Thread by @dp_oneill

I am a huge fan of @afrakt, but I think this article inadvertently misstates the evidence on hospital reimbursement cuts and quality in a subtle but important way. 1/n

nytimes.com/2019/10/07/ups…

The @UpshotNYT article asserts:

"...studies show that when hospitals are paid less, quality can degrade, even leading to higher mortality rates."

If I'm not mistaken, however, all of the studies which showed lower quality examined *Medicare* payment reductions.

That's understandable, because Medicare offers natural experiments from legislative changes, and the data are readily available.

But, we also know that hospitals which rely most heavily on Medicare and Medicaid tend to be the most efficient...

...while those with the most private pricing power (and hence high private prices) are often the least efficient.

Which is to say, these Medicare-focused studies arguably examine the quality impact of cutting reimbursement to facilities which have the least fat to cut.

It seems plausible that, if the reimbursement cuts fall instead on the most inefficient facilities (via private price reductions), the effect might be rather different than a Medicare-driven cut which disproportionately falls on those which already run a tight ship.

I'm not aware of much research on the effect of cutting private prices, apart from the BCBSMA AQC example that Dr. Frakt has cited, which found "spending reductions of 1.9 and 3.3 percent in its first and second years, respectively, along with evidence of improvements in quality"

Until we have more evidence, it could be quite misleading to draw system-wide conclusions based on Medicare studies, just as patterns of overuse in Medicare are often not mirrored in the private population, where prices play a much larger role in cost inflation. /end