John Billings

John Billings
Professor of Health Policy and Public Service

John Billings, Professor of Health Policy and Public Service, is the director of NYU Wagner's Health Policy and Management Program. He is principal investigator on numerous projects to assess the performance of the safety net for vulnerable populations and to understand the nature and extent of barriers to optimal health for vulnerable populations. Much of his work has involved analysis of patterns of hospital admission and emergency room visits as a mechanism to evaluate access barriers to outpatient care and to assess the performance of the ambulatory care delivery system. He has also examined the characteristics of high cost Medicaid patients in to help in designing interventions to improve care and outcomes for these patients. Parallel work in the United Kingdom has involved creating an algorithm for the National Health Service to identify patients at risk of future hospital admissions and designing interventions to improve care for these high risk patients.  As a founding member of the Foundation for Informed Decision Making, Professor Billings is helping to provide patients with a clearer mechanism for understanding and making informed decisions about a variety of available treatments. Professor Billings received his J.D. from the University of California (Berkeley).

Semester Course
Spring 2014 HPAM-GP.2836.001 Current Issues in Health Policy

Required for M.P.A. health policy specialization students.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.


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Spring 2014 UPADM-GP.236.001 Topics in Health: Policy, Politics, and Power

Health care now constitutes almost 15% of the U.S. economy. The broad range of issues involving health care and health care delivery are at the center of national and local policy debates: Disparities in access and outcomes for vulnerable populations; right to control decisions about treatment and about dying; medical malpractice; the adequacy of the evidence base underlying medical decisions; the pharmaceutical industry and its role in health care and politics; the impact of an aging population; and coping with accelerating health cost.

This course is an introduction for undergraduate students to the major policy issues affecting health care and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, several sessions involve some discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, with an emphasis on Medicare and Medicaid reforms currently being implemented or considered.


Download Syllabus
Fall 2013 HPAM-GP.2836.001 Current Issues in Health Policy

Required for M.P.A. health policy specialization students.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.


Download Syllabus
Spring 2013 HPAM-GP.2836.001 Current Issues in Health Policy

Required for M.P.A. health policy specialization students.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.


Download Syllabus
Spring 2013 UPADM-GP.236.001 Topics in Health: Policy, Politics, and Power

Health care now constitutes almost 15% of the U.S. economy. The broad range of issues involving health care and health care delivery are at the center of national and local policy debates: Disparities in access and outcomes for vulnerable populations; right to control decisions about treatment and about dying; medical malpractice; the adequacy of the evidence base underlying medical decisions; the pharmaceutical industry and its role in health care and politics; the impact of an aging population; and coping with accelerating health cost.

This course is an introduction for undergraduate students to the major policy issues affecting health care and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, several sessions involve some discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, with an emphasis on Medicare and Medicaid reforms currently being implemented or considered.


Download Syllabus
Fall 2012 HPAM-GP.2836.001 Current Issues in Health Policy

Required for M.P.A. health policy specialization students.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.


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Spring 2011 UPADM-GP.0236.001 Current Issues in Health Policy

Required for M.P.A. health policy specialization students.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.


Download Syllabus
Fall 2010 HPAM-GP.2836.001 Current Issues in Health Policy

Required for M.P.A. health policy specialization students.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.


Download Syllabus
Fall 2009 HPAM-GP.2836.001 Current Issues in Health Policy

Required for M.P.A. health policy specialization students.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.


Download Syllabus
Summer 2009 HPAM-GP.2836.001 Current Issues in Health Policy

Required for M.P.A. health policy specialization students.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.


Download Syllabus
Spring 2009 UPADM-GP.0236.001 Topics in Health: Policy, Politics, and Power

Health care now constitutes almost 15% of the U.S. economy. The broad range of issues involving health care and health care delivery are at the center of national and local policy debates: Disparities in access and outcomes for vulnerable populations; right to control decisions about treatment and about dying; medical malpractice; the adequacy of the evidence base underlying medical decisions; the pharmaceutical industry and its role in health care and politics; the impact of an aging population; and coping with accelerating health cost.

This course is an introduction for undergraduate students to the major policy issues affecting health care and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, several sessions involve some discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, with an emphasis on Medicare and Medicaid reforms currently being implemented or considered.


Download Syllabus
Fall 2008 HPAM-GP.2836.001 Current Issues in Health Policy

Required for M.P.A. health policy specialization students.

This course is an introduction to major health policy issues and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, emphasis will be placed on the discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, as well as Medicare and Medicaid reforms currently being implemented or considered.


Download Syllabus
Spring 2008 UPADM-GP.0236.001 Topics in Health: Policy, Politics, and Power

Health care now constitutes almost 15% of the U.S. economy. The broad range of issues involving health care and health care delivery are at the center of national and local policy debates: Disparities in access and outcomes for vulnerable populations; right to control decisions about treatment and about dying; medical malpractice; the adequacy of the evidence base underlying medical decisions; the pharmaceutical industry and its role in health care and politics; the impact of an aging population; and coping with accelerating health cost.

This course is an introduction for undergraduate students to the major policy issues affecting health care and examines the role of government in the health care system. An important focus of the course is an assessment of the role of policy analysis in the formation and implementation of national and local health policy. Because much of government health policy relates to or is implemented through payment systems, several sessions involve some discussion of the policy implications of how government pays for care. The role of the legal system with respect to adverse medical outcomes, economic rights, and individual rights is also discussed. Proposals for health policy reform at the national and local level are examined throughout the course, with an emphasis on Medicare and Medicaid reforms currently being implemented or considered.


Download Syllabus
  Projects
ECHO Endocrine Project
Date Publication/Paper
2013

Billings, John and Maria C. Raven 2013. Dispelling An Urban Legend: Frequent Emergency Department Users Have Substantial Burden Of Disease Health Affairs, 32, no.12 (2013):2099-2108
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Abstract

Urban legend has often characterized frequent emergency department (ED) patients as mentally ill substance users who are a costly drain on the health care system and who contribute to ED overcrowding because of unnecessary visits for conditions that could be treated more efficiently elsewhere. This study of Medicaid ED users in New York City shows that behavioral health conditions are responsible for a small share of ED visits by frequent users, and that ED use accounts for a small portion of these patients’ total Medicaid costs. Frequent ED users have a substantial burden of disease, and they have high rates of primary and specialty care use. They also have linkages to outpatient care that are comparable to those of other ED patients. It is possible to use predictive modeling to identify who will become a repeat ED user and thus to help target interventions. However, policy makers should view reducing frequent ED use as only one element of more-comprehensive intervention strategies for frequent health system users.

2012

John Billings, Ian Blunt, Adam Steventon, Theo Georghiou, Geraint Lewis, Martin Bardsley 2012. Development of a predictive model to identify inpatients at risk of re-admission within 30 days of discharge (PARR-30) BMJ Open 2012;2:e001667 doi:10.1136/bmjopen-2012-001667
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Abstract

Objectives To develop an algorithm for identifying inpatients at high risk of re-admission to a National Health Service (NHS) hospital in England within 30 days of discharge using information that can either be obtained from hospital information systems or from the patient and their notes.

Design Multivariate statistical analysis of routinely collected hospital episode statistics (HES) data using logistic regression to build the predictive model. The model's performance was calculated using bootstrapping.

Setting HES data covering all NHS hospital admissions in England.

Participants The NHS patients were admitted to hospital between April 2008 and March 2009 (10% sample of all admissions, n=576 868).

Main outcome measures Area under the receiver operating characteristic curve for the algorithm, together with its positive predictive value and sensitivity for a range of risk score thresholds.

Results The algorithm produces a ‘risk score’ ranging (0–1) for each admitted patient, and the percentage of patients with a re-admission within 30 days and the mean re-admission costs of all patients are provided for 20 risk bands. At a risk score threshold of 0.5, the positive predictive value (ie, percentage of inpatients identified as high risk who were subsequently re-admitted within 30 days) was 59.2% (95% CI 58.0% to 60.5%); representing 5.4% (95% CI 5.2% to 5.6%) of all inpatients who would be re-admitted within 30 days (sensitivity). The area under the receiver operating characteristic curve was 0.70 (95% CI 0.69 to 0.70).

Conclusions We have developed a method of identifying inpatients at high risk of unplanned re-admission to NHS hospitals within 30 days of discharge. Though the models had a low sensitivity, we show how to identify subgroups of patients that contain a high proportion of patients who will be re-admitted within 30 days. Additional work is necessary to validate the model in practice.

Steventon A, Bardsely M, Billings J., et al 2012. Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial BMJ 2012;344:e3874
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Abstract

Objective: To assess the effect of home based telehealth interventions on the use of secondary healthcare and mortality.

Design: Pragmatic, multisite, cluster randomised trial comparing telehealth with usual care, using data from routine administrative datasets. General practice was the unit of randomisation. We allocated practices using a minimisation algorithm, and did analyses by intention to treat.

Setting: 179 general practices in three areas in England.

Participants: 3230 people with diabetes, chronic obstructive pulmonary disease, or heart failure recruited from practices between May 2008 and November 2009.

Interventions: Telehealth involved remote exchange of data between patients and healthcare professionals as part of patients’ diagnosis and management. Usual care reflected the range of services available in the trial sites, excluding telehealth.

Main outcome measure: Proportion of patients admitted to hospital during 12 month trial period.

Results: Patient characteristics were similar at baseline. Compared with controls, the intervention group had a lower admission proportion within 12 month follow-up (odds ratio 0.82, 95% confidence interval 0.70 to 0.97, P=0.017). Mortality at 12 months was also lower for intervention patients than for controls (4.6% v 8.3%; odds ratio 0.54, 0.39 to 0.75, P<0.001). These differences in admissions and mortality remained significant after adjustment. The mean number of emergency admissions per head also differed between groups (crude rates, intervention 0.54 v control 0.68); these changes were significant in unadjusted comparisons (incidence rate ratio 0.81, 0.65 to 1.00, P=0.046) and after adjusting for a predictive risk score, but not after adjusting for baseline characteristics. Length of hospital stay was shorter for intervention patients than for controls (mean bed days per head 4.87 v 5.68; geometric mean difference −0.64 days, −1.14 to −0.10, P=0.023, which remained significant after adjustment). Observed differences in other forms of hospital use, including notional costs, were not significant in general. Differences in emergency admissions were greatest at the beginning of the trial, during which we observed a particularly large increase for the control group.

Conclusions: Telehealth is associated with lower mortality and emergency admission rates. The reasons for the short term increases in admissions for the control group are not clear, but the trial recruitment processes could have had an effect.

Steventon, A., Bardsley, M., Billings, J., Georghiou, T. and Lewis, G. H. 2012. The Role of Matched Controls In Building An Evidence Base For Hospital Avoidance Schemes: A Retrospective Evaluation Health Services Research, 47: 1679–1698. doi: 10.1111/j.1475-6773.2011.01367.x
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Abstract

Objective
To test whether two hospital-avoidance interventions altered rates of hospital use: “intermediate care” and “integrated care teams.”

Data Sources/Study Setting
Linked administrative data for England covering the period 2004 to 2009.

Study Design
This study was commissioned after the interventions had been in place for several years. We developed a method based on retrospective analysis of person-level data comparing health care use of participants with that of prognostically matched controls.

Data Collection/Extraction Methods
Individuals were linked to administrative datasets through a trusted intermediary and a unique patient identifier.

Principal Findings
Participants who received the intermediate care intervention showed higher rates of unscheduled hospital admission than matched controls, whereas recipients of the integrated care team intervention showed no difference. Both intervention groups showed higher rates of mortality than did their matched controls.

Conclusions
These are potentially powerful techniques for assessing impacts on hospital activity. Neither intervention reduced admission rates. Although our analysis of hospital utilization controlled for a wide range of observable characteristics, the difference in mortality rates suggests that some residual confounding is likely. Evaluation is constrained when performed retrospectively, and careful interpretation is needed.

2010

Billings, J., Raven, M., Carrier, E. et al. 2010. Substance Use Treatment Barriers for Patients with Frequent Hospital Admissions Journal of Substance Abuse Treatment
Abstract

Substance use (SU) disorders adversely impact health status and contribute to inappropriate health services use. This qualitative study sought to determine SU-related factors contributing to repeated hospitalizations and to identify opportunities for preventive interventions. Fifty Medicaid-insured inpatients identified by a validated statistical algorithm as being at high-risk for frequent hospitalizations were interviewed at an urban public hospital. Patient drug/alcohol history, experiences with medical, psychiatric and addiction treatment, and social factors contributing to readmission were evaluated. Three themes related to SU and frequent hospitalizations emerged: (a) barriers during hospitalization to planning long-term treatment and follow-up, (b) use of the hospital as a temporary solution to housing/family problems, and (c) unsuccessful SU aftercare following discharge. These data indicate that homelessness, brief lengths of stay complicating discharge planning, patient ambivalence regarding long-term treatment, and inadequate detox-to-rehab transfer resources compromise substance-using patients' likelihood of avoiding repeat hospitalization. Intervention targets included supportive housing, detox-to-rehab transportation, and postdischarge patient support.

2009

Goldfrank, L., Billings, J., Raven, M., et al. 2009. Medicaid Patients at High Risk for Frequent Hospital Admission: Real-time Identification and Remedial Risks Journal of Urban Health. 86, no 2 230-241
Abstract

Patients with frequent hospitalizations generate a disproportionate share of hospital visits and costs. Accurate determination of patients who might benefit from interventions is challenging: most patients with frequent admissions in 1 year would not continue to have them in the next. Our objective was to employ a validated regression algorithm to case-find Medicaid patients at high-risk for hospitalization in the next 12 months and identify intervention-amenable characteristics to reduce hospitalization risk. We obtained encounter data for 36,457 Medicaid patients with any visit to an urban public hospital from 2001 to 2006 and generated an algorithm-based score for hospitalization risk in the subsequent 12 months for each patient (0 = lowest, 100 = highest). To determine medical and social contributors to the current admission, we conducted in-depth interviews with high-risk hospitalized patients (scores >50) and analyzed associated Medicaid claims data. An algorithm-based risk score >50 was attained in 2,618 (7.2%) patients. The algorithm’s positive predictive value was equal to 0.67. During the study period, 139 high-risk patients were admitted: 60 met inclusion criteria and 50 were interviewed. Fifty-six percent cited the Emergency Department as their usual source of care or had none. Sixty-eight percent had >1 chronic medical conditions, and 42% were admitted for conditions related to substance use. Sixty percent were homeless or precariously housed. Mean Medicaid expenditures for the interviewed patients were $39,188 and $84,040 per patient for the years immediately prior to and following study participation, respectively. Findings including high rates of substance use, homelessness, social isolation, and lack of a medical home will inform the design of interventions to improve community-based care and reduce hospitalizations and associated costs.

2007

Billings, J. & Mijanovich, T. 2007. Improving The Management Of Care For High- Cost Medicaid Patients Health Affairs, Nov/Dec 2007, Vol. 26 Issue 6, p1643-1655, 13p.
Abstract

The article discusses the improvement of care management for high-cost Medicaid patients. It explores on Medicaid budgets which have prompted policymakers to redouble efforts to explore ways of boosting efficiency in care delivery, particularly for people with high-cost and chronic conditions. It also illustrates John Billings and Tod Mijanovich's article which examines the cost-effectiveness of care management for chronic disease patients treated in fee-for-service practice. The authors present an algorithm that identifies patients at high risk of future hospitalizations and offer a business-case analysis about the rate of reduction in future hospitalization and the cost of the intervention.

Billings, J. 2007. Some Reflections On A Few Of The Pitfalls In The World Of Foundation Grant Making Health Affairs, Nov/Dec 2007, Vol. 26 Issue 6, p1772-1775, 4p.
Abstract

This paper offers some reflections on the grant-making process from a former foundation executive. Some of the opportunities, challenges, and pitfalls inherent in the foundation world are described, and one approach to grant making, the "call for proposals," is examined as an example of the need for greater attention to and investment in the science of grant making itself, to maximize the potential return from philanthropy.

Blustein, J., Regenstein, M., Seigel, B. & Billings, J. 2007. Notes from the Field: Jumpstarting the IRB Approval Process in Multicenter Studies Health Services Research, Volume 42, Number 4, August 2007 , pp. 1773-1782(10) Blackwell Publishing.
Abstract

Objective. To identify strategies that facilitate readiness for local Institutional Review Board (IRB) review, in multicenter studies.

Study Setting. Eleven acute care hospitals, as they applied to participate in a foundation-sponsored quality improvement collaborative.

Study Design. Case series.

Data Collection/Extraction. Participant observation, supplemented with review of written and oral communications.

Principal Findings. Applicant hospitals responded positively to efforts to engage them in early planning for the IRB review process. Strategies that were particularly effective were the provisions of application templates, a modular approach to study description, and reliance on conference calls to collectively engage prospective investigators, local IRB members, and the evaluation/national program office teams. Together, these strategies allowed early identification of problems, clarification of intent, and relatively timely completion of the local IRB review process, once hospitals were selected to participate in the learning collaborative.

Conclusions. Engaging potential collaborators in planning for IRB review may help expedite and facilitate review, without compromising the fairness of the grant-making process or the integrity of human subjects protection.

2006

Billings, J., Dixon, J., Wennberg, D. et. al. 2006. Case Findings for Patients at Risk of Re-Hospitalisation Development of an Algorithm to Identify High Risk Patients British Medical Journal. Jun 30
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Abstract

OBJECTIVE: To develop a method of identifying patients at high risk of readmission to hospital in the next 12 months for practical use by primary care trusts and general practices in the NHS in England. DATA SOURCES: Data from hospital episode statistics showing all admissions in NHS trusts in England over five years, 1999-2000 to 2003-4; data from the 2001 census for England Population. All residents in England admitted to hospital in the previous four years with a subset of "reference" conditions for which improved management may help to prevent future admissions. DESIGN: Multivariate statistical analysis of routinely collected data to develop an algorithm to predict patients at highest risk of readmission in the next 12 months. The algorithm was developed by using a 10% sample of hospital episode statistics data for all of England for the period indicated. The coefficients for 21 most powerful (and statistically significant) variables were then applied against a second 10% test sample to validate the findings of the algorithm from the first sample. RESULTS: The key factors predicting subsequent admission included age, sex, ethnicity, number of previous admissions, and clinical condition. The algorithm produces a risk score (from 0 to 100) for each patient admitted with a reference condition. At a risk score threshold of 50, the algorithm identified 54.3% of patients admitted with a reference condition who would have an admission in the next 12 months; 34.7% of patients were "flagged" incorrectly (they would not have a subsequent admission). At risk score threshold levels of 70 and 80, the rate of incorrectly "flagged" patients dropped to 22.6% and 15.7%, but the algorithm found a lower percentage of patients who would be readmitted. The algorithm is made freely available to primary care trusts via a website. CONCLUSIONS: A method of predicting individual patients at highest risk of readmission to hospital in the next 12 months has been developed, which has a reasonable level of sensitivity and specificity. Using various assumptions a "business case" has been modelled to demonstrate to primary care trusts and practices the potential costs and impact of an intervention using the algorithm to reduce hospital admissions.

Kaplan S.A., Calman N.S., Golub M., Ruddock C. & Billings J. 2006. Fostering Organizational Change Through a Community-Based Initiative Health Promotion Practice 2006; 7:1-10.
Abstract

Program funders and managers are increasingly interested in fostering changes in the policies, practices, and procedures of organizations participating in community-based initiatives. But little is know about what factors contribute to the institutionalization of change. In this study, we assess whether the organizational members of the Bronx Health REACH Coalition have begun to change their functioning and role with regard to their clients, their staff, and in the broader community, apart from their implementation of the funded programs for which they are responsible. The study identifies factors that seemed to contribute to or hinder such institutional change, and suggests several strategies for coalitions and funders that are seeking to promote and sustain organizational change.

Kaplan S.A., Calman N.S., Golub M., Davis J.H. & Billings J. 2006. Racial and Ethnic Disparities in Health: A View from the South Bronx Journal of Health Care for the Poor and Underserved 2006; 17:116-127.
Abstract

This study seeks to understand the perspective of Black and Hispanic/Latino residents of the South Bronx, New York, on the causes of persistent racial and ethnic disparities in health outcomes. In particular, it focuses on how people who live in this community perceive and interact with the health care system. Findings from 9 focus groups with 110 participants revealed a deep and pervasive distrust of the health care system and a sense of being disrespected, exacerbated by difficulties that patients experience in communicating with their providers. The paper suggests how health care institutions might respond to these perceptions.

Kaplan S.A., Calman, N.S., Golub M., Davis J.H. & Billings, J. 2006. The Role of Faith-Based Institutions in Providing Health Education and Promoting Equal Access to Care: A Case Study of an Initiative in the Southwest Bronx Journal of Health Care for the Poor and Underserved 2006; 17.2: 9-19.
Abstract

Although many public health initiatives have been implemented through collaborations with faith-based institutions, little is known about best practices for developing such programs. Using a community-based participatory approach, this case study examines the implementation of an initiative in the Bronx, New York, that is designed to educate community members about health promotion and disease management and to mobilize church members to seek equal access to health care services. The study used qualitative methods, including the collaborative development of a logic model for the initiative, focus groups, interviews, analysis of program reports, and participant observation. The paper examines three key aspects of the initiative’s implementation: (1) the engagement of the church leadership; (2) the use of church structures as venues for education and intervention; and (3) changes in church policies. Key findings include the importance of pre-existing relationships within the community and the prominent agenda-setting role played by key pastors, and the strength of the Coalition’s dual focus on health behaviors and health disparities. Given the churches’ demonstrated ability to pull people together, to motivate and to inspire, there is great potential for faith-based interventions, and models developed through such interventions, to address health disparities.
2005

Billings, J., Mijanovich, J., Dixon, J., Curry, N., Wennberg, D., Darin, B. & Steinhort, K. 2005. Case Findings for Patients at Risk of Re-Hospitalization: The PARR1 and PARR Algorithm National Health Service and Kings Fund December

Cantor, J. & Billings, J. 2005. Access to Health Care Services in Health Care Delivery in the United States, Eight Edition, by Kovner A., Jonas, S. (Eds.) New York: Springer Publishing Company,
Abstract

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? Health Care Delivery in the United States, 8 th Edition discusses these and other core issues in the field. Under the editorship of Dr. Kovner and with the addition of Dr. James Knickman, Senior VP of Evaluation, Robert Wood Johnson Foundation, leading thinkers and practitioners in the field examine how medical knowledge creates new healthcare services. Emerging and recurrent issues from wide perspectives of health policy and public health are also discussed. With an easy to understand format and a focus on the major core challenges of the delivery of health care, this is the textbook of choice for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

2004

Billings, J. 2004. High Cost Medicaid Patients United Hospital Fund of New York,
Abstract

High cost patients account for a large share of Medicaid costs (20 percent of patients account for 70 to 80 percent of expenditures). This study analyzes expenditures, patterns of utilization, and diagnostic characteristics of the most costly of these patients.

Billings, J. 2004. The Dissemination of Decision Aids: An Odyssey in a Dysfunctional Health Care Financing System Health Affairs, Web Exclusive, October 7,
Abstract

The usefulness of patient decision aids (PtDAs) is well documented, yet they are not in widespread use. Barriers include assuring balance and fairness (auspices matter), the cost of producing and maintaining them, and getting them into the hands of patients at the right time. The Foundation for Informed Medical Decision Making and its for-profit partner, Health Dialog, have developed a creative business model that helps overcome these barriers and has greatly expanded the reach of decision aids.

Kaplan, S.A., Dillman, K.N., Calman, N.S. & Billings, J. 2004. Opening Doors and Building Capacity: Employing a Community-Based Approach to Surveying Journal of Urban Health. 2004;81:291-300.
Abstract

Although many community-based initiatives employ community residents to undertake door-to-door surveys as a form of community mobilization or for purposes of needs assessment or evaluation, very little has been published on the strengths and weaknesses of this approach. This article discusses our experience in undertaking such a survey in collaboration with a coalition of community-based organizations (CBOs) in the South Bronx, New York. Although resource constraints limited the already-strained capacity of the CBOs to provide supervision, the CBOs and community surveyors helped us gain access to neighborhood buildings and to individuals who might otherwise have been inaccessible. The survey process also contributed to the coalition's community outreach efforts and helped to link the CBO leadership and staff more closely to the coalition and its mission. Many of the surveyors enhanced their knowledge and skills in ways that have since benefited them or the coalition directly. The participating CBOs continue to be deeply engaged in the coalition's work, and many of the surveyors are active as community health advocates and have taken leadership roles within the coalition.

Delia, D., Hall, A. & Billings, J. 2004. What Matters to Low-Income Patients in Ambulatory Care Facilities? Medical Care Research and Review. Sep 2004; 61: 352 - 375.
Abstract

Poor, uninsured, and minority patients depend disproportionately on hospital outpatient departments (OPDs) and freestanding health centers for ambulatory care. These providers confront significant challenges, including limited resources, greater demand for services, and the need to improve quality and patient satisfaction. The authors use a survey of patients in OPDs and health centers in New York City to determine which aspects of the ambulatory care visit have the greatest influence on patients’ overall site evaluation. The personal interaction between patients and physicians, provider continuity, and the general cleanliness/appearance of the facility stand out as high priorities. Access to services and interactions with other facility staff are of significant, although lesser, importance. These findings suggest ways to restructure the delivery of care so that it is more responsive to the concerns of low-income patients.
2003

Billings, J. & Weinick, R. 2003. A Tool Kit for Monitoring the Local Safety Net Agency for Health Care Research and Quality, July

Billings, J. 2003. Using Administrative Data to Monitor Access, Identify Disparities, and Assess Performance of the Safety Net In Billings, J. and Weinick, R. Eds., A Took Kit for Monitoring the Local Safety Net, Agency for Health Care Research and Quality, July

Billings, J. & Weinick, R. 2003. Monitoring the Health Care Safety Net: A Data Book for U.S. Cities, Counties, and States Agency for Health Care Research and Quality, June
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Billings, J. & Weinick, R. 2003. Monitoring the Health Care Safety Net: Understanding Barriers to Care in the U.S. Agency for Health Care Research and Quality, June

Billings, J. 2003. Management Matters: Strengthening the Research Base to Help Improve Performance of Safety Net Providers Health Care Management Review, Volume 28, Number 4, pages 323-334.
Abstract

It is becoming increasingly apparent that some disparities in health outcomes for vulnerable populations relate to performance of providers. Based on analysis of Medicaid claims records, large differences in performance among primary care providers are documented for New York City patients, suggesting the need for better evidence in making management decisions.

Billings, J. & Weinick, R. 2003. Monitoring the Health Care Safety Net: A Data Book for Metropolitan Areas Agency for Healthcare Research and Quality, Pub No. 03-0025, August,
Abstract

One of the challenges in monitoring the Nation's health care safety net is that safety net services are provided in a myriad of different configurations, largely at the local level. Book 1. Data for Metropolitan Areas presents data from 90 metropolitan areas in 30 States and the District of Columbia, including 354 counties and 171 cities. The data describe the health care safety net where 80 percent of Americans with family incomes below the Federal poverty line live.

R. Weinick & Billings, J. 2003. Tools for Monitoring the Health Care Safety Net Agency for Healthcare Research and Quality, December,
Abstract

Tools for Monitoring the Health Care Safety Net offers strategies and concrete tools for assessing local health care safety nets. With topics ranging from estimating the size of local uninsured populations to using administrative data to presenting information to policymakers, it can assist state and local health officials, planners, and analysts in assessing the capacity and viability of their existing safety net providers as well as understand the characteristics and health outcomes for the populations served.

2001

Gordon, J.A., Billings, J., Asplin, B.R. & Rhodes, K.V. 2001. Safety Net Research in Emergency Medicine: The Unraveling Safety Net Academic Emergency Medicine, November 2001, 8(11): 1024-1029.
Abstract

A primary goal of the Academic Emergency Medicine Consensus Conference, "The Unraveling Safety Net: Research Opportunities and Priorities," was to explore a formal research agenda for safety net research in emergency medicine. This paper represents the thoughts of active health services researchers regarding the structure and direction of such work, including some examples from their own research. The current system for safety net care is described, and the emergency department is conceptualized as a window on safety net patients and systems, uniquely positioned to help study and coordinate integrated processes of care.

Billings, J. & Cantor, J. 2001. Access to Health Care Services in Health Care Delivery in the United States, Seventh Edition Kovner A., Jonas, S. Eds. New York: Springer Publishing Company,
Abstract

How do we understand and also assess the health care of America? Where is health care provided? What are the characteristics of those institutions which provide it? Over the short term, how are changes in health care provisions affecting the health of the population, the cost of care, and access to care? Health Care Delivery in the United States, 8 th Edition discusses these and other core issues in the field. Under the editorship of Dr. Kovner and with the addition of Dr. James Knickman, Senior VP of Evaluation, Robert Wood Johnson Foundation, leading thinkers and practitioners in the field examine how medical knowledge creates new healthcare services. Emerging and recurrent issues from wide perspectives of health policy and public health are also discussed. With an easy to understand format and a focus on the major core challenges of the delivery of health care, this is the textbook of choice for course work in health care, the handbook for administrators and policy makers, and the standard for in-service training programs.

2000

Billings, J., Mijanovich, T. & Cantor, J. 2000. Analysis of Selection Effects in New York City's Medicaid Managed Care Population Journal of Urban Health. (December 2000): 625-644. Dec
Abstract

It is becoming increasingly apparent that over the next several years the majority of Medicaid patients in many states will become enrolled in managed care plans, some voluntarily, but most as the result of mandatory initiatives. An important issue related to this development is the extent to which this movement to managed care is accompanied by serious selection effects, either across the board during the phase in or among individual plans or plan types with full-scale implementation. This paper examines selection effects in New York City between 1993 and 1997 during the voluntary enrollment period prior to implementation of mandatory enrollment pursuant to a Section 1115 waiver. No substantial selection bias was documented between patients entering managed care and those remaining in the fee-for-service system among the largest rate groups, although some selection effect was found among plans and plan types (with investor-owned plans enrolling patients with lower prior utilization and expenses).

Billings, J., Parikh, N. & Mijanovich, T. 2000. Emergency Department Use in New York City: A Substitute for Primary Care? Commonwealth Fund Issue Brief.(November).
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Abstract

For the uninsured and many low-income people, hospital emergency departments (EDs) are a crucial entryway to the health care system. New York City's uninsured-27 percent of the nonelderly population in 1998, up from 20 percent in 1990-rely heavily on the ED for their medical care. Residents who regularly get their health care at an ED do not have regular doctors or continuity in their care, use costlier services, and often receive treatment that could have been avoided. Low-income New Yorkers may be depending on emergency department care even more as Medicaid enrollment declines and physician reimbursement rates are cut. This Issue Brief describes patterns of ED use throughout
New York City and discusses some of the ways to improve the availability of primary care services and reduce ED dependency.

Billings, J., Parikh, N. & Mijanovich, T. 2000. Emergency Department Use in New York City: A Survey of Bronx Patients Commonwealth Fund Issue Brief.(November).
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Abstract

In the absence of universal coverage and an effective primary care delivery system for vulnerable populations, hospital emergency departments (EDs) are the ultimate safety net for many patients. This is especially true in New York City, where nearly 75 percent of ED visits in 1998 were for nonemergent care, or for emergent care that could have been treated in a doctor's office.1 Another 7 percent of visits required care in the ED, but were for potentially preventable conditions such as acute flare-ups of asthma or diabetes. New Yorkers who rely on EDs lack continuity in their health care and end up using costlier services. Why do so many patients depend on hospital emergency departments for primary care? Do they seek emergency care immediately, or do they have time and opportunity to obtain care at a doctor's office or neighborhood clinic? Do these patients have a usual source of care other than the ED? Do they have any contact with the health care system prior to their ED visit? Does insurance status, race, ethnicity, national origin, or gender have an influence on ED use?

To answer these questions, the Center for Health and Public Service Research at New York University conducted face-to-face interviews with 669 emergency department patients ages 18 to 55 at four hospitals in the Bronx.

 

Billings, J., Parikh, N. & Mijanovich, T. 2000. Emergency Department Use: The New York Story Commonwealth Fund Issue Brief. (November).
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Abstract

The inability of the nation's health care delivery system to assure access to basic primary care services for large segments of the population has meant that hospital emergency departments (EDs) are the providers of first and last resort for millions of Americans. Individuals who cannot afford the cost of an office visit, or who are unwilling to wait for care in overcrowded and understaffed community clinics or hospital outpatient departments, rely on EDs for primary care. But reliance on the ED means patients lack continuity in their health care and use costlier services. Moreover, economic constraints cause many of the uninsured to delay seeking treatment until their medical condition has seriously worsened. Had they received treatment earlier in an ambulatory care setting, the trip to the ED might have been avoided.

Kovner, A.R., Elton, J.J. & Billings, J. 2000. Transforming Health Management: An Evidence Based Approach Frontiers of Health Services Management, 16:4, Summer 2000, pp 3-24.
Abstract

Explores the concept of evidence-based management, demonstrates how it can enhance health management practice, and introduces an organizational structure for promoting the evidence-based approach. Challenge of making better-informed strategic decisions; Management research in healthcare; Approaches related to evidence-based management; Evidence-based management decision making; Case vignettes.

1999

Billings, J. 1999. Access to Health Care Services Health Care Delivery in the United States, Sixth Edition New York: Springer Publishing Company,.
Abstract

Thoroughly presents today's health care system, its administration and its dissemination.

1998

Cantor, J.C., Weiss, E.W., Haslanger, K., Madeala, J., Heisler, T., Kaplan, S.A. & Billings, J. 1998. Ambulatory Care Providers and the Transition to Medicaid Managed Care in New York City Remaking Medicaid: Managed Care for the Public Good. Eds. S. Somers and S. Davidson. San Francisco: Josey-Bass, , pp. 339-356.
Abstract

This book is a collection of 18 essays by health services researchers that analyze Medicaid managed care, its historical context, its implementation in several states, its applicability to disabled and other special needs populations, and its potential for monitoring quality and provider performance.

Billings, J., Greene, J. & Mijanovich, T. 1998. Analysis of primary care practitioner capacity for Medicaid managed care in New York City. New York City Department of Health, March .

1996

Billings, J. 1996. Findings for Ambulatory Care Sensitive Conditions in Michigan, 1983-1994 HRP Reports, October.

Billings, J., Kretz, S.E., Rose, R., Rosenbaum, S., Sullivan, M., Fowles, J. & Weiss, K.B. 1996. National Asthma Education and Prevention Program Working Group Report on the Financing of Asthma Care Am J Respirt Crit Care Med ; 154: s119-130.

Billings, J., Kaplan, S & Mijanovich, T. 1996. Projecting Hospital Utilization and Bed Need in New York City for the Year 2000 HRP Reports, April .

Billings, J., Anderson, G. & Newman, L. 1996. Recent Findings on Preventable Hospitalizations Health Affairs (Fall): 239-249.
Abstract

Reports on the rates of preventable hospital admissions among low-income populations in the United States even with the efforts of improving primary health care. Comparison of low-income populations health outcomes between U.S. and Canada; Implications of results for U.S. policy makers.

1995

Billings, J. & T. Mijanovich. 1995. Findings on the Costs of Alcohol and Substance Abuse in New York City Center for Addiction and Substance Abuse.

Bindman, A., Grumbach, K., Osmond, D., Komaromy, M., Vranizan, K., Lurie, N. & Billings J. 1995. Preventable Hospitalizations and Access to Health Care Journal of American Medical Association 274, no. 4 : 305-311.
Abstract

The objective is to examine whether the higher hospital admission rates for chronic medical conditions such as asthma, hypertension, congestive heart failure, chronic obstructive pulmonary disease, and diabetes in low-income communities resulted from community differences in access to care, prevalence of the diseases, propensity to seek care, or physician admitting style.

In the Press

12/06/2013
Study Challenges Myths About Frequent ER Users
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