Footnotes: "Chronic Diseases and the High Price of U.S. Healthcare"

In This Section:

Publications and Resources

by Carl F. Ameringer

1 Organisation for Economic Co-operation and Development (OECD). 2010. “OECD Health Data,” OECD Health Statistics (accessed Oct. 10, 2011).

2 Reported data come from Paez, K. A., L. Zhao, and W. Hwang. 2009. “Rising Out-of-Pocket Spending for Chronic Conditions: A Ten-Year Trend.” Health Affairs 28(1):15-25. And from Marshall Protocol Knowledge Base. 2009. Autoimmunity Research Foundation. Available at http://mpkb.org (accessed Dec. 15, 2009).

3 Thorpe, K. E., D. H. Howard, and K. Galactinova. 2007. “Differences in Disease Prevalence as a Source of the U.S.-European Health Care Spending Gap.” Health Affairs Oct. 2, w678-686. Ham, C. 2009. “Chronic Care in the English National Health Service: Progress and Challenges.” Health Affairs 28(1):190-201. Bodenheimer, T., E. Chen, and H. D. Bennett. 2009. “Confronting the Growing Burden of Chronic Disease: Can the U.S. Health Care Workforce Do the Job?” Health Affairs 28(1):64-74.

4 Reported in Thorpe, K. E., D. H. Howard, and K. Galactinova. 2007. “Differences in Disease Prevalence as a Source of the U.S.-European Health Care Spending Gap.” Health Affairs Oct. 2, w678-686.

5 Today’s primary care physicians (PCPs) are yesterday’s general practitioners. Most PCPs are board-certified specialists in one of four practice areas: family medicine, internal medicine, pediatrics, and obstetrics/gynecology. PCPs differ from most specialists by focusing on the whole person rather than a specific body part or disease. See Starfield, B., L. Shi, and J. Macinko. 2005. “Contributions of Primary Care to Health Systems and Health.” The Milbank Quarterly 83(3):457-500. Schoen, C., R. Osborn, M. M. Doty, D. Squires, J. Peugh, and S. Applebaum. 2009. “A Survey of Primary Care Physicians in Eleven Countries, 2009: Perspectives on Care, Costs, and Experiences.” Health Affairs 5 Nov., w1171-1180.

6 Dentzer, S. 2010. “Reinventing Primary Care: A Task That Is Far ‘Too Important to Fail.’” Health Affairs 29(5):757-759.

7 Council on Graduate Medical Education (COGME). 2010. “Advancing Primary Care.” Twentieth Report of COGME. Available at www.cogme.gov (accessed July 23 2011).

8 Goodson, J. 2007. “Unintended Consequences of Resource-Based Relative Value Scale Reimbursement.” The Journal of the American Medical Association (JAMA) 298:2308-2310.

9 This statement receives support from numerous scholarly articles and publications. See, for example, the May 25, 2010, issue of Health Affairs 29(5).

10 Reported data come from Bodenheimer, T., E. Chen, and H. D. Bennett. 2009. “Confronting the Growing Burden of Chronic Disease: Can the U.S. Health Care Workforce Do the Job?” Health Affairs 28(1):64-74.

11 Ibid.
12 Goodson, J. 2007. “Unintended Consequences of Resource-Based Relative Value Scale Reimbursement.” The Journal of the American Medical Association (JAMA) 298:2308-2310. Vaughn, B. T., S. R. DeVrieze, S. D. Reed, and K. A. Schulman. 2010. “Can We Close the Income and Wealth Gap Between Specialists and Primary Care Physicians?” Health Affairs 29(5):933-940.

13 Vaughn, B. T., S. R. DeVrieze, S. D. Reed, and K. A. Schulman. 2010. “Can We Close the Income and Wealth Gap Between Specialists and Primary Care Physicians?” Health Affairs 29(5):933-940.

14 Council on Graduate Medical Education (COGME). 2010. “Advancing Primary Care. Twentieth Report of COGME.” Available at www.cogme.gov (accessed July 23 2011).

15 See, generally, American Medical Association. “The Medicare Physician Payment Schedule,”  (accessed Oct. 21, 2011).

16 American College of Physicians. 2008. “Aligning Incentives: The Case for Delivery System Reform.” Statement for the Record of the American College of Physicians to the Senate Finance Committee, 16 Sept.

17 Vladeck, B. C. 2010. “Fixing Medicare’s Physician Payment System.” The New England Journal of Medicine 362:1955-1957. COGME (Council on Graduate Medical Education). 2010. “Advancing Primary Care.” Twentieth Report of COGME. Available at www.cogme.gov (accessed July 23 2011).

18 Council on Graduate Medical Education (COGME). 2010. “Advancing Primary Care. Twentieth Report of COGME.” Available at www.cogme.gov (accessed July 23 2011).

19 For a “detailed history — a detailed examination — and medical decision-making of low complexity,” the benchmark payment is $93.86 (CPT-4 Code 99243). For a “comprehensive history — a comprehensive examination — and medical decision-making of moderate complexity,” the benchmark payment is $131.88 (CPT-4 Code). For a “comprehensive history — a comprehensive examination — and medical decision-making of high complexity,” the benchmark payment is $177.63. See CPT-4 Outpatient Benchmarks. Available at www.myhealthscore.com (accessed Nov. 11, 2011).

20 Reinhardt, U. E. 2010. “The Little-Known Decision-Makers for Medicare Physician Fees.” The New York Times Dec. 10, (accessed Dec. 17, 2011).

21 Pauly, M. V. 1968. “The Economics of Moral Hazard: Comment.” The American Economic Review 58(3):531-537.

22 Banthin, J. S. and D. M. Bernard. 2006. “Changes in Financial Burdens for Health Care: National Estimates for the Population Younger than 65 Years, 1996-2003.” The Journal of the American Medical Association (JAMA) 296(22):2712-2719. Cunningham, P. J. 2010. “The Growing Financial Burden of Health Care: National and State Trends, 2001-2006.” Health Affairs 29(5):1037-1044. Auerbach, D. and A. L. Kellermann. 2011. “A Decade of Health Care Cost Growth Has Wiped Out Real Income Gains for an Average U.S. Family.” Health Affairs 30(9):1620-1636 (out-of-pocket healthcare expenditures for a typical family of four with employer-based coverage increased from $805 in 1999 to $1,420 in 2009).

23 A.N. Trivedi, H. Moloo, and V. Mor. 2010. “Increased Ambulatory Care Copayments and Hospitalizations among the Elderly.” The New England Journal of Medicine 362:320-328. U.S. Department of Health and Human Services. 2010. “New Study Implicates Healthcare Utilization Rates, More than Biology, in Colorectal Cancer Disparities.” National Institutes of Health News, 6 April (accessed Oct. 20, 2011).

24 Trivedi, A. N., M. Husein, and V. Mor. 2010. “Increased Ambulatory Care Copayments and Hospitalizations among the Elderly.” The New England Journal of Medicine 362:320-328.

25 Schoen, C., R. Osborn, M. M. Doty, D. Squires, J. Peugh, and S. Applebaum. 2009. “A Survey of Primary Care Physicians in Eleven Countries, 2009: Perspectives on Care, Costs, and Experiences.” Health Affairs 5 Nov., w1171-1180.

26 Moral hazard, as economists well know, may occur in principal/agent situations in which principals, lacking the information and knowledge to know the proper course of action, rely on agents who promote their own interests over those of their principals. See Zweifel, P. and W. G. Manning. 2000. “Moral Hazard and Consumer Incentives in Health Care.” In Handbook of Health Economics, Volume IA, eds. A. J. Culyer and J. P. Newhouse. The Netherlands: Elsevier, B.V.

27 Lesser, C. S., H. V. Fineberg, and C. K. Cassel. 2010. “Physician Payment Reform: Principles That Should Shape It.” Health Affairs 29(5):948-952. If Lesser and colleagues are correct that the way physicians are paid accounts for much of the growth in spending, then insurers need to look at physician behavior, not consumer behavior, for evidence of moral hazard.

28 See Staff of The Washington Post. 2010. Landmark: The Inside Story of America’s New Health-Care Law and What it Means for Us All. New York: PublicAffairs.

29 See Vaughn, B. T., S. R. DeVrieze, S. D. Reed, and K. A. Schulman. 2010. “Can We Close the Income and Wealth Gap Between Specialists and Primary Care Physicians?” Health Affairs 29(5):933-940.

30 Ham, C. 2009. “Chronic Care in the English National Health Service: Progress and Challenges.” Health Affairs 28(1):190-201. Starfield, B. 2010. “Reinventing Primary Care: Lessons from Canada for the United States.” Health Affairs 29(5):1030-1036.

31 Starfield, B. 2010. “Reinventing Primary Care: Lessons from Canada for the United States.” Health Affairs 29(5):1030-1036.

32 Many proposals are on the table, from curtailing the influence of the Relative Value Scale Update Committee to paying doctors an aggregate or set amount to treat certain chronic conditions. See Wilensky, G. R. 2009. “Reforming Medicare’s Physician Payment System.” The New England Journal of Medicine 360(7):653-655; and Vladeck, B. C. 2010. “Fixing Medicare’s Physician Payment System.” The New England Journal of Medicine 362:1955-1957.

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