David M Cutler

• Ph.D.
• Harvard University

Objective To examine differences between patients treated in integrated systems of care and patients treated outside of such systems during the COVID pandemic in the use of primary and preventive care, emergency services, inpatient services, and mortality. Data Sources and Study Setting Data are used from all enrollees in traditional Medicare aged...

This JAMA Forum discusses immigration in the context of the health care workforce, the potential negative effects from a reduced supply of workers, and potential policy options.

This JAMA Forum discusses ideas for saving money in health care such as reducing the need for care, reducing excessive prices, and shifting to lower-cost practices.

OBJECTIVES This paper provides an examination of: (1) the frequency and net rates of change for general pediatric inpatient (GPI) unit closures and openings nationally and by state; (2) how often closures or openings are caused by GPI unit changes only or caused by hospital-level changes; and (3) the relationship between hospital financial status a...

Background During the COVID-19 pandemic, patients with Alzheimer’s disease and related dementias (ADRD) were especially vulnerable, and modes of medical care delivery shifted rapidly. This study assessed the impact of the pandemic on care for people with ADRD, examining the use of primary, emergency, and long-term care, as well as deaths due to COV...

This JAMA Forum discusses the cost of newly approved weight loss medications in the US compared with other countries and provides arguments for why these medications should be more available for individuals in the US and covered by more insurers.

Importance Shifting care to alternative sites when clinically appropriate may be associated with reduced US health care spending, improved access, and, in some cases, improved care outcomes. Objective To fill 2 main gaps in the current literature on site-of-care shifts: (1) understanding the clinician perspective on appropriateness of alternative...

This JAMA Forum discusses dimensions of financial manipulation in health care and highlights policies that might address it.

Telemedicine use remains substantially higher than it was before the COVID-19 pandemic, although it has fallen from pandemic highs. To inform the ongoing debate about whether to continue payment for telemedicine visits, we estimated the association of greater telemedicine use across health systems with utilization, spending, and quality. In 2020, M...

Importance Increasing integration across medical services may have important implications for health care quality and spending. One major but poorly understood dimension of integration is between physician organizations and pharmacies for self-administered drugs or in-house pharmacies. Objective To describe trends in the use of in-house pharmacies...

This JAMA Forum discusses the good and bad of innovation in health care delivery, tax policy, an escrow account for failure, and state monitoring.

This JAMA Forum discusses resiliency, telehealth, the health care labor force, and public health in the context of the health system changes occurring since the start of the COVID-19 pandemic.

US healthcare administrative spending is roughly $1 trillion annually. A major operational area is the financial transactions ecosystem, about $200 billion in spending annually. Efficient financial transactions ecosystems from other industries and countries exhibit two features: immediate payment assurance and high use of automation throughout the...

Purpose: To describe the supply of cancer specialists, the organization of cancer care within versus outside of health systems, and the distance to multispecialty cancer centers. Methods: Using the 2018 Health Systems and Provider Database from the National Bureau of Economic Research and 2018 Medicare data, we identified 46,341 unique physician...

Importance: Health systems play a central role in the delivery of health care, but relatively little is known about these organizations and their performance. Objective: To (1) identify and describe health systems in the United States; (2) assess differences between physicians and hospitals in and outside of health systems; and (3) compare quali...

PURPOSE To characterize racial and ethnic disparities and trends in opioid access and urine drug screening (UDS) among patients dying of cancer, and to explore potential mechanisms. METHODS Among 318,549 non-Hispanic White (White), Black, and Hispanic Medicare decedents older than 65 years with poor-prognosis cancers, we examined 2007-2019 trends...

1584 Background: There has been increasing hospital and health system ownership of physician practices in recent years, particularly in oncology. However, relatively little is known about how this impacts care delivery for patients with cancer, who use many hospital-based services that may be impacted by integration. We evaluated the impact of phys...

This paper develops a satellite account for the US health sector and measures productivity growth in health care for the elderly population between 1999 and 2012. We measure the change in medical spending and health outcomes for a comprehensive set of 80 conditions. Medical care has positive productivity growth over the time period, with aggregate...

Purpose: Heightened regulations have decreased opioid prescribing across the United States, yet little is known about trends in opioid access among patients dying of cancer. Methods: Among 270,632 Medicare fee-for-service decedents with poor prognosis cancers, we used part D data to examine trends from 2007 to 2017 in opioid prescription fills a...

Life expectancy in the US increased 3.3 years between 1990 and 2015, but the drivers of this increase are not well understood. We used vital statistics data and cause-deletion analysis to identify the conditions most responsible for changing life expectancy and quantified how public health, pharmaceuticals, other (nonpharmaceutical) medical care, a...

To understand the cost burden of medical care it is essential to partition medical spending into conditions. Two broad strategies have been used to measure disease-specific spending. The first attributes each medical claim to the condition that physicians list as its cause. The second decomposes total spending for a person over a year to their cumu...

7005 Background: Heightened US opioid regulations may limit advanced cancer patients’ access to effective pain management, particularly for racial/ethnic minority and other vulnerable populations. We examined trends in opioid access, disparities in access, and pain-related emergency department (ED) visits among cancer patients near end of life (EOL...

Information about an extensive set of health conditions on a well-defined sample of subjects is essential for assessing population health, gauging the impact of various policies, modeling costs, and studying health disparities. Unfortunately, there is no single data source that provides accurate information about health conditions. We combine infor...

We examined trends in per capita spending for Medicare beneficiaries ages sixty-five and older in the United States in the period 1999-2012 to determine why spending growth has been declining since around 2005. Decomposing spending by condition, we found that half of the spending slowdown was attributable to slower growth in spending for cardiovasc...

Risk prediction is central to both clinical medicine and public health. While many machine learning models have been developed to predict mortality, they are rarely applied in the clinical literature, where classification tasks typically rely on logistic regression. One reason for this is that existing machine learning models often seek to optimize...

Health care is one of the economy's biggest industries, so it is natural that the health care industry should play some role in the teaching of introductory economics. There are many ways that health care can appear in such a context: in the teaching of microeconomics, as a macroeconomic issue, to learn about social welfare, and even to learn how t...

Background: In 2012, the EPA enacted more stringent National Ambient Air Quality Standards (NAAQS) for fine particulate matter (PM2.5). Few studies have characterized the health effects of air pollution levels lower than the most recent NAAQS for long-term exposure to PM2.5 (now 12 μg/m). Methods: We constructed a cohort of 32,119 Medicare benef...

Objective To measure incidence of early death after discharge from emergency departments, and explore potential sources of variation in risk by measurable aspects of hospitals and patients. Design Retrospective cohort study. Setting Claims data from the US Medicare program, covering visits to an emergency department, 2007-12. Participants Nation...

Appendix 1: Supplementary tables

Appendix 2: Supplementary figures

Freestanding emergency departments (EDs), which offer emergency medical care at sites separate from hospitals, are a rapidly growing alternative to traditional hospital-based EDs.We evaluated state regulations of freestanding EDs and describe their effect on the EDs' location, staffing, and services. As of December 2015, thirty-two states collectiv...

In the period 2005-13 the US prescription drug market grew at an average annual pace of only 1.8 percent in real terms on an invoice price basis (that is, in constant dollars and before manufacturers' rebates and discounts). But the growth rate increased dramatically in 2014, when the market expanded by 11.5 percent-which raised questions about fut...

Objective To measure the association between a surgeon’s degree of specialization in a specific procedure and patient mortality. Design Retrospective analysis of Medicare data. Setting US patients aged 66 or older enrolled in traditional fee for service Medicare. Participants 25 152 US surgeons who performed one of eight procedures (carotid endarte...

Appendix

Background: There is substantial interest in identifying low-acuity visits to emergency departments (EDs) that could be treated more appropriately in other settings. Systematic differences in illness severity between ED patients and comparable patients elsewhere could make such strategies unsafe, but little evidence exists to guide policy makers....

Objectives: To compare patterns of emergency department (ED) use and inpatient admission rates for elderly adults with cancer with a poor prognosis who enrolled in hospice to those of similar individuals who did not. Design: Matched case-control study. Setting: Nationally representative sample of Medicare fee-for-service beneficiaries with can...

Background: Older adults have the highest influenza-related morbidity and mortality risk, but the influenza vaccine is less effective in the elderly. It is unknown whether influenza vaccination of nonelderly adults confers additional disease protection on the elderly population. Methods: We examined the association between county-wide influenza...

Risk prediction is central to both clinical medicine and public health. While many machine learning models have been developed to predict mortality, they are rarely applied in the clinical literature, where classification tasks typically rely on logistic regression. One reason for this is that existing machine learning models often seek to optimize...

We looked at trends in AMI (acute myocardial infarction) hospitalization rates among elderly Medicare beneficiaries over the 10-year period 2002 to 2011, focusing specifically on whether the post-2007 declines are also more modest for blacks than for whites, potentially reflecting a growing gap in care.

Dear Editor: Despite mounting evidence that hospice provides high-value, high-quality care, many eligible Medicare beneficiaries do not enroll, and lengths of hospice stay remain short. Policymakers have considered changes to Medicare policies to encourage hospice use, but there are persistent concerns about the impact of expanding services on the...

Population-wide screening for epidermal growth factor receptor (EGFR) mutations and anaplastic lymphoma kinase (ALK) gene rearrangements to inform cancer therapy in non-small cell lung cancer (NSCLC) is recommended by guidelines. We estimated cost-effectiveness of multiplexed predictive biomarker screening in metastatic NSCLC from a societal perspe...

We analyze the incidence of public-employee health benefits. Because these benefits are negotiated through the political process, relevant labor market institutions deviate significantly from the competitive, private-sector benchmark. Empirically, we find that roughly 15 percent of the cost of recent benefit growth was passed onto school district e...

Introduction: In the Medicare population, 1% of the patients is responsible for 15% of spending. There are two patterns typical of highest-cost patients: those who cycle in and out of the hospital with preventable conditions, and those who have a single catastrophic event. While a great deal of focus has been placed on the former, much less is know...

Importance More patients with cancer use hospice currently than ever before, but there are indications that care intensity outside of hospice is increasing, and length of hospice stay decreasing. Uncertainties regarding how hospice affects health care utilization and costs have hampered efforts to promote it.Objective To compare utilization and c...

Objectives The objective was to measure the variation in missed diagnosis and costs of care for older acute myocardial infarction (AMI) patients presenting to emergency departments (EDs) and to identify the hospital and ED characteristics associated with this variation.Methods Using 2004–2005 Medicare inpatient and outpatient records, the authors i...

The organization of medical care is changing more rapidly now than at any point in the last century. For decades, health care was a cottage industry: physicians practiced independently or in small groups and had arms-length relationships with hospitals, imaging and laboratory facilities, and other health care entities. Those organizations alternate...

BACKGROUND: A number of instruments have been developed to measure health-related quality of life (HRQoL), differing in the health domains covered and their scoring. Although few such measures have been consistently included in US national health surveys over time, the surveys have included data on a broad range of symptoms and impairments, which e...

Background Stroke is a major cause of morbidity and mortality. We describe trends in the incidence, outcomes, and risk factors for stroke in the US Medicare population from 1988 to 2008. Methods We analyzed data from a 20% sample of hospitalized Medicare beneficiaries with a primary discharge diagnoses of ischemic (n=918,124) or hemorrhagic stroke...

To better understand the financial viability of hospital emergency departments (EDs), we created national estimates of the cost to hospitals of providing ED care and the associated hospital revenue using hospital financial reports and patient claims data from 2009. We then estimated the effect the Affordable Care Act (ACA) will have on the future p...

Objective: Black and Hispanic individuals synthesize less vitamin D per unit of sun exposure than white individuals. The relationship between UV radiation and vitamin D insufficiency in minorities has not been well explored. Design: Prospective cohort study. Setting: Using the National Health and Nutrition Examination Survey, we obtained serum...

Background In 2011, federal incentive payments for meaningful use of electronic health records (EHRs) began. This study evaluates the impact of the program on hospitals and EHR vendors, identifying how it affects EHR planning and development. Specifically, it assesses whether vendors and Chief Information Officers (CIOs) are viewing the meaningful...

Background: Early detection and treatment of cardiovascular disease (CVD) risk factors produces significant clinical benefits, but no consensus exists on optimal screening algorithms. This study aimed to evaluate the comparative and cost-effectiveness of staged laboratory-based and non-laboratory-based total CVD risk assessment. Methods and resul...

A large reduction in use of inpatient care combined with the incentives in the Affordable Care Act is leading to significant consolidation in the hospital industry. What was once a set of independent hospitals having arms-length relationships with physicians and clinicians who provide ambulatory care is becoming a small number of locally integrated...

Recent scientific advances suggest that slowing the aging process (senescence) is now a realistic goal. Yet most medical research remains focused on combating individual diseases. Using the Future Elderly Model-a microsimulation of the future health and spending of older Americans-we compared optimistic "disease specific" scenarios with a hypotheti...

In the past several decades, some risk factors for cardiovascular disease have improved, while others have worsened. For example, smoking rates have dropped and treatment rates for cardiovascular disease have increased-factors that have made the disease less fatal. At the same time, Americans' average body mass index and incidence of diabetes have...

Objectives: We used data from multiple national health surveys to systematically track the health of the US adult population. Methods: We estimated trends in quality-adjusted life expectancy (QALE) from 1987 to 2008 by using national mortality data combined with data on symptoms and impairments from the National Medical Expenditure Survey (1987)...

Background: Studies suggest that low levels of vitamin D may be associated with prostate cancer, and darker skin reduces the body's ability to generate vitamin D from sunshine. The impact of sunshine on racial disparities in prostate cancer incidence and mortality is unknown. Methods: Using the Surveillance, Epidemiology, and End Results program...

The simultaneous growth in longevity and mounting budget deficits in the U.S. have increased interest in raising the age of eligibility for public health and retirement benefits. The consequences of this policy depend on the health of the near elderly, and on the distribution of health by demographic group. We simulate the work capacity and likely...

Uganda is widely viewed as a public health success for curtailing its HIV/AIDS epidemic in the early 1990s. The period of rapid HIV decline coincided with a dramatic rise in girls' secondary school enrollment. We instrument for this enrollment with distance to school, conditional on a rich set of demographic and locational controls, including dista...

Despite earlier forecasts to the contrary, US health care spending growth has slowed in the past four years, continuing a trend that began in the early 2000s. In this article we attempt to identify why US health care spending growth has slowed, and we explore the spending implications if the trend continues for the next decade. We find that the 200...

Bundled payment entails paying a single price for all services delivered as part of an episode of care for a specific condition. It is seen as a promising way to slow the growth of health care spending while maintaining or improving the quality of care. To implement bundled payment, policy makers must set base payment rates for episodes of care and...

Accounting for changes in coding practices may be important in analyzing trends based on administrative data. Several studies have demonstrated large reductions in mortality over time among pneumonia patients. However, a recent study suggested that this reduction may have been an artifact of case definition because more of the highest-risk patients...

The United States spends $361 billion annually on health care administration - more than twice our total spending on heart disease and three times our spending on cancer. But the experience of other industries shows how to realize large savings rapidly.

This paper evaluates whether health plans in Germany's Social Health Insurance select on an easily observable predictor of risk: geography. To identify plan behavior separately from concurrent demand-side adverse selection, I implement a double-blind audit study in which plans are contacted by fictitious applicants from different locations. I find...

In the United States, black males have an annual death rate from prostate cancer that is 2.4 times that of white males. The reasons for this are poorly understood. Using the Surveillance, Epidemiology, and End Results-Medicare database, 77,038 black and white males aged >65 years were identified with a first primary diagnosis of prostate cancer bet...

This amicus brief was filed in Federal Trade Commission v. Phoebe Putney Health System, Inc., in which the FTC has obtained review of an 11th Circuit decision that insulated a merger of two nonprofit hospitals from antitrust scrutiny. We make two arguments in the amicus brief. First, there is no compelling theoretical basis for an antitrust exempti...

The idea of a premium support (or voucher) system for Medicare has generated substantial debate. Under premium support, Medicare beneficiaries would choose from health plans that compete in a market-based bidding system. In some models, traditional Medicare is abandoned entirely in favor of private health plans. In other models such as the Ryan-Wyd...

In this election year, U.S. national spending on health care will reach $2.8 trillion, or about 18% of total spending on all goods and services. This high level of spending reduces our ability to invest in other important parts of the economy and also adds to our unsustainable national debt. There is wide agreement that we must find ways to bend th...

We develop a model of induced innovation that applies to medical research. Our model yields three empirical predictions. First, initial death rates and subsequent research effort should be positively correlated. Second, research effort should be associated with more rapid mortality declines. Third, as a byproduct of targeting the most common condit...

A key question about aggregating payments to health care providers is determining whether to bundle services for individual, if extended, episodes of care or for whole patients. What are the tradeoffs of the two approaches, and how much money could be saved?

As the core health expenditure survey in the United States, the Medical Expenditure Panel Survey (MEPS) is increasingly being used by statistical agencies to track expenditures by disease. However, while MEPS provides a wealth of data, its sample size precludes examination of spending on all but the most prevalent health conditions. To overcome thi...

No abstract available.

In the United States, two patients with the same medical condition can receive drastically different treatments. In addition, the same patient can walk into two physician offices and receive equally disparate treatments. This chapter attempts to understand why. It focuses on three areas: the patient, the physician, and the clinical situation. Speci...

In this review we synthesize what is known about the relationship between education and health. A large number of studies from both rich and poor countries show that education is associated with better health. While previous work has thought of the effect of education separately for rich and poor countries, we argue that there are insights to be ga...