Health Policy

Valuing Improvement in Value Based Purchasing

Valuing Improvement in Value Based Purchasing
Circulation:  Cardiovascular Quality and Outcomes.  5:163-170  

Borden, William and Jan Blustein.
03/01/2012

Background

Medicare will soon implement hospital value-based purchasing (VBP), using a scoring system that rewards both achievement (absolute performance) and improvement (performance increase over time).  However, improvement is defined so as to give less credit to initial low performers than initial high performers.  Since initial low performers are disproportionately hospitals in socioeconomically disadvantaged areas, these institutions stand to lose under Medicare’s VBP proposal. 

 

Methods

We developed an alternative improvement scale, and applied it to hospital performance throughout the US.   Using 2005-2008 Medicare process measures for acute myocardial infarction (AMI) and heart failure (HF), we calculated hospital scores using Medicare’s proposal and our alternative.  Hospital performance scores were compared across 5 locational dimensions of socioeconomic disadvantage: poverty, unemployment, physician shortage, high school and college graduation rates.

 

Results

Medicare’s proposed scoring system yielded higher overall scores for the most locationally advantaged hospitals for 4 out of 5 dimensions in AMI and 2 out of 5 for HF.  Using our alternative, differences in overall scores between hospitals in the most and least advantaged areas were attenuated, with locationally advantaged hospitals having higher overall scores for 3 out of 5 dimensions in AMI and 1 out of 5 dimensions for HF. 

 

Conclusions

Using an alternative VBP formula that reflects the principle of “equal credit for equal improvement,” resulted in a more equitable distribution of overall payment scores, which could allow hospitals in both socioeconomically advantaged and disadvantaged areas to succeed under VBP.

 

 

The economic burden placed on healthcare systems by childhood obesity

The economic burden placed on healthcare systems by childhood obesity
Expert Rev Pharmacoecon Outcomes Res. 2012 Feb;12(1):39-45.

Trasande L and Brian Elbel.
02/01/2012

The obesity epidemic has transformed children's healthcare, such that diabetes, hypertension and the metabolic syndrome are phrases more commonly used by child health providers than ever before. This article reviews the economic consequences of this epidemic for healthcare delivery systems, both in the short term when obesity has been associated with increased utilization, and in the long term where increased likelihood of adult obesity and cardiovascular disease is well documented. Large investments through research and prevention are needed and are likely to provide strong returns in cost savings, and would optimally emerge through a cooperative effort between private and government payers alike. 

From Research to Health Policy Impact

From Research to Health Policy Impact
Health Services Research, 2012. Volume 47 / Issue 01 / February 2012, pp 337-343, Published online

Carolyn M. Clancy, Sherry A. Glied and Nicole Lurie
01/12/2012

The opportunities for researchers to improve health and health care by contributing to the formulation and implementation of policy are almost unlimited. Indeed, the availability of these opportunities is a tribute to a generation of health services researchers questioning existing policies or studying essential "Why?" and “What if?” questions using rigorous analysis. Moreover, the steady albeit uneven transition of health care delivery from a paper-based cottage industry toward an enterprise that provides transparent information to clinicians, patients, policy makers and the public, and potentially vast amounts of data to policy researchers, combined with the expectations of an increasingly information-savvy public, have increased the focus on health care quality, access, and costs.

Our health care system, like those in other countries, confronts continued pressures from increasing costs; inconsistent quality; avoidable patient harms; pervasive disparities in health and health care associated with individual characteristics such as race, ethnicity, income, education and geography; and poor population health outcomes. The persistence of many of these challenges reflects, in part, a failure of science alone to improve heath. Strategies to address many of these challenges exist in the laboratory, but the contribution of this science to the health of the public is limited by a research enterprise that values discovery of new knowledge far more than its successful application.

An Intervention to Improve Care and Reduce Costs for High Risk Patients with Frequent Health Services Use

An Intervention to Improve Care and Reduce Costs for High Risk Patients with Frequent Health Services Use
BMC Health Serv Res. 2011; 11: 270.

Maria C Raven, Kelly M Doran, Shannon Kostrowski, Colleen C Gillespie and Brian D Elbel
10/13/2011

Background

A small percentage of high-risk patients accounts for a large proportion of Medicaid spending in the United States, which has become an urgent policy issue. Our objective was to pilot a novel patient-centered intervention for high-risk patients with frequent hospital admissions to determine its potential to improve care and reduce costs.

Methods

Community and hospital-based care management and coordination intervention with pre-post analysis of health care utilization. We enrolled Medicaid fee-for-service patients aged 18-64 who were admitted to an urban public hospital and identified as being at high risk for hospital readmission by a validated predictive algorithm. Enrolled patients were evaluated using qualitative and quantitative interview techniques to identify needs such as transportation to/advocacy during medical appointments, mental health/substance use treatment, and home visits. A community housing partner initiated housing applications in-hospital for homeless patients. Care managers facilitated appropriate discharge plans then worked closely with patients in the community using a harm reduction approach.

Results

Nineteen patients were enrolled; all were male, 18/19 were substance users, and 17/19 were homeless. Patients had a total of 64 inpatient admissions in the 12 months before the intervention, versus 40 in the following 12 months, a 37.5% reduction. Most patients (73.3%) had fewer inpatient admissions in the year after the intervention compared to the prior year. Overall ED visits also decreased after study enrollment, while outpatient clinic visits increased. Yearly study hospital Medicaid reimbursements fell an average of $16,383 per patient.

Conclusions

A pilot intervention for high-cost patients shows promising results for health services usage. We are currently expanding our model to serve more patients at additional hospitals to see if the pilot's success can be replicated.

Reducing Racial and Ethnic Disparities: The Action Plan from the Department of Health and Human Services

Reducing Racial and Ethnic Disparities: The Action Plan from the Department of Health and Human Services
Health Affairs, 2011. Volume 30 / Issue 10 / October 2011, pp 1822-1829, Published online

Howard K. Koh, Garth Graham and Sherry Glied
10/12/2011

The Department of Health and Human Services (HHS) recently unveiled the most comprehensive federal commitment yet to reducing racial and ethnic health disparities. The 2011 HHS Action Plan to Reduce Racial and Ethnic Health Disparities not only responds to advice previously offered by stakeholders around the nation, but it also capitalizes on new and unprecedented opportunities in the Affordable Care Act of 2010 to benefit diverse communities. The Action Plan advances five major goals: transforming health care; strengthening the infrastructure and workforce of the nation’s health and human services; advancing Americans’ health and well-being; promoting scientific knowledge and innovation; and upholding the accountability of HHS for making demonstrable progress. By mobilizing HHS around these goals, the Action Plan moves the country closer to realizing the vision of a nation free of disparities in health and health care.

Advancing Research Data Infrastructure for Patient-Centered Outcomes Research

Advancing Research Data Infrastructure for Patient-Centered Outcomes Research
JAMA: The Journal of the American Medical Association, 2011. Volume 306 / Issue 11 / September 2011, pp 1254-1255, Published online

Amol Navathe, Carolyn Clancy and Sherry Glied
09/21/2011

Patient-centered outcomes research, which aims to assist clinicians and patients in making informed decisions regarding prevention, diagnosis, and treatment, is essential for improving the delivery of quality health care. Much of patient-centered outcomes research relies on observational and quasi-experimental methods applied to data generated as a byproduct of providing care. While existing data sources have improved, there remain important data-related barriers to rapid, efficient research. Recent changes in the policy environment, coupled with significant technological progress, provide an opportunity to surmount some of these obstacles.

Higher Fees Paid to US Physicians Drive Higher Spending for Physician Services Compared to Other Countries

Higher Fees Paid to US Physicians Drive Higher Spending for Physician Services Compared to Other Countries
Health Affairs, 2011. Volume 30 / Issue 09 / September 2011, pp 1647-1656, Published online

Sherry Glied and Miriam Laugesen
09/08/2011

Higher health care prices in the United States are a key reason that the nation’s health spending is so much higher than that of other countries. Our study compared physicians’ fees paid by public and private payers for primary care office visits and hip replacements in Australia, Canada, France, Germany, the United Kingdom, and the United States. We also compared physicians’ incomes net of practice expenses, differences in financing the cost of medical education, and the relative contribution of payments per physician and of physician supply in the countries’ national spending on physician services. Public and private payers paid somewhat higher fees to US primary care physicians for office visits (27 percent more for public, 70 percent more for private) and much higher fees to orthopedic physicians for hip replacements (70 percent more for public, 120 percent more for private) than public and private payers paid these physicians’ counterparts in other countries. US primary care and orthopedic physicians also earned higher incomes ($186,582 and $442,450, respectively) than their foreign counterparts. We conclude that the higher fees, rather than factors such as higher practice costs, volume of services, or tuition expenses, were the main drivers of higher US spending, particularly in orthopedics.

Geographic Variations in Health Care Workforce Training in the US: The Case of Registered Nurses (RNs)

Geographic Variations in Health Care Workforce Training in the US: The Case of Registered Nurses (RNs)
Med Care. 2011 Aug;49(8):769-74.

Blustein, Jan.
08/01/2011

Background: In the United States, registered nurses [RNs] are trained through one of three educational pathways: a diploma course; an associate's degree, or a baccalaureate degree in nursing (the BSN). A national consensus has emerged that the proportion of RNs that are baccalaureate-trained should be substantially increased. Yet achieving that goal may be difficult in areas where college graduates are unlikely to reside.


Objectives: To determine whether the level of training of the hospital registered nurse [RN] workforce varies geographically, along with the education of the local general workforce.


Research design: Cross sectional, ecological study.


Subjects: Hospital nurses who participated in the National Sample Survey of Registered Nurses [NSSRN] in 2004 (n = 16,567).


Measures. Registered Nurse training was measured as Diploma, Associates degree, or Baccalaureate degree or above. County-level general workforce quality was assessed as the adult college graduation rate. Counties were divided into US population quartiles, with the highest quartile (Q4) having more than 29.3% college graduates, and the lowest quartile (Q1) having fewer than 16.93% college graduates.


Results: Hospital RNs have a higher level of training in counties where the general population is better
educated. For example, in Q4, 55.2% of hospital RNs are baccalaureate-trained, in Q3, 50.2%; in Q2,45.2%; and in Q1, 34.9% (p < .001 for all pairwise comparisons). The association between RN training and general workforce education is found in cities, towns and rural areas.

Conclusions: Nationwide, there are substantial geographic variations in the training of hospital RNs. Educational segregation (the tendency for educated people to cluster geographically) may make it more difficult to achieve a BSN-rich nursing workforce in some areas of the US. Further work is needed to assess whether educational segregation similarly influences the distribution of other health care professionals, and whether it leads to variations in the local quality of care.

Resetting our priorities in environmental health: An example from the south-north partnership in Lake Chapala, Mexico

Resetting our priorities in environmental health: An example from the south-north partnership in Lake Chapala, Mexico
Environ Res. 2011 Aug;111(6):877-80.

Cifuentes E, Lozano Kasten F, Trasande L, Goldman RH.
08/01/2011

Lake Chapala is a major source of water for crop irrigation and subsistence fishing for a population of 300,000 people in central Mexico. Economic activities have created increasing pollution and pressure on the whole watershed resources. Previous reports of mercury concentrations detected in fish caught in Lake Chapala have raised concerns about health risks to local families who rely on fish for both their livelihood and traditional diet. Our own data has indicated that 27% of women of childbearing age have elevated hair mercury levels, and multivariable analysis indicated that frequent consumption of carp (i.e., once a week or more) was associated with significantly higher hair mercury concentrations. In this paper we describe a range of environmental health research projects. Our main priorities are to build the necessary capacities to identify sources of water pollution, enhance early detection of environmental hazardous exposures, and deliver feasible health protection measures targeting children and pregnant women. Our projects are led by the Children's Environmental Health Specialty Unit nested in the University of Guadalajara, in collaboration with the Department of Environmental Health of Harvard School of Public Health and Department of Pediatrics of the New York School of Medicine. Our partnership focuses on translation of knowledge, building capacity, advocacy and accountability. Communication will be enhanced among women's advocacy coalitions and the Ministries of Environment and Health. We see this initiative as an important pilot program with potential to be strengthened and replicated regionally and internationally.

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