ASD). This study asks whether policies that target health care utilization for ASD affect children differentially based on this variation. Specifically, we examine the impact of state-level insurance mandates that require commercial insurers to cover certain treatments for ASD for any fully-insured plan. Using insurance claims between 2008 and 2012 from three national insurers, we used a difference-in-differences approach to compare children with ASD who were subject to mandates to children with ASD who were not. To allow for differential effects, we estimated quantile regressions that evaluate the impact of mandates across the spending distributions of three outcomes: (1) monthly spending on ASD-specific outpatient services; (2) monthly spending on ASD-specific inpatient services; and (3) quarterly spending on psychotropic medications. The change in spending on ASD-specific outpatient services attributable to mandates varied based on the child's level of spending. For those children with ASD who were subject to the mandate, monthly spending for a child in the 95th percentile of the ASD-specific outpatient spending distribution increased by $1460 (P<0.001). In contrast, the effect was only $2 per month for a child in the fifth percentile (P<0.001). Mandates did not significantly affect spending on ASD-specific inpatient services or psychotropic medications. State-level insurance mandates have larger effects for those children with higher levels of spending. To the extent that spending approximates treatment intensity and the underlying severity of ASD, these results suggest that mandates target children with greater service needs.

Effects of the Affordable Care Act on Health Care Access and Self-Assessed Health After 3 Years.

Using data from the Behavioral Risk Factor Surveillance System, we examine the causal impact of the Affordable Care Act on health-related outcomes after 3 years. We estimate difference-in-difference-in-differences models that exploit variation in treatment intensity from 2 sources: (1) local area prereform uninsured rates from 2013 and (2) state participation in the Medicaid expansion. Including the third postreform year leads to 2 important insights. First, gains in health insurance coverage and access to care from the policy continued to increase in the third year. Second, an improvement in the probability of reporting excellent health emerged in the third year, with the effect being largely driven by the non-Medicaid expansions components of the policy.

Early Effects of the Affordable Care Act on Health Care Access, Risky Health Behaviors, and Self‐Assessed Health

The goal of the Affordable Care Act (ACA) was to achieve nearly universal health insurance coverage through a combination of mandates, subsidies, marketplaces, and Medicaid expansions, most of which took effect in 2014. We use data from the Behavioral Risk Factor Surveillance System to examine the impacts of the ACA on health care access, risky health behaviors, and self‐assessed health after two years. We estimate difference‐in‐difference‐in‐differences models that exploit variation in treatment intensity from state participation in the Medicaid expansion and pre‐ACA uninsured rates. Results suggest that the ACA led to sizeable improvements in access to health care in both Medicaid expansion and nonexpansion states, with the gains being larger in expansion states along some dimensions. However, we do not find clear effects on risky behaviors or self‐assessed health.

Early Effects of the Affordable Care Act on Health Care Access, Risky Health Behaviors, and Self-Assessed Health

The goal of the Affordable Care Act (ACA) was to achieve nearly universal health insurance coverage through a combination of mandates, subsidies, marketplaces, and Medicaid expansions, most of which took effect in 2014. We use data from the Behavioral Risk Factor Surveillance System to examine the impacts of the ACA on health care access, risky health behaviors, and self-assessed health after two years. We estimate difference-in-difference-in-differences models that exploit variation in treatment intensity from state participation in the Medicaid expansion and pre-ACA uninsured rates. Results suggest that the ACA led to sizeable improvements in access to health care in both Medicaid expansion and non-expansion states, with the gains being larger in expansion states along some dimensions. No statistically significant effects on risky behaviors or self-assessed health emerge for the full sample. However, we find some evidence that the ACA improved self-assessed health among older non-elderly adults, particularly in expansion states.

Do Protestant Missionaries Undermine Political Authority? Evidence From Peru

The relation between religious organizations and political authority is notoriously tense. Max Weber argued that this is because both compete over the same resource: human commitment. This article revisits Weber’s hypothesis. Specifically, we explore two psychological mechanisms through which Protestant missionaries affect political authority: obedience and persuadability. Exploiting exogenous variation in missionary activity in Peru, we demonstrate that missionaries make converts more obedient, which we attribute to a theological and a social mechanism. Yet, we also find that missionaries make converts less susceptible to persuasion by political authorities because they shift attention from secular topics to questions of theological importance, and endorse a skeptical stance toward the government. Exploiting variation in treatment intensity, we argue that the degree to which political authority is affected depends on a given mission’s theological strictness. We arrive at these findings by combining experimental outcomes and process-tracing evidence using Bayesian integration.

Targeted Debt Relief and the Origins of Financial Distress: Experimental Evidence from Distressed Credit Card Borrowers

We study the drivers of financial distress using a large-scale field experiment that offered randomly selected borrowers a combination of (i) immediate payment reductions to target short-run liquidity write-downs to target long-run debt constraints. We identify the separate effects of the payment reductions and interest write-downs using both the experiment and cross-sectional variation in treatment intensity. We find that the interest write-downs significantly improved both financial and labor market outcomes, despite not taking effect for three to five years. In sharp contrast, there were no positive effects of the more immediate payment reductions. These results run counter to the widespread view that financial distress is largely the result of short-run constraints. (JEL G56, K35)

The effect of length, duration, and intensity of psychological therapy on CORE global distress scores.

This study explores whether improvements, as measured by the CORE-OM/10, as a result of psychological therapy were related to length of treatment in weeks, number of treatment sessions, or treatment intensity, as well as any effect of diagnostic group. Pre- and post-therapy CORE-OM/10 scores were extracted from the clinical records of all secondary care adult psychological therapy team patients who undertook psychological therapy between 2010 and 2013 in one mental health trust. Of the 4,877 patients identified, 925 had complete records. Length of therapy was divided by the number of sessions to create 'treatment intensity' (sessions per week). Nonparametric analyses were used, initial score was controlled for, and diagnostic group was explored. No relationship was found between change in score and the number of sessions, therapy length, or treatment intensity; however, change in score was positively correlated with first-session score. Patients with higher initial scores had longer therapies; however, treatment intensity was similar for patients with lower pre-therapy distress. There were differences in treatment length (weeks) between diagnostic groups. Demographic differences were found between patients with and without complete records, prompting caution in terms of generalizability. These findings are consistent with the responsive regulation model (Barkham etal., 1996) which proposes that patients vary in their response to treatment, resulting in no associations between session numbers or treatment intensity and therapeutic gain with aggregated scores. Patients with higher CORE scores at the outset of psychological therapy had longer not more intensive therapy. There was variation in treatment intensity between diagnostic clusters. Number of sessions, length of therapy (in weeks), and treatment intensity (the number of sessions per week between the first and last therapy sessions) were not related to therapeutic gains. These results fit with a responsive regulation model of therapy duration, suggesting an individualized approach to therapy cessation as opposed to therapy session limits as the number of sessions a patient experienced was not generally associated with outcome. We found that clients with a diagnosis of a behavioural syndrome (F50-59) had less 'intensive' therapy; they experienced the same number of sessions over a longer time frame. Despite this, there were no associations between diagnosis category and change in score.

Early Effects of the Affordable Care Act on Health Care Access, Risky Health Behaviors, and Self-Assessed Health

The goal of the Affordable Care Act (ACA) was to achieve nearly universal health insurance coverage through a combination of mandates, subsidies, marketplaces, and Medicaid expansions, most of which took effect in 2014. We use data from the Behavioral Risk Factor Surveillance System to examine the impacts of the ACA on health care access, risky health behaviors, and self-assessed health after two years. We estimate difference-in-difference-in-differences models that exploit variation in treatment intensity from state participation in the Medicaid expansion and pre-ACA uninsured rates. Results suggest that the ACA led to sizeable improvements in access to health care in both Medicaid expansion and non-expansion states, with the gains being larger in expansion states along some dimensions. No statistically significant effects on risky behaviors or self-assessed health emerge for the full sample. However, we find some evidence that the ACA improved self-assessed health among older non-elderly adults, particularly in expansion states.

How to Increase Turnout in Low-Salience Elections: Quasi-Experimental Evidence on the Effect of Concurrent Second-Order Elections on Political Participation

Voter turnout in second-order elections is on a dramatic decline in many modern democracies. This article investigates how electoral participation can be substantially increased by holding multiple of these less important elections simultaneously. Leading to a relative decrease in voting costs, concurrent elections theoretically have economies of scale to the individual voter and thus should see turnout levels larger than those obtained in any stand-alone election. Leveraging as-if-random variation of local election timing in Germany, we estimate the causal effect of concurrent mayoral elections on European election turnout at around 10 percentage points. Exploiting variation in treatment intensity, we show that the magnitude of the concurrency effect is contingent upon district size and the competitiveness of the local race.

The Association between Medical Malpractice Risk and Healthcare Quality: Evidence from Texas

According to tort law theory, medical malpractice liability may deter negligence by healthcare providers. However, advocates of malpractice reform often argue that most malpractice claims are unrelated to provider performance. We study the connection between hospital adverse events and malpractice claim rates in the two states with public datasets on med mal claim rates: Florida and Texas. We use Patient Safety Indicators (“PSIs”), developed by the Agency for Healthcare Research and Quality, to measure rates for 17 types of adverse events. Hospitals with high rates for one PSI usually have high rates for other PSIs. We find a strong association between PSI rates and malpractice claim rates with extensive control variables and hospital fixed effects (in Florida) or county fixed effects (in Texas). Our results, if causal, provide evidence that malpractice claims leading to payouts are not random events. Instead, hospitals that improve patient safety can reduce malpractice payouts.We also study local variation in adverse event rates, in the spirit of the Dartmouth Atlas work on variation in treatment intensity. We find large variations, both across counties and across hospitals within counties. This suggests that many adverse hospital events are avoidable at reasonable cost, since some hospitals are avoiding them.

Education and Fertility: Evidence from a Policy Change in Kenya

This paper investigates the relationship between women's education and fertility by exploiting a 1985 policy change in Kenya that lengthened primary school by one year. An instrumental variables approach measures the exogenous variation in treatment intensity across birth cohorts. The reform led to an increase in education, a delay in marriage, and reduced fertility beginning at the age of 20. The effect on fertility becomes increasingly negative through age 25. The findings suggest that postponement of marriage, reduction in the marital education gap, and increased early use of modern contraceptives contribute to reduced fertility. These results are consistent with women having greater control over their fertility decision.

Inpatient treatment time across disciplines in spinal cord injury rehabilitation

Background/objectiveLength of stay (LOS) for rehabilitation treatment after spinal cord injury (SCI) has been documented extensively. However, there is almost no published research on the nature, extent, or intensity of the various treatments patients receive during their stay. This study aims at providing such information on a large sample of patients treated by specialty rehabilitation inpatient programs.MethodsSix hundred patients with traumatic SCI admitted to six rehabilitation centers were enrolled. Time spent on various therapeutic activities was documented by each rehabilitation clinician after each patient encounter. Patients were grouped by neurologic level and completeness of injury. Total time spent by each rehabilitation discipline over a patient's stay and total minutes of treatment per week were calculated. Ordinary least squares stepwise regression models were used to identify patient and injury characteristics associated with time spent in rehabilitation treatment overall and within each discipline.ResultsAverage LOS was 55 days (standard deviation 37), during which 180 (106) hours of treatment were received, or 24 (5) hours per week. Extensive variation was found in the amount of treatment received, between and within neurologic groups. Total hours of treatment provided throughout a patient's stay were primarily determined by LOS, which in turn was primarily predicted by medical acuity. Variation in minutes per week of treatment delivered by individual disciplines was predicted poorly by patient and injury characteristics.ConclusionsVariations between and within SCI rehabilitation patient groups in LOS, minutes of treatment per week overall, and for each rehabilitation discipline are large. Variation in treatment intensity was not well explained by patient and injury characteristics. In accordance with practice-based evidence methodology, the next step in the SCIRehab study will be to determine which treatment interventions are related with positive outcomes (at 1 year post injury), after controlling for patient and injury differences.

Understanding the variation in treatment intensity among patients with early stage bladder cancer

Given the uncertainty surrounding the optimal management for early stage bladder cancer, physicians vary in how they approach the disease. The authors of this report linked cancer registry data with medical claims to identify the sources of variation and opportunities for improving the value of cancer care. By using data from the Surveillance, Epidemiology, and End Results-Medicare database (1992-2005), patients with early stage bladder cancer were abstracted (n=18,276). The primary outcome was the intensity of initial treatment that patients received, as measured by all Medicare payments for bladder cancer incurred in the 2 years after diagnosis. Multilevel models were fitted to partition the variation in treatment intensity attributable to patient versus provider factors, and the potential savings to Medicare from reducing the physician contribution were estimated. Provider factors accounted for 9.2% of the variation in treatment intensity. Increasing provider treatment intensity did not correlate with improved cancer-specific survival (P=.07), but it was associated with the subsequent receipt of major interventions, including radical cystectomy (P<.001). If provider-level variation was reduced and clinical practice was aligned with that of physicians who performed in the 25th percentile of treatment intensity, then total payments made for the average patient could be lowered by 18.6%, saving Medicare $18.7 million annually. The current results indicated that a substantial amount of the variation in initial treatment intensity for early stage bladder cancer is driven by the physician. Furthermore, a more intensive practice style was not associated with improved cancer-specific survival or the avoidance of major interventions. Therefore, interventions aimed at reducing between-provider differences may improve the value of cancer care.

Treatment Intensity in Child and Adolescent Mental Health Services and Health Care Reform in Norway, 1998–2006

Treatment Intensity in Child and Adolescent Mental Health Services and Health Care Reform in Norway, 1998–2006

Socioeconomic and Health Determinants of Health Care Utilization among Elderly Europeans: A Semiparametric Assessment of Equity, Intensity and Responsiveness for Ten European Countries

This paper investigates the interplay of socioeconomic and medical determinants of health care utilization among elderly Europeans from ten countries. Using novel strictly comparable cross-national data from the Survey of Health, Ageing and Retirement in Europe (SHARE), the study exploits recent semi- and nonparametric estimation methods to illustrate how individual socioeconomic status and health determine health care utilization in different institutional settings. Our flexible estimation method allows for the use of multiple health measures to adjust for individual differences in health care need without sacrificing cross-national comparability of the resulting estimates. Within countries, we find only a small, if any, socioeconomic gradient. Moreover, all health systems appear to be reasonably responsive to differences in care need. At the same time, wefind considerable variation in treatment intensity across countries, which we cannot fully explain by differences in health care need.

UNDERSTANDING THE VARIATION IN TREATMENT INTENSITY AMONG PATIENTS WITH EARLY STAGE BLADDER CANCER

You have accessJournal of Urology1 Apr 2009UNDERSTANDING THE VARIATION IN TREATMENT INTENSITY AMONG PATIENTS WITH EARLY STAGE BLADDER CANCER John M Hollingsworth, Sean Zhang, Sarah L. Krein, Zaojun Ye, and Brent K. Hollenbeck John M HollingsworthJohn M Hollingsworth More articles by this author , Sean ZhangSean Zhang More articles by this author , Sarah L. KreinSarah L. Krein More articles by this author , Zaojun YeZaojun Ye More articles by this author , and Brent K. HollenbeckBrent K. Hollenbeck More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(09)60016-1AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "UNDERSTANDING THE VARIATION IN TREATMENT INTENSITY AMONG PATIENTS WITH EARLY STAGE BLADDER CANCER." The Journal of Urology, 181(4S), p. 1 © 2009 by American Urological AssociationFiguresReferencesRelatedDetails Volume 181Issue 4SApril 2009Page: 1 Advertisement Copyright & Permissions© 2009 by American Urological AssociationMetricsAuthor Information John M Hollingsworth More articles by this author Sean Zhang More articles by this author Sarah L. Krein More articles by this author Zaojun Ye More articles by this author Brent K. Hollenbeck More articles by this author Expand All Advertisement Loading ...

The Forest and the Trees: the Human Costs of Cancer

The Forest and the Trees: the Human Costs of Cancer

Experimental Analysis of Neighborhood Effects

Families, primarily female-headed minority households with children, living in high-poverty public housing projects in five U.S. cities were offered housing vouchers by lottery in the Moving to Opportunity program. Four to seven years after random assignment, families offered vouchers lived in safer neighborhoods that had lower poverty rates than those of the control group not offered vouchers. We find no significant overall effects of this intervention on adult economic self-sufficiency or physical health. Mental health benefits of the voucher offers for adults and for female youth were substantial. Beneficial effects for female youth on education, risky behavior, and physical health were offset by adverse effects for male youth. For outcomes that exhibit significant treatment effects, we find, using variation in treatment intensity across voucher types and cities, that the relationship between neighborhood poverty rate and outcomes is approximately linear.

How do Zero Tolerance Drunk Driving Laws work?

This paper provides the first comprehensive analysis of the effects of “Zero Tolerance” (ZT) Drunk Driving Laws—which set very low legal blood alcohol limits for individuals under age 21—on self-reported alcohol use and drunk driving using data from the 1984 to 2001 Behavioral Risk Factor Surveillance System (BRFSS). I estimate two-way fixed effects models of alcohol-related behaviors of 18–20-year-olds that can condition on unobserved differences across states that may be correlated with determinants of drinking and drunk driving, and I use 22–24-year-olds as a control group. Results indicate that the laws reduced heavy episodic drinking (five or more drinks at one sitting) among underage males by 13%. This result is supported by models that use variation in treatment intensity induced by differences in body weight. I find mixed evidence of ZT effects for females, and no robust effects on drinking participation or drunk driving for either sex.