Health Policy

Medicare’s Flagship Test Of Pay-For-Performance Did Not Spur More Rapid Quality Improvement Among Low-Performing Hospitals

Medicare’s Flagship Test Of Pay-For-Performance Did Not Spur More Rapid Quality Improvement Among Low-Performing Hospitals
Health Affairs; 31(4):797-805.

Ryan, Andrew M., Jan Blustein, Lawrence P. Casalino.
04/01/2012

Medicare’s flagship hospital pay-for-performance program, the Premier Hospital Quality Incentive Demonstration, began in 2003 but changed its incentive design in late 2006. The goals were to encourage greater quality improvement, particularly among lower-performing hospitals. However, we found no evidence that the change achieved these goals. Although the program changes were intended to provide strong incentives for improvement to the lowest-performing hospitals, we found that in practice the new incentive design resulted in the strongest incentives for hospitals that had already achieved quality performance ratings just above the median for the entire group of participating hospitals. Yet during the course of the program, these hospitals improved no more than others. Our findings raise questions about whether pay-for-performance strategies that reward improvement can generate greater improvement among lower performing providers. They also cast some doubt on the extent to which hospitals respond to the specific structure of economic incentives in pay-for-performance programs.

Efficiency Considerations of Donor Fatigue, Universal Access to ARTs and Health Systems

Efficiency Considerations of Donor Fatigue, Universal Access to ARTs and Health Systems
Sex Transm Infect 2012;88:75-78

Grépin, Karen
03/01/2012

Objectives: To investigate trends in official development assistance for health, HIV and non-HIV activities over time and to discuss the efficiency implications of these trends in the context of achieving universal access to treatment and health systems.

Methods: Official development assistance for health, HIV programmes and non-HIV programmes were tracked using data from 2000 to 2009. A review of the literature on efficiency, treatment and health systems was conducted. Findings The rate of growth of donor funding to HIV programmes has slowed in recent years at levels below those required to sustain programmes and to move towards universal access to treatment. These trends are likely due to increased pressure on foreign aid budgets and donor fatigue for HIV programmes.

Conclusions: There is great need to consider how the limited resources available can be used most efficiently to increase the number of lives saved and to ensure that these resources also benefit health systems. Improving efficiency is much more than just improving the productive efficiency and also about ensuring that resources are going to where they will be the most beneficial and making investments that are the most efficient over time. These choices may be essential to achieving the goal of universal access to treatment as well as the sustainability of these programmes. 

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 Relationship Between Clinical Benefit and Receipt of Curative Therapy for Prostate Cancer

The Relationship Between Clinical Benefit and Receipt of Curative Therapy for Prostate Cancer
Archives of Internal Medicine, Vol. 172, no. 4, pp. 362-363. DOI: 10.1001/archinternmed.2011.1494

Raldow, A.C., C.J. Presley, J.B. Yu, R. Sharma, L.D. Cramer, P.R. Soulos, J.B. Long, D.V. Makarov, and C.P. Gross
02/27/2012

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.

Access to, use of and satisfaction with health services among adults enrolled in Brazil’s Family Health Strategy: evidence from the 2008 National Household Survey

Access to, use of and satisfaction with health services among adults enrolled in Brazil’s Family Health Strategy: evidence from the 2008 National Household Survey
Tropical Medicine & International Health, Vol. 17, no. 1, pp. 36-42. 10.1111/j.1365-3156.2011.02866.x

Macinko, J., and M.F. Lima Costa
01/01/2012

Objective  To assess the effects of participation in Brazil’s primary healthcare programme (the Family Health Strategy or FHS) on access, use and satisfaction with health services among adults.

Methods  Data are from the 2008 National Household Survey (PNAD) on 264 754 adults. This cross-sectional analysis compares FHS enrollees to both non-enrollees and those with private health plans. We calculated predicted probabilities of each outcome stratified by household wealth quintile, rural/urban location and sex using robust Poisson regression. We performed propensity score analysis to assess the differences in access among FHS enrollees and the rest of the population, once relevant socio-demographic characteristics and other determinants of access were balanced.

Results  Compared to families with neither FHS enrolment nor private health plans, adult FHS enrollees were generally more likely to have a usual source of care, to have visited a doctor or dentist in the past 12 months, to have access to needed medications and to be satisfied with the care they received. The FHS effect was largest among urban dwellers and the poorest.

Conclusions  The FHS appears to be associated with enhanced access to and utilization of health services in Brazil. However, it has not yet been able to match levels of access experienced by those with private health plans, perhaps because the population served by the FHS is among the poorest, most rural and least healthy in the country.

The Population Level Prevalence and Correlates of Appropriate and Inappropriate Imaging to Stage Incident Prostate Cancer in the Medicare Population

The Population Level Prevalence and Correlates of Appropriate and Inappropriate Imaging to Stage Incident Prostate Cancer in the Medicare Population
Journal of Urology, Vol. 187, no. 1, pp. 97-102. DOI: 10.1016/j.juro.2011.09.042

Makarov, D.V., R.A. Desai, J.B. Yu, R. Sharma, N. Abraham, P.C. Albertsen, D.F. Penson, and C.P. Gross
01/01/2012

Purpose: According to guidelines most men with incident prostate cancer do not require staging imaging. We determined the population level prevalence and correlates of appropriate and inappropriate imaging in this cohort.

Materials and Methods: We performed a cross-sectional study of men 66 to 85 years old who were diagnosed with prostate cancer in 2004 and 2005 from the SEER (Surveillance, Epidemiology and End Results)-Medicare database. Low risk (no prostate specific antigen greater than 10 ng/ml, Gleason score greater than 7 or clinical stage greater than T2) and high risk (1 or more of those features) groups were formed. Inappropriate imaging was defined as any imaging for men at low risk and appropriate imaging was defined as bone scan for men at high risk as well as pelvic imaging as appropriate. Logistic regression modeled imaging in each group.

Results: Of 18,491 men at low risk 45% received inappropriate imaging while only 66% of 10,562 at high risk received appropriate imaging. For patients at low risk inappropriate imaging was associated with increasing clinical stage (T2 vs T1 OR 1.35, 95% CI 1.27–1.44), higher Gleason score (7 vs less than 7 OR 1.80, 95% CI 1.69–1.92), increasing age and comorbidity as well as decreasing education. Appropriate imaging for men at high risk was associated with lower stage (T4, T3 and T2 vs T1 OR 0.63, 95% CI 0.48–0.82, OR 0.67, 95% CI 0.60–0.80 and OR 0.87, 95% CI 0.80–0.86) and with higher Gleason score (greater than 8 and 7 vs less than 7 OR 2.18, 95% CI 1.92–2.48 and 1.51, 95% CI 1.35–1.70, respectively) as well as with younger age, white race, higher income, lower stage and more comorbidity.

Conclusions: We found poor adherence to imaging guidelines for men with incident prostate cancer. Understanding the patterns by which clinicians use imaging for prostate cancer should guide educational efforts as well as research to suggest evidence-based guideline improvements.

Trajectories of cognitive decline over 10 years in a Brazilian elderly population: the Bambuí Cohort Study of Aging

Trajectories of cognitive decline over 10 years in a Brazilian elderly population: the Bambuí Cohort Study of Aging
Cadernos de Saude Publica, Vol. 27, supp. 3. 10.1590/S0102-311X2011001500003

Macinko, J., V. Camargos, J.O.A. Firmo, and M.F. Lima Costa
12/01/2011

We use data from a population-based cohort of elderly Brazilians to assess predictors of hospitalizations during ten years of follow-up. Participants were 1,448 persons aged 60 years and over at baseline (1997). The outcome was self-reported number of hospitalizations per year. Slightly more than a fifth (23%) experienced no hospitalizations during the 10 year follow-up. About 30% had 1-2 events, 31% had between 3 and 7 events, and about 18% had 8 or more events during this time. Results of multivariable hurdle and Cox proportional hazards models showed that the risk of hospitalization was positively associated with male sex, increased age, chronic conditions, and visits to the doctors in the previous 12 months. Underweight was a predictor of any hospitalization, while obesity was an inconsistent predictor of hospitalization.

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