Health Policy

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


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.


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.


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.


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

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.

The Influence of Primary Care and Hospital Supply on Ambulatory Care–Sensitive Hospitalizations Among Adults in Brazil, 1999–2007

The Influence of Primary Care and Hospital Supply on Ambulatory Care–Sensitive Hospitalizations Among Adults in Brazil, 1999–2007
American Journal of Public Health: October 2011, Vol. 101, No. 10, pp. 1963-1970. 10.2105/AJPH.2010.198887

Macinko, J., V.B. de Oliveira, M.A. Turci, F.C. Guanais, P.F. Bonolo, and M.F. Lima Costa

Objectives. We assessed the influence of changes in primary care and hospital supply on rates of ambulatory care–sensitive (ACS) hospitalizations among adults in Brazil.

Methods. We aggregated data on nearly 60 million public sector hospitalizations between 1999 and 2007 to Brazil's 558 microregions. We modeled adult ACS hospitalization rates as a function of area-level socioeconomic factors, health services supply, Family Health Program (FHP) availability, and health needs by using dynamic panel estimation techniques to control for endogenous explanatory variables.

Results. The ACS hospitalization rates declined by more than 5% annually. When we controlled for other factors, FHP availability was associated with lower ACS hospitalization rates, whereas private or nonprofit hospital beds were associated with higher rates. Areas with highest predicted ACS hospitalization rates were those with the highest private or nonprofit hospital bed supply and with low (< 25%) FHP coverage. The lowest predicted rates were seen for areas with high (> 75%) FHP coverage and very few private or nonprofit hospital beds.

Conclusions. These results highlight the contribution of the FHP to improved health system performance and reflect the complexity of the health reform processes under way in Brazil.

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

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

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.

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.

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.

We All Want It, but We Don't Know What It Is: Toward a Standard of Affordability for Health Insurance Premiums

We All Want It, but We Don't Know What It Is: Toward a Standard of Affordability for Health Insurance Premiums
Journal of Health Politics, Policy and Law, 2011. Volume 36 / Issue 05 / July 2011, pp 829-853, Published online

Peter Muennig, Bhaven Sampat, Nicholas Tilipman, Lawrence D. Brown and Sherry A. Glied

The 2010 Patient Protection and Affordable Care Act (P.L. 111-148), or ACA, requires that U.S. citizens either purchase health insurance or pay a fine. To offset the financial burden for lower-income households, it also provides subsidies to ensure that health insurance premiums are affordable. However, relatively little work has been done on how such affordability standards should be set. The existing literature on affordability is not grounded in social norms and has methodological and theoretical flaws. To address these issues, we developed a series of hypothetical vignettes in which individual and household sociodemographic characteristics were varied. We then convened a panel of eighteen experts with extensive experience in affordability standards to evaluate the extent to which each vignette character could afford to pay for one of two health insurance plans. The panel varied with respect to political ideology and discipline. We find that there was considerable disagreement about how affordability is defined. There was also disagreement about what might be included in an affordability standard, with substantive debate surrounding whether savings, debt, education, or single parenthood is relevant. There was also substantial variation in experts' assessed affordability scores. Nevertheless, median expert affordability assessments were not far from those of ACA.

The Brazilian Health System: History, Advances, and Challenges

The Brazilian Health System: History, Advances, and Challenges
The Lancet, Vol. 377, no. 9779, pp. 1778-1797. 10.1016/S0140-6736(11)60054-8

Paim, J., C. Travassos, C. Almeida, L. Bahia, and J. Macinko

Brazil is a country of continental dimensions with widespread regional and social inequalities. In this report, we examine the historical development and components of the Brazilian health system, focusing on the reform process during the past 40 years, including the creation of the Unified Health System. A defining characteristic of the contemporary health sector reform in Brazil is that it was driven by civil society rather than by governments, political parties, or international organisations. The advent of the Unified Health System increased access to health care for a substantial proportion of the Brazilian population, at a time when the system was becoming increasingly privatised. Much is still to be done if universal health care is to be achieved. Over the past 20 years, there have been other advances, including investments in human resources, science and technology, and primary care, and a substantial decentralisation process, widespread social participation, and growing public awareness of a right to health care. If the Brazilian health system is to overcome the challenges with which it is presently faced, strengthened political support is needed so that financing can be restructured and the roles of both the public and private sector can be redefined.


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