Pe Peer Re Review is not simply a hurdle to overcome: an example - - PowerPoint PPT Presentation
Pe Peer Re Review is not simply a hurdle to overcome: an example on transforming a preterm birth cost analysis Norman J Waitzman, PhD Professor and Chair, Economics DeCART, Data Science for the Health Sciences, August 3, 2018 Order of Service
Norman J Waitzman, PhD Professor and Chair, Economics DeCART, Data Science for the Health Sciences, August 3, 2018
(Cost) to birth certificates (GA)
preterm relative to term)
mortality)
2011 data. . . . While updates are perhaps always welcome, the justification and indeed, conclusion of the piece is that there have been dramatic increases in costs due to changes in technology.”
maintained, methods for updating cost need to be applied with greater precision. Otherwise, a more nuanced conclusion is merited.”
rate (CDC).
approximate 10% average preterm birth rate for CA reported in Vital Statistics for 2009-2011 (see Martin et al., "Measuring Gestational Age in Vital Statistics Data, . . .", National Vital Statistics Report 64 (5), June 1, 2015,Table 4). This 30% is the difference from the LMP establishment of preterm birth on the birth certificate. OE, the preferred method, was significantly lower still, at about 8.7%. One assumes that LMP was adopted for this study, but the authors should state whether LMP or OE was used.
population estimate of 12.9% with a 10% official rate?
rate is used (CPI) rather than one tailored to the services provided
general CPI rather than an index tailored to health care. The CPI is for all goods and services in a consumer
addresses inpatient hospital services, and its costs, not reimbursements.
adjust these costs (producer prices reflect actual prices paid for inputs, approximating costs). That PPI has increased dramatically faster over the past decade than has the CPI, and when deployed, the residual increase in cost dwindles to the extent that the uncovered increase could border on noise . . .
this analysis noted above, this is the major issue with the manuscript, as it leaves its primary justification/conclusion (major cost-driving changes over the past decade in technology) wanting.
Fees, which are absent from the Discharge Abstracts
and not reimbursement? This creates an asymmetry relative to inpatient hospital costs using cost-to-charge ratios where all like DRGs are accorded the same cost regardless of payer. If specialty mix are different by payer, then fine.
regardless of payer so as to avoid inconsistency.
An Expenditure or Cost is Price X Quantity (P x Q). If the claim is that intensity of services, “Q’s” have grown, have to adjust properly for “P’s”. Authors have not. “Charge” is not “Reimbursement” which departs from“Cost.” Cost is estimate of value of Real Resources; Reimbursement is amount paid and may reflect market power and conditions; Charges are simply an accounting mechanism with no definitive relationship to cost. Discharge abstracts permit estimates of “Cost” through “Cost-to-Charge” ratios. Methods applied to professional fees, however, rely on “reimbursement”, not cost. State or area costs vary and change differently from a national trajectory. Improper to apply national indices to adjust for local estimates.
estimate
referenced Vital Statistics report, as the reviewer noted in the initial review, showed an 8.7% estimate by the OE method and 10% for the LMP method. By switching to the OE method and arriving now at a 10.2% preterm rate, there is no consistency with current data at all as claimed by the authors.
exercise as suggested?
generous assessment is that the authors lack s rudimentary command of the extensive price index literature, particularly in the area of health care economics, concerning which index is most appropriate under what context. . . . [T]hey are comparing a specific type of health care service (inpatient delivery care) several years ago to the same type years later, and seek to express the change in real terms. That is how it is used in the referenced paragraph. The reviewer suggested an index tailored precisely to what the authors are assessing, the producer price index (PPI) for inpatient care. This index does not suffer the weaknesses of transaction prices that the authors appear to claim. In one recent review in a vast literature on the appropriate price index to apply in health care analysis, I quote: "To adjust estimates of costs of inpatient services from different years, the PPI for inpatient services appears currently to be the best option (Dunn, Grosse and Zuvekas. 2016. "Adjusting Health Expenditures for Inflation: A Review of Measures for Health Services Research in the United States" Health Services Research, 175-196. DOI: 10.1111/1475-6773.12612).
undertake a proper adjustment to cost, thereby yielding asymmetric methods on the professional versus inpatient facility components of estimates in this paper The authors, it would seem, would either 1) acknowledge the asymmetry in method , that one reflects "cost" whereas the other reflects "payment" and therefore there estimates are not uniformly
physicians for inpatient delivery services covers cost or Medicaid as % of Medicare payment to physicians (treating Medicare as cost-based numerare)., and then adjust Medicaid payment from Peterson et al. across the board accordingly.
Comment on an even more precise index: This paper has come a long way … and the authors are very close. The "general and surgical hospital" component of the PPI is clearly the superior index for this piece (as the overall PPI includes psychiatric and other specialty hospitals, and also Medicare payment). As the general and surgical hospital hospital PPI is split for the period required by payer (Medicare/Medicaid/Private and Other, and given nearly all births are Medicaid reimbursed or Private/Other, the "best" index, it would seem to the reviewer, would be Medicaid general and surgical PPI applied to discharges where Medicaid was expected payer and Private/Other for other discharges. . . . This modification would not require a lot of effort.
Authors return to recalcitrance: disagree with the more refined index
responses:
is what is superior in the context
unproven assertion of unchanged market power in the hospital sector;
lacking any empirical foundation for contradicting it or for greater market concentration, this argument runs against the thrust of the discipline;
suggested index does not go far enough back.
acknowledge the limitation involved. Furthermore, while this historical comparison is provided for insights, the iterations of the paper demonstrate that the historical insights have evolved
themselves, one should not be shy about adopting them.
None of the assertions by the authors essentially challenges the superiority of the suggested index. And yet, as it stands, this is a worthwhile contribution, and perhaps 3) should be taken most seriously . . . that the additional benefit derived from the extra effort is not justified by the effort. The readers will simply have to take the stated limitations seriously and cautiously digest the stated lessons. It is not just incumbent upon these authors, but other health economists, to take the fundamental issues involved with deploying price indices more seriously rather than cavalierly adopting an erroneous protocol as they approach their empirical work, as good policy is
What did the peer review process accomplish? Could it have been improved