Health Policy

A Philanthropy Tackles Growth In Health Costs At The State Level

A Philanthropy Tackles Growth In Health Costs At The State Level
Health Affairs, 29, no. 7 (2010): 1411-1414 

Sandman, D., & Kovner, A.
07/01/2010

Slowing the rate of growth of health spending is as critical a goal at the state level as it is at the national level. Philanthropy can hardly address this issue alone, yet it has an obligation to take on big and seemingly intractable problems. The New York State Health Foundation is committed to stimulating innovative and replicable approaches to bending the cost curve.

This article describes how the foundation recently awarded six grants to support efforts related to payment reform, hospital re-admissions, medical malpractice reform, palliative care, and the quantification of other cost containment approaches that could be pursued atthe state level.

Hospital Performance, the Local Economy, and the Local Workforce: Findings from a US National Longitudinal Study

Hospital Performance, the Local Economy, and the Local Workforce: Findings from a US National Longitudinal Study
PLoS Med 7(6): e1000297. doi:10.1371/journal.pmed.1000297

Blustein, J., Borden, W.B., Valentine, M.
06/29/2010

Abstract

Background: Pay-for-performance is an increasingly popular approach to improving health care quality, and the US government will soon implement pay-for-performance in hospitals nationwide. Yet hospital capacity to perform (and

improve performance) likely depends on local resources. In this study, we quantify the association between hospital performance and local economic and human resources, and describe possible implications of pay-for-performance for socioeconomic equity.

Methods and Findings: We applied county-level measures of local economic and workforce resources to a national sample of US hospitals (n = 2,705), during the period 2004–2007. We analyzed performance for two common cardiac conditions (acute myocardial infarction [AMI] and heart failure [HF]), using process-of-care measures from the Hospital Quality Alliance [HQA], and isolated temporal trends and the contributions of individual resource dimensions on performance, using multivariable mixed models. Performance scores were translated into net scores for hospitals using the Performance Assessment Model, which has been suggested as a basis for reimbursement under Medicare’s ‘‘Value-Based Purchasing’’ program. Our analyses showed that hospital performance is substantially associated with local economic and workforce resources. For example, for HF in 2004, hospitals located in counties with longstanding poverty had mean HQA composite scores of 73.0, compared with a mean of 84.1 for hospitals in counties without longstanding poverty (p,0.001). Hospitals located in counties in the lowest quartile with respect to college graduates in the workforce had mean HQA composite scores of 76.7, compared with a mean of 86.2 for hospitals in the highest quartile (p,0.001). Performance on AMI measures showed similar patterns. Performance improved generally over the study period. Nevertheless, by 2007—4 years after public reporting began—hospitals in locationally disadvantaged areas still lagged behind their locationally advantaged counterparts. This lag translated into substantially lower net scores under the Performance Assessment Model for hospital reimbursement.

Conclusions: Hospital performance on clinical process measures is associated with the quantity and quality of local economic and human resources. Medicare’s hospital pay-for-performance program may exacerbate inequalities across regions, if implemented as currently proposed. Policymakers in the US and beyond may need to take into consideration the balance between greater efficiency through pay-for-performance and socioeconomic equity.

Please see later in the article for the Editors’ Summary.

Health Care in World Cities: New York, London and Paris

Health Care in World Cities: New York, London and Paris
Johns Hopkins University Press, April

Gusmano, M.K., Rodwin, V.G. & Weisz, D.
04/01/2010

New York. London. Paris. Although these cities have similar sociodemographic characteristics, including income inequalities and ethic diversity, they have vastly different health systems and services. This book compares the three and considers lessons that can be applied to current and future debates about urban health care.

Highlighting the importance of a national policy for city health systems, the authors use well-established indicators and comparable data sources to shed light on urban health policy and practice. Their detailed comparison of the three city health systems and the national policy regimes in which they function provides information about access to health care in the developed world's largest cities.

The authors first review the current literature on comparative analysis of health systems and offer a brief overview of the public health infrastructure in each city. Later chapters illustrate how timely and appropriate disease prevention, primary care, and specialty health care services can help cities control such problems as premature mortality and heart disease.

In providing empirical comparisons of access to care in these three health systems, the authors refute inaccurate claims about health care outside of the United States.

Click here for a brief excerpt of the content.

A qualitative analysis of environmental policy and children's health in Mexico

A qualitative analysis of environmental policy and children's health in Mexico
Environ Health. 2010 Mar 23;9:14

Cifuentes E, Trasande L, Ramirez M, Landrigan PJ.
03/01/2010

BACKGROUND:

Since Mexico's joining the North American Free Trade Agreement (NAFTA) and the Organization for Economic Cooperation and Development (OECD) in 1994, it has witnessed rapid industrialization. A byproduct of this industrialization is increasing population exposure to environmental pollutants, of which some have been associated with childhood disease. We therefore identified and assessed the adequacy of existing international and Mexican governance instruments and policy tools to protect children from environmental hazards.

METHODS:

We first systematically reviewed PubMed, the Mexican legal code and the websites of the United Nations, World Health Organization, NAFTA and OECD as of July 2007 to identify the relevant governance instruments, and analyzed the approach these instruments took to preventing childhood diseases of environmental origin. Secondly, we interviewed a purposive sample of high-level government officials, researchers and non-governmental organization representatives, to identify their opinions and attitudes towards children's environmental health and potential barriers to child-specific protective legislation and implementation.

RESULTS:

We identified only one policy tool describing specific measures to reduce developmental neurotoxicity and other children's health effects from lead. Other governance instruments mention children's unique vulnerability to ozone, particulate matter and carbon monoxide, but do not provide further details. Most interviewees were aware of Mexican environmental policy tools addressing children's health needs, but agreed that, with few exceptions, environmental policies do not address the specific health needs of children and pregnant women. Interviewees also cited state centralization of power, communication barriers and political resistance as reasons for the absence of a strong regulatory platform.

CONCLUSIONS:

The Mexican government has not sufficiently accounted for children's unique vulnerability to environmental contaminants. If regulation and legislation are not updated and implemented to protect children, increases in preventable exposures to toxic chemicals in the environment may ensue.

How much should we invest in preventing childhood obesity?

How much should we invest in preventing childhood obesity?
Health Aff (Millwood). 2010 Mar-Apr;29(3):372-8.

Trasande L
03/01/2010

Policy makers generally agree that childhood obesity is a national problem. However, it is not always clear whether enough is being spent to combat it. This paper presents nine scenarios that assume three different degrees of reduction in obesity/overweight rates among children in three age groups. A mathematical model was then used to project lifetime health and economic gains. Spending $2 billion a year would be cost-effective if it reduced obesity among twelve-year-olds by one percentage point. The analysis also found that childhood obesity has more profound economic consequences than previously documented. Large investments to reduce this major contributor to adult disability may thus be cost-effective by widely accepted criteria.

Medicare Payments, Health Care Services Use, and Telemedicine Implementation Cost in Randomized Trial Comparing Telemedicine Case Management With Usual Care in Medically Underserved Patients With Diabetes Mellitus

Medicare Payments, Health Care Services Use, and Telemedicine Implementation Cost in Randomized Trial Comparing Telemedicine Case Management With Usual Care in Medically Underserved Patients With Diabetes Mellitus
Journal of the American Medical Informatics Association

Palmas, W., Shea, S., Starren, J., Teresi, J.E., Ganz, M.L., Burton, T.M., Pashos, C.L., Blustein, J., Field, L., Morin, P.C., Izquierdo, R.E., Silver, S., Eimicke, J.P., Langiua, R.A. & Weinstock, S.
03/01/2010

Objective
To determine whether a diabetes case management telemedicine intervention reduced healthcare expenditures, as measured by Medicare claims, and to assess the costs of developing and implementing the telemedicine intervention.
Design
We studied 1665 participants in the Informatics for Diabetes Education and Telemedicine (IDEATel), a randomized controlled trial comparing telemedicine case management of diabetes to usual care. Participants were aged 55 years or older, and resided in federally designated medically underserved areas of New York State.
Measurements
We analyzed Medicare claims payments for each participant for up to 60 study months from date of randomization, until their death, or until December 31, 2006 (whichever happened first). We also analyzed study expenditures for the telemedicine intervention over six budget years (February 28, 2000- February 27, 2006).
Results
Mean annual Medicare payments (SE) were similar in the usual care and telemedicine groups, $9040 ($386) and $9669 ($443) per participant, respectively (p>0.05). Sensitivity analyses, including stratification by censored status, adjustment by enrollment site, and semi-parametric weighting by probability of dropping-out, rendered similar results. Over six budget years 28 821 participant/months of telemedicine intervention were delivered, at an estimated cost of $622 per participant/month.
Conclusion
Telemedicine case management was not associated with a reduction in Medicare claims in this medically underserved population. The cost of implementing the telemedicine intervention was high, largely representing special purpose hardware and software costs required at the time. Lower implementation costs will need to be achieved using lower cost technology in order for telemedicine case management to be more widely used.

Review: The Net Benefits of Depression Management in Primary Care

Review: The Net Benefits of Depression Management in Primary Care
Medical Care Research and Review, 2010. Volume 67 / Issue 03 / January 2010, pp 251-274, Published online

Sherry Glied, Karin Herzog and Richard Frank
01/21/2010

Depression is often diagnosed and treated in primary care settings. Organizational and systems interventions that restructure primary care practices and train staff have been shown to be cost-effective strategies for treating depression. Funders are increasingly calling for a cost–benefit assessment of such programs. In this study, the authors review existing cost-effectiveness studies of primary care depression treatments, classify them into categories, translate the results into net benefit terms, and assess whether more costly programs generate greater net benefit. The authors find that interventions that provide training to primary care teams in how to manage depression most consistently produce net benefits, with more costly interventions of this type generating larger net benefits than less costly interventions. Collaborative care interventions, which add specialized staff to primary care practices, and therapy interventions, in which clinicians are trained to provide therapy, also generate net social benefits at conventional valuations of quality-adjusted life years.

Substance Use Treatment Barriers for Patients with Frequent Hospital Admissions

Substance Use Treatment Barriers for Patients with Frequent Hospital Admissions
Journal of Substance Abuse Treatment

Billings, J., Raven, M., Carrier, E. et al.
01/01/2010

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.

Transportation to Clinic: Findings from a Pilot Clinic-Based Survey of Low-Income Suburbanites

Transportation to Clinic: Findings from a Pilot Clinic-Based Survey of Low-Income Suburbanites
Journal of Immigrant and Minority Health 2010.  DOI: 10.1007/s10903-010-9410-0

Silver D, J Blustein, BC Weitzman.
01/01/2010

Health care policymakers have cited transportation barriers as key obstacles to providing health care to low-income suburbanites, particularly because suburbs have become home to a growing number of recent immigrants who are less likely to own cars than their neighbors. In a suburb of New York City, we conducted a pilot survey of low income, largely immigrant clients in four public clinics, to find out how much transportation difficulties limit their access to primary care. Clients were receptive to the opportunity to participate in the survey (response rate = 94%). Nearly one-quarter reported having transportation problems that had caused them to miss or reschedule a clinic appointment in the past. Difficulties included limited and unreliable local bus service, and a tenuous connection to a car. Our pilot work suggests that this population is willing to participate in a survey on this topic. Further, since even among those attending clinic there was significant evidence of past transportation problems, it suggests that a population based survey would yield information about substantial transportation barriers to health care.

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