Aaron L Schwartz's research while affiliated with University of Pennsylvania and other places

Publications (32)

Preprint
Full-text available
Background Low-value services are common in cancer care. The onset of the COVID-19 pandemic caused a dramatic decrease in health care utilization, leading many to suspect that low-value cancer services may decrease. Methods In this retrospective cohort study, we used administrative claims from the HealthCore Integrated Research Environment, a repos...
Article
Importance: Low-value care in the Medicare program is prevalent, costly, potentially harmful, and persistent. Although Medicare Advantage (MA) plans can use managed care strategies not available in traditional Medicare (TM), it is not clear whether this flexibility is associated with lower rates of low-value care. Objectives: To compare rates of...
Article
Importance: Within the Veterans Health Administration (VA), the use and cost of low-value services delivered by VA facilities or increasingly by VA Community Care (VACC) programs have not been comprehensively quantified. Objective: To quantify veterans' overall use and cost of low-value services, including VA-delivered care and VA-purchased comm...
Article
6594 Background: Low-value services, which provide minimal patient benefit while entailing costs and risks, are prevalent in cancer care. Shifts in cancer care delivery during the COVID-19 pandemic to minimize exposure provided opportunities for health systems and clinicians to prioritize higher-value over low-value oncology services. Methods: In t...
Article
Background: Low-value care cascades, defined as the receipt of downstream health services potentially related to a low-value service, can result in harm to patients and wasteful healthcare spending, yet have not been characterized within the Veterans Health Administration (VHA). Objective: To examine if the receipt of low-value preoperative test...
Article
Little is publicly known about coverage denials for medical services that do not meet medical necessity criteria. We characterized the extent of these denials and their key features, using Medicare Advantage claims for a large insurer from the period 2014-19. In this setting, claims could be denied because of traditional Medicare's coverage rules o...
Article
Full-text available
Importance Medicare Advantage (MA) has entailed a major expansion of government-financed, privately administered health insurance in the US. As policy makers consider options to expand Medicare further, it is informative to compare the performance of traditional Medicare (TM) and MA. Objective To assess whether MA is associated with differential c...
Article
Research Objective Coverage policy may be an important tool to reduce spending while discouraging low-value medical services. Government and private insurers may also differ in their scope of coverage restrictions for suspected low-value services. However, basic facts about coverage denials are unknown because denials are not identifiable in standa...
Article
Importance Health insurers use prior authorization to evaluate the medical necessity of planned medical services. Data challenges have precluded measuring the frequency with which medical services can require prior authorization, the spending on these services, the types of services and clinician specialties affected, and differences in the scope o...
Article
Full-text available
Importance Patient reviews of health care experiences are increasingly used for public reporting and alternative payment models. Critics have argued that this incentivizes physicians to provide more care, including low-value care, undermining efforts to reduce wasteful practices. Objective To assess associations between rates of low-value service...
Article
Full-text available
Importance: Overuse of health care services exposes patients to unnecessary risk of harm and costs. Distinguishing patterns of overuse among hospitals requires hospital-level measures across multiple services. Objective: To describe characteristics of hospitals associated with overuse of health care services in the US. Design, setting, and part...
Article
Background: Children frequently receive low-value services that do not improve health, but it is unknown whether the receipt of these services differs between publicly and privately insured children. Methods: We analyzed 2013-2014 Medicaid Analytic eXtract and IBM MarketScan Commercial Claims and Encounters databases. Using 20 measures of low-va...
Article
Our patient looked bad, and his labs looked worse. We’d never seen such a high lactate level. What was going on? The diagnosis would soon emerge, along with a lesson: the different perspectives and types of expertise within our team were crucial to solving the case.
Article
Importance Facing new financial incentives to reduce unnecessary spending, health care organizations may attempt to reduce wasteful care by influencing physician practices or selecting more cost-effective physicians. However, physicians’ role in determining the use of low-value services has not been well described. Objectives To quantify variation...
Article
In reducing wasteful health care utilization, patient-focused strategies targeting high-cost patients may be less effective than systems-focused strategies intended to reduce low-value services for everyone. But current incentives favor a focus on high-cost patients.
Article
Full-text available
Background: Claims-based measures of "low-value" pediatric services could facilitate the implementation of interventions to reduce the provision of potentially harmful services to children. However, few such measures have been developed. Methods: We developed claims-based measures of 20 services that typically do not improve child health accordi...
Article
Objective: To assess whether provider organizations exhibit distinct profiles of low-value service provision. Data sources: 2007-2011 Medicare fee-for-service claims and enrollment data. Study design: Use of 31 services that provide minimal clinical benefit was measured for 4,039,733 beneficiaries served by 3,137 provider organizations. Variat...
Article
Importance: Reducing unnecessary tests and treatments is a potentially promising approach for improving the value of health care. However, relatively little is known about whether insurance type or local practice patterns are associated with delivery of low-value care. Objectives: To compare low-value care in the Medicaid and commercially insure...
Article
Objectives: State Medicaid programs are under increasing pressure to contain pharmaceutical spending. Many states have attempted to limit spending through greater Medicaid managed care penetration, which rose nationally from 54.5% in 1999 to 74.9% in 2011. It is not clear how this expansion has affected beneficiaries with serious mental illness (S...
Article
Background In the Medicare Shared Savings Program (MSSP), accountable care organizations (ACOs) have financial incentives to lower spending and improve quality. We used quasi-experimental methods to assess the early performance of MSSP ACOs. Methods Using Medicare claims from 2009 through 2013 and a difference-in-differences design, we compared ch...
Article
Objective: To assess whether geographic access to family planning services is associated with a reduced female high school dropout rate. Methods: We conducted a retrospective cross-sectional study. We merged the location of Planned Parenthood and Title X clinics with microdata from the 2012-2013 American Community Surveys. The association betwee...
Article
In Reply Dr Saver raises an important question regarding our study1 of the Medicare Pioneer Accountable Care Organization (ACO) program, which was associated with modest reductions in the use of low-value services in its first year. Specifically, how can we know whether a reduction in the use of low-value services reflects an overall improvement in...
Article
Importance Wasteful practices are widespread in the US health care system. It is unclear if payment models intended to improve health care efficiency, such as the Medicare accountable care organization (ACO) programs, discourage the provision of low-value services.Objective To assess whether the first year of the Medicare Pioneer ACO program was...
Article
Teen pregnancy is associated with decreased educational attainment, with 34% of teen mothers not achieving high school equivalency. This study explores whether geographic access to family planning services is associated with reduced high school non-completion for women. The current locations of 725 Planned Parenthood clinics were merged with microd...
Article
Background: In 2012, a total of 32 organizations entered the Pioneer accountable care organization (ACO) program, in which providers can share savings with Medicare if spending falls below a financial benchmark. Performance differences associated with characteristics of Pioneer ACOs have not been well described. Methods: In a difference-in-diffe...
Article
Insurance coverage has increased among young adults as a result of the Affordable Care Act (ACA) provision that allows young adults to remain covered under their parents’ plans until age twenty-six. However, little is known about the provision’s effects on the clinical outcomes and insurance coverage of patients with trauma—the most frequent cause...
Article
Full-text available
Background The United States spends more than $750 billion annually on tests and procedures that do not benefit patients. Although there is no physiological indication for carotid ultrasound in “simple” syncope in the absence of focal neurological signs or symptoms suggestive of stroke, there is concern that this practice remains common for routine...
Article
Importance: Despite the importance of identifying and reducing wasteful health care use, few direct measures of overuse have been developed. Direct measures are appealing because they identify specific services to limit and can characterize low-value care even among the most efficient providers. Objectives: To develop claims-based measures of lo...
Article
Starting in 2014, many low-income adult residents of states that forgo the Affordable Care Act's expansion of Medicaid would be eligible for that program if they moved to a state that had chosen to expand its coverage. Some of these people may migrate to receive coverage, thereby increasing costs for states that have expanded the program. This is k...
Article
Growth in the health information technology (health IT) workforce will be necessary for the widespread adoption of electronic health records called for by the Health Information Technology for Economic and Clinical Health (HITECH) provisions of the American Recovery and Reinvestment Act. However, the health IT workforce is difficult to track using...

Citations

... This analysis also allowed us to explore whether imbalances in the geographic distribution of MA and TM beneficiaries in our study population sample might bias our ascertainment of the overall association between MA enrollment and low-value services because, as would be expected, there was imbalance in county-level averages of MA and TM beneficiaries in our sample across quintiles-Quintile 1 (218 MA and 238 TM), Quintile 2 (620 MA and 333 TM), Quintile 3 (963 MA and 463 TM), Quintile 4 (1345 MA and 746 TM), and Quintile 5 (1548 MA and 404 TM). 6. High-Value Service -Past research has found that several measures of utilization (e.g., acute and post-acute care) are lower in MA than TM. [8][9][10] If we observed lower rates of low-value services in MA, it could represent indiscriminate utilization differences between the two programs, rather than a specific association for low-value care. To address this possibility, we modeled the association between MA enrollment and receipt of a "high-value" service. ...
... MA plans can limit their enrollees to a limited set of potentially lower cost clinicians and facilities 3 and also have the flexibility to enforce greater control over the care received through the use of prior authorization requirements. 4 An ACO typically does not have as much control over what care their patients receive and where they receive that care, putting similar models at a disadvantage when trying to control spending relative to MA plans. ...
... Clinicians and other stakeholders perceive negative impacts to patients as a barrier to de-implementing LVC. Some [26,38], but not all [39], previous research has shown diminished patient satisfaction ratings when LVC was not provided. However, the impact of LVC de-implementation on the patient-clinician relationship is unknown. ...
... Many such well-documented geographical variations cannot be explained by demographical differences or in epidemiological terms and appear to be iatrogenic or systemic. Accordingly, it has been claimed that such geographical variations indicate underuse and overuse [62][63][64][65][66][67][68][69][70][71] and pose challenges to clinical practice, health services provision, and health policy making. This has spurred a series of initiatives, such as the Choosing Wisely Campaign, Too Much Medicine (BMJ) series, Smarter Medicine movement, Prudent Health Care, Slow Medicine, Do Not Do (NICE), just to mention a few [72]. ...
... 27 Unwarranted practice variation exists in the emergency care of children, 27,28 and differences in ED settings are important contributors to this phenomenon. 4,[27][28][29][30][31][32] Specifically, EDs with pediatric designation provide higher-value care and are associated with improved outcomes for respiratory emergencies in children. 3,[33][34][35][36][37] Institutions with higher pediatric patient volumes are associated with better adherence to resuscitation guidelines in the ED setting. ...
... Therefore, increasing attention has been paid to identifying factors that influence the use of LVC [18]. Considerable variation in the provision of LVC among individual primary care physicians indicates that differences in individual physicians' behaviors are of great importance [19]. However, the use of LVC in primary health care can also be influenced by organizational factors [10,16,[19][20][21][22][23][24][25][26][27][28][29][30][31][32], such as economic incentives [18,[27][28][29]31], physician work culture [28], time pressure [10,16,[28][29][30], and gatekeeping functions [28]. ...
... Systemic approaches to reduce spending may help them succeed in value-based contracts, but they will reduce their fee-for-service revenue. (20) Abbreviations Funding: Funding for this paper came from the West Health Institute. West Health Institute did not exert any editorial authority over the content of the paper. ...
... 27 Unwarranted practice variation exists in the emergency care of children, 27,28 and differences in ED settings are important contributors to this phenomenon. 4,[27][28][29][30][31][32] Specifically, EDs with pediatric designation provide higher-value care and are associated with improved outcomes for respiratory emergencies in children. 3,[33][34][35][36][37] Institutions with higher pediatric patient volumes are associated with better adherence to resuscitation guidelines in the ED setting. ...
... Considerable variation in the provision of LVC among individual primary care physicians indicates that differences in individual physicians' behaviors are of great importance [19]. However, the use of LVC in primary health care can also be influenced by organizational factors [10,16,[19][20][21][22][23][24][25][26][27][28][29][30][31][32], such as economic incentives [18,[27][28][29]31], physician work culture [28], time pressure [10,16,[28][29][30], and gatekeeping functions [28]. Thus, reducing LVC is not only individual health care professionals' responsibility but also an issue to be considered at the organizational level [25]. ...
... A study using state-level data reported some association between prescription utilization for serious mental illnesses and managed-care penetration rates. Because most states carved out pharmaceutical benefits, the authors argued that the results reflect a failure to coordinate medication adherence by HMOs, leading to a decrease in necessary psychiatric medications (43). The authors did not account, however, for variation in access to prescribing providers, which could also explain differences in medication utilization. ...