CONTEXT: Cigarette
smoking causes more preventable deaths from cardiovascular disease and cancer
than any other modifiable risk factor, but smokers may discount the increased
personal risk they face from continued smoking. OBJECTIVE: To assess smokers'
perceptions of their risks of heart disease and cancer. DESIGN AND SETTING:
Telephone and self-administered survey in 1995 of a probability sample of US
households with telephones. PARTICIPANTS: A total of 3031 adults aged 25 to 74
years, including 737 current smokers (24.3%). MAIN OUTCOME MEASURES: Respondents
with no history of myocardial infarction (MI) (96.2 %) or cancer (92.9%)
assessed their risk of these conditions relative to other people of the same age
and sex. Among current smokers, perceived risks were analyzed by demographic and
clinical factors using logistic regression. RESULTS: Only 29% and 40% of current
smokers believed they have a higher-than-average risk of MI or cancer,
respectively, and only 39% and 49% of heavy smokers (> or =40 cigarettes per
day) acknowledged these risks. Even among smokers with hypertension, angina, or
a family history of MI, 48%, 49%, and 39%, respectively, perceived their risk of
MI as higher than average. In multivariate analyses, older (> or =65 years),
less educated ( high school graduate), and light smokers (1-19 cigarettes per
day) were less likely than younger, more educated, and heavy smokers to perceive
an increased personal risk of MI or cancer. CONCLUSIONS: Most smokers do not
view themselves at increased risk of heart disease or cancer. As part of
multifaceted approaches to smoking cessation, physicians and public health
professionals should identify and educate smokers who are not aware of
smoking-related health risks.
Ayanian, J. Z., J. S. Weissman, S. Chasan-Taber, and A. M.
Epstein. 1998. Quality of care for two common illnesses in teaching and
nonteaching hospitals. Health Aff
(Millwood) 17 (6):194-205.
Teaching hospitals are
recognized for treating rare diseases, but their value in caring for common
illnesses is less clear. To assess quality of care for congestive heart failure
and pneumonia, we reviewed the medical records of Medicare beneficiaries in
major teaching, other teaching, and nonteaching hospitals in four states.
Overall quality was rated better in major and other teaching hospitals than in
nonteaching hospitals by physician reviewers and explicit process criteria, but
the results varied for different subsets of explicit measures. Future studies
should assess whether outcomes differ between teaching and nonteaching
hospitals.
Bailit, H. 1999. Dental insurance, managed care and
traditional practice. J Am Dent Assoc 130 (12):1721-7.
BACKGROUND AND OVERVIEW: The author examined the impact of
trends in commercial insurance plans and their managed care products on the
traditional fee-for-service solo or partnership model of dental practice.
CONCLUSION: In response to rising dental expenditures, employers are passing on
more costs of dental insurance to employees, dropping dental benefits altogether
and moving from indemnity to managed care plans, mainly preferred provider
organizations. These trends are likely to continue, resulting in fewer people
with employer- based dental insurance coverage. PRACTICE IMPLICATIONS: These
changes in dental insurance coverage are unlikely to challenge the traditional
model of dental practice within the next five years, largely because of the
growing decline in the supply of dental services and a lack of local market
concentration of dental managed care companies.
Berndt, E. R., H. L. Bailit, M. B. Keller, J. C. Verner, and
S. N. Finkelstein. 2000. Health care use and at-work productivity among
employees with mental disorders. Health Aff (Millwood) 19 (4):244-56.
This
study examines the differential medical care use and work productivity of
employees with and without anxiety and with other mental disorders at a large
national firm. A unique aspect of this study is that we integrate medical claims
and employer-provided, objective productivity data for the same employees. We
find extensive mental health comorbidities among anxious employees. Although
medical care use differs considerably among employees having no, one, or several
treated mental disorders, in most cases their annual average absenteeism and
average at-work productivity performance do not differ. Differences among
subgroups are observed for job tenure and maternity claims. We discuss these
long-term average productivity findings in relation to other literature
encompassing shorter time periods.
Blumenthal, D., and M. B. Buntin. 1998. Carve outs:
definition, experience, and choice among candidate conditions. Am J Manag Care 4
Suppl:SP45-57.
Despite increasing discussion of carve outs as a device for
controlling costs and improving quality of care, little systematic information
exists on the effects of carve outs on cost, quality, and access to healthcare
services. In the absence of such information, a conceptual framework is useful
for deciding which conditions and populations may benefit from carve-out
strategies, and how such arrangements should be designed. After carefully
defining carve outs, and distinguishing them from other similar arrangements,
this paper identifies five characteristics of a healthcare condition that
increase the likelihood that a carve out's benefits will outweigh its drawbacks.
The paper also examines the advantages and disadvantages of alternative
approaches to structuring and administering carve-out arrangements, including
how to pay for services, how to integrate them with mainstream care, provisions
for consumer choice and provisions for carve-out accountability. The piece
concludes that population carve outs, in which all the healthcare problems of a
group of patients are managed by the carve-out organization, have inherent
advantages, and identifies candidate conditions for population carve outs.
Bozzette, S. A., S. H. Berry, N. Duan, M. R. Frankel, A. A.
Leibowitz, D. Lefkowitz, C. A. Emmons, J. W. Senterfitt, M. L. Berk, S. C.
Morton, and M. F. Shapiro. 1998. The care of HIV-infected adults in the United
States. HIV Cost and Services Utilization Study Consortium. N Engl J Med 339
(26):1897-904.
BACKGROUND AND METHODS: In order to elucidate the medical
care of patients with human immunodeficiency virus (HIV) infection in the United
States, we randomly sampled HIV-infected adults receiving medical care in the
contiguous United States at a facility other than military, prison, or emergency
department facility during the first two months of 1996. We interviewed 76
percent of 4042 patients selected from among the patients receiving care from
145 providers in 28 metropolitan areas and 51 providers in 25 rural areas.
RESULTS: During the first two months of 1996, an estimated 231,400 HIV-infected
adults (95 percent confidence interval, 162,800 to 300,000) received care.
Fifty-nine percent had the acquired immunodeficiency syndrome according to the
case definition of the Centers for Disease Control and Prevention, and 91
percent had CD4+ cell counts of less than 500 per cubic millimeter. Eleven
percent were 50 years of age or older, 23 percent were women, 33 percent were
black, and 49 percent were men who had had sex with men. Forty-six percent had
incomes of less than $10,000 per year, 68 percent had public health insurance or
no insurance, and 30 percent received care at teaching institutions. The
estimated annual direct expenditures for the care of the patients seen during
the first two months of 1996 were $5.1 billion; the expenditures for the
estimated 335,000 HIV-infected adults seen at least as often as every six months
were $6.7 billion, which is about $20,000 per patient per year. CONCLUSIONS: In
this national survey we found that most HIV- infected adults who were receiving
medical care had advanced disease. The patient population was disproportionately
male, black, and poor. Many Americans with diagnosed or undiagnosed HIV
infection are not receiving medical care at least as often as every six months.
The total cost of medical care for HIV-infected Americans accounts for less than
1 percent of all direct personal health expenditures in the United States.
Cleary, P. D., A. M. Zaslavsky, and M. Cioffi. 2000. Sex
differences in assessments of the quality of Medicare managed care. Women's Health
Issues 10 (2):70-79.
Women rate their care slightly more positively than men on the Medicare managed care Consumer Assessments of Health Plans Study (CAHPS®)survey. On four of five composites, women have comparable or slightly more positive composite scores than men. Responses to individual questions in 1997 indicate that women may have slightly more problems getting referrals, equipment, and assistance. In 1998, there were no differences in difficulty getting a referral or assistance, but women were less likely to say their plan provided help, services, and equipment. Women were less likely to get a flu shot in both years. Further monitoring of CAHPS® data on sex differences in difficulty getting needed medical equipment are warranted.
Cutler, D. M., M. McClellan, J. P. Newhouse, and D. Remler.
1998. Are medical prices declining? Evidence from heart attack treatments. Quarterly Journal of
Economics 113 (4):991-1024.
We address long-standing problems in measuring medical inflation by estimating two types of price indices. '1 'he first, a Set-vice Price Index, prices specific medical services, as clues the current CI'I. The second, a Cost of Living Index, measures a quality-adjusted cost of treating a health problem. We apply these indices to heart attack treatment between 198;1 and 1111)4. More frequent reweighting and accounting for price discounts lowers the measured price change fur heart attacks by three percentage points annually. Accounting for quality change lowers it further; we estimate that the real Cost of Living index fell about 1 percent annually.
Eisen, S. V., J. A. Shaul, B. Clarridge, D. Nelson, J.
Spink, and P. D. Cleary. 1999. Development of a consumer survey for behavioral
health services. Psychiatr Serv 50 (6):793-8.
A
consumer survey was designed to assess the quality of mental health and
substance abuse services and evaluate insurance plans that provide such
services. This paper describes the development of the Consumer Assessment of
Behavioral Health Services instrument, which began with a review of existing
consumer satisfaction surveys and input from several groups working toward
development of nationally standardized satisfaction instruments. Consumer focus
groups were used to ensure that all the important domains of quality were
included, and group members were interviewed to ensure that all items on the
instrument were understandable. Results of a pilot test conducted with 160
consumers, 82 enrolled in Medicaid plans and 78 in commercial plans, suggested
that the survey was able to distinguish between the two groups in terms of
evaluations of their care and insurance plans. Future efforts will focus on
further testing of larger, more diverse samples and on developing scoring and
reporting formats for the survey that will be useful to consumers and purchasers
in choosing behavioral health services and plans.
Epstein, A., and J. P. Newhouse. 1998. Impact of Medicaid
expansion on early prenatal care and health outcomes. Health Care Financing
Review 19 (4):85-99.
To assess the impact of Medicaid expansion for pregnant women in South Carolina and California, the authors compared change in rates of timely prenatal care, adverse infant and maternal health outcomes, and use of cesarean section for groups of pregnant women who were either uninsured or covered by Medicaid, versus women with private coverage. The results showed small and/or inconsistent changes. Provision of coverage may be the first logical step in improving health care for the uninsured, but outcomes may rely more on outreach, coordination of care, and nonmedical interventions than on provision of insurance coverage per se.
Epstein, A. M. 1998. Rolling down the runway: the challenges
ahead for quality report cards. JAMA 279 (21):1691-6.
Today, steadily increasing numbers of hospitals and health
plans are publicly releasing performance reports on the quality of care to
permit comparisons across different providers. Our experience in recent years
has provided important new evidence of what public quality reporting can
accomplish and the difficulties it faces. Several years ago, the most important
impediments to quality reporting may have been the availability of acceptable
quality indicators and the feasibility of voluntary, standardized data
collection by health plans. We have made strides in these areas. The Health
Employer Data and Information Set (HEDIS) has expanded, and there have been new
innovations in collecting data on quality from both patients and physicians.
Hundreds of health plans have begun to report standardized quality data on a
routine basis either voluntarily or in response to requirements from the Health
Care Financing Administration, state Medicaid agencies, or private payers. Now,
the more formidable barriers to the use of quality report cards may relate to
the ways we report the data and use it. We need to find acceptable middle ground
for those who believe information on individual physicians is critical and those
who believe it is harmful. We need to reap the advantages in different
modalities of data collection and different tools for quality management. Most
of all, we need to find better ways to use quality reporting to empower
purchasers and consumers and improve quality of care.
Frank, R. G., C. Koyanagi, and T. G. McGuire. 1997. The
politics and economics of mental health 'parity' laws. Health Aff
(Millwood) 16 (4):108-19.
The
enactment of the Domenici-Wellstone amendment in September 1996, which calls for
the elimination of certain limits on coverage for mental health care under
private insurance, is being hailed as a major step forward in the quest for
"parity" in mental health coverage. Parity legislation is being introduced in a
number of state legislatures and is finding new enthusiasm in Congress. In this
paper we consider the efficiency rationale for these laws and examine their
likely impact in the era of managed care. We conclude that although such
successes represent important political events, they may offer only small gains
in the efficiency and fairness of insurance markets.
Frank, R. G., and T. G. McGuire. Parity for mental health
and substance abuse care under managed care. Journal of Mental Health
Policy and Economics (in press).
Background: Parity in insurance coverage for mental
health and substance abuse has been a key goal of mental health and substance
abuse care advocates in the United States during most of the past 20 years. The
push for parity began during the era of indemnity insurance and fee for service
payment when benefit design was the main rationing device in health care. The
central economic argument for enacting legislation aimed at regulating the
insurance benefit was to address market failure stemming from adverse selection.
The case against parity was based on inefficiency related to moral hazard.
Empirical analyses provided evidence that ambulatory mental health services were
considerably more responsive to the terms of insurance than were ambulatory
medical services.
Aims: Our goal in this
research is to reexamine the economics of parity in the light of recent changes
in the delivery of health care in the United States. Specifically managed care
has fundamentally altered the way in which health services are rationed. Benefit
design is now only one mechanism among many that are used to allocate health
care resources and control costs. We examine the implication of these changes
for policies aimed at achieving parity in insurance coverage.
Method: We develop a theoretical approach to
characterizing rationing under managed care. We then analyze the traditional
efficiency concerns in insurance, adverse selection and moral hazard in the
context of policy aimed at regulating health and mental health benefits under
private insurance.
Results: We show that since
managed care controls costs and utilization in new ways Parity in benefit design
no longer implies equal access to and quality of mental health and substance
abuse care. Because costs are controlled by management under managed care and
not primarily by out of pocket prices paid by consumers, demand response recedes
as an efficiency argument against parity. At the same time parity in benefit
design may accomplish less with respect to providing a remedy to problems
related to adverse selection.
Frank, R. G., and T. G. McGuire. 1998. The economic
functions of carve outs in managed care. Am J Manag Care 4 Suppl:SP31-9.
This
paper considers the economic functions of contracting separately for a portion
of the insurance risk, offering both the payer's (i.e., employer's) and the
health plan's perspective. Four major forms of carve outs are discussed: (1)
payer specialty carve outs from all health plans; (2) payer specialty carve outs
from only indemnity and preferred provider organization arrangements; (3)
individual health plan carve outs to specialty vendors; and (4) group practice
carve outs to specialty organizations. The paper examines whether carving out
care fosters the payer's goal of delivering reasonable healthcare efficiently,
how adverse selection affects the provision of healthcare, and the costs of
providing this specialized care.
Frank, R. G., T. G. McGuire, J. P. Bae, and A. Rupp. 1997.
Solutions for adverse selection in behavioral health care. Health Care Financing
Review 18 (3):109-122.
Health plans have incentives to discourage high-cost enrollees (such as persons with mental illness) from joining. Public policy to counter incentives created by adverse selection is difficult when managed care controls cost through methods that are largely beyond the grasp of direct regulation. In this article, the authors evaluate three approaches to dealing with selection incentives: risk adjustment, the carving out of benefits, and cost- or risk-sharing between the payer and the plan. Adverse selection is a serious problem in the context of managed care. Risk adjustment is not likely to help much, but carving out the benefit and cost-sharing are promising directions for policy.
Gittell, J. H., K. M. Fairfield, B. Bierbaum, W. Head, R.
Jackson, M. Kelly, R. Laskin, S. Lipson, J. Siliski, T. Thornhill, and J.
Zuckerman. 2000. Impact of relational coordination on quality of care,
postoperative pain and functioning, and length of stay: a nine-hospital study of
surgical patients. Med Care 38 (8):807-19.
BACKGROUND: Health care organizations face pressures from
patients to improve the quality of care and clinical outcomes, as well as
pressures from managed care to do so more efficiently. Coordination, the
management of task interdependencies, is one way that health care organizations
have attempted to meet these conflicting demands. OBJECTIVES: The objectives of
this study were to introduce the concept of relational coordination and to
determine its impact on the quality of care, postoperative pain and functioning,
and the length of stay for patients undergoing an elective surgical procedure.
Relational coordination comprises frequent, timely, accurate communication, as
well as problem-solving, shared goals, shared knowledge, and mutual respect
among health care providers. RESEARCH DESIGN: Relational coordination was
measured by a cross-sectional questionnaire of health care providers. Quality of
care was measured by a cross-sectional postoperative questionnaire of total hip
and knee arthroplasty patients. On the same questionnaire, postoperative pain
and functioning were measured by the WOMAC osteoarthritis instrument. Length of
stay was measured from individual patient hospital records. SUBJECTS: The
subjects for this study were 338 care providers and 878 patients who completed
questionnaires from 9 hospitals in Boston, MA, New York, NY, and Dallas, TX,
between July and December 1997. MEASURES: Quality of care, postoperative pain
and functioning, and length of acute hospital stay. RESULTS: Relational
coordination varied significantly between sites, ranging from 3.86 to 4.22 (P
0.001). Quality of care was significantly improved by relational coordination (P
0.001) and each of its dimensions. Postoperative pain was significantly reduced
by relational coordination (P = 0.041), whereas postoperative functioning was
significantly improved by several dimensions of relational coordination,
including the frequency of communication (P = 0.044), the strength of shared
goals (P = 0.035), and the degree of mutual respect (P = 0.030) among care
providers. Length of stay was significantly shortened (53.77%, P 0.001) by
relational coordination and each of its dimensions. CONCLUSIONS: Relational
coordination across health care providers is associated with improved quality of
care, reduced postoperative pain, and decreased lengths of hospital stay for
patients undergoing total joint arthroplasty. These findings support the design
of formal practices to strengthen communication and relationships among key
caregivers on surgical units.
Goldman, D. P., J. L. Buchanan, and E. B. Keeler. 2000.
Simulating the impact of medical savings accounts on small business. Health Serv Res 35
(1 Pt 1):53-75.
OBJECTIVE: To simulate whether allowing small businesses to
offer employer-funded medical savings accounts (MSAs) would change the amount or
type of insurance coverage. STUDY SETTING: Economic policy evaluation using a
national probability sample of nonelderly non- institutionalized Americans from
the 1993 Current Population Survey (CPS). STUDY DESIGN: We used a behavioral
simulation model to predict the effect of MSAs on the insurance choices of
employees of small businesses (and their families). The model predicts spending
by each family in a FFS plan, an HMO plan, an MSA, and no insurance. These
predictions allow us to compute community-rated premiums for each plan, but with
firm-specific load fees. Within each firm, employees then evaluate each option,
and the firm decides whether to offer insurance- and what type-based on these
evaluations. If firms offer insurance, we consider two scenarios: (1) all
workers elect coverage; and (2) workers can decline the coverage in return for a
wage increase. PRINCIPAL FINDINGS: In the long run, under simulated conditions,
tax-advantaged MSAs could attract 56 percent of all employees offered a plan by
small businesses. However, the fraction of small-business employees offered
insurance increases only from 41 percent to 43 percent when MSAs become an
option. Many employees now signing up for a FFS plan would switch to MSAs if
they were universally available. CONCLUSIONS: Our simulations suggest that MSAs
will provide a limited impetus to businesses that do not currently cover
insurance. However, MSAs could be desirable to workers in firms that already
offer HMOs or standard FFS plans. As a result, expanding MSA availability could
make it a major form of insurance for covered workers in small businesses.
Overall welfare would increase slightly.
Goldman, D. P., A. Leibowitz, and J. L. Buchanan. 1998. Cost
containment and adverse selection in Medicaid HMOs. Journal of the American
Statistical Association (March).
This article examines whether substituting a health maintenance organization (HMO) for traditional fee-for-service (FFS) Medicaid insurance reduces the cost of children's health care. The estimation is complicated by the fact that in nonrandomized settings, unobserved selection can bias estimates of HMO performance. To control for selection, researchers often rely on parametric assumptions or instrumental variables estimation to compute selection-free estimates. But the robustness of these approaches has been questioned. We pursue a different approach based on semiparametric maximum likelihood techniques. Monte Carlo and applied economic studies have shown this method to be quite robust in a variety of contexts. We apply this model to data from a self-selected sample of children in either a Medicaid HMO or a traditional FFS in Florida. After controlling for selection, we estimate that the HMO reduced expenditures on children by 9.1%. Conversely, a model assuming no selection predicts no savings from the HMO. We also validate our estimates by comparing our results with those obtained from a randomized sample of HMO and FFS enrollees. These indicate that the HMO reduces expenditures by 13.6%. We conclude that selection can substantially bias estimates of HMO impact and that this technique provides a potentially useful method for accounting for this bias.
Haas, J. S., P. D. Cleary, A. L. Puopolo, H. R. Burstin, E.
F. Cook, and T. A. Brennan. 1998. Differences in the professional satisfaction
of general internists in academically affiliated practices in the greater-Boston
area. Ambulatory Medicine Quality Improvement Project Investigators. J Gen Intern Med 13
(2):127-30.
Managed care has created more professional constraints for
general internists. We surveyed 198 general internists at 12 academically
affiliated practices in the greater-Boston area to examine professional
satisfaction. Overall, these physicians were moderately satisfied (mean of 59.1
on a 100-point scale). Before adjustment, women had lower overall satisfaction
than men, as well as poorer satisfaction with the domains of career concerns and
patient access. Gender had no independent effect on satisfaction after
adjustment for age, income, percentage of time providing direct patient care,
work status, and site. Younger physicians also had lower overall satisfaction,
and these differences remained after adjustment. Improvements in professional
satisfaction may be required to ensure the continued recruitment of young
physicians, particularly women, into general internal medicine.
Hays, R. D., J. A. Shaul, V. S. Williams, J. S. Lubalin, L.
D. Harris-Kojetin, S. F. Sweeny, and P. D. Cleary. 1999. Psychometric properties
of the CAHPS 1.0 survey measures. Consumer Assessment of Health Plans Study. Med Care 37 (3
Suppl):MS22-31.
OBJECTIVES: Consumer surveys are being used increasingly to
assess the quality of care provided by health plans, physician groups, and
clinicians. The purpose of the Consumer Assessment of Health Plans Study (CAHPS)
is to develop an integrated and standardized set of surveys designed to collect
reliable and valid information about health plan performance from consumers.
This article reports psychometric results for the CAHPS 1.0 survey items in
samples of individuals with Medicaid or private health insurance coverage.
METHODS: Reliability estimates for CAHPS 1.0 measures were estimated in a sample
of 5,878 persons on Medicaid and 11,393 persons with private health insurance.
Correlations of the CAHPS global rating of the health plan with willingness to
recommend the plan and intention to re-enroll were estimated in a sample of 313
persons on Medicaid. The association of the rating of the health plan with
ratings using a 5-point Excellent-to- Poor response scale also was investigated
in the latter sample and in a sample of 539 persons with private health
insurance. RESULTS: The CAHPS measures appeared to have good reliability,
particularly at the health- plan level. Responses from 300 consumers per health
plan tend to yield estimates that are reliable enough for health plan
comparisons, especially among the privately insured. The global health plan
rating was significantly correlated with consumers' willingness to recommend the
plan to family and friends and to their intention to re-enroll in the plan if
given a choice. CONCLUSIONS: The CAHPS 1.0 survey instrument appears to have
excellent psychometric properties.
Huskamp, H. A. 1998. How a managed behavioral health care
carve-out plan affected spending for episodes of treatment [see comments]. Psychiatr Serv 49
(12):1559-62.
OBJECTIVE: This study examined the impact on spending for
episodes of mental health and substance abuse treatment of a managed behavioral
health care carve-out program implemented by the Massachusetts Group Insurance
Commission in July 1993. METHODS: Episodes of mental health and substance abuse
treatment were defined using claims and enrollment data from before and after
the carve-out implementation. Regression models were used to compare spending
per episode for different types of episodes of mental health and substance abuse
care: those involving care provided only in an inpatient facility (that is,
inpatient care or partial hospitalization), those involving both
inpatient-facility and outpatient care, and those involving only outpatient
care. RESULTS: Adoption of the carve-out plan was associated with a large
decrease in spending per episode across all three episode types, particularly
for episodes involving inpatient-facility care. The decrease was 54 percent for
inpatient-facility-only episodes, 46 percent for combined inpatient facility and
outpatient episodes, and 21 percent for outpatient-only episodes. The decrease
in spending per episode was larger for episodes involving a diagnosis of either
unipolar depression or substance dependence. CONCLUSIONS: The findings suggest
that spending per episode of mental health and substance abuse treatment may
drop substantially after a carve-out is implemented. Individuals with a
diagnosis of either unipolar depression or substance dependence seem to be
disproportionately affected. It appears that even weak financial incentives
placed on the managed behavioral health care vendor can result in dramatic
changes in spending patterns for episodes of mental health and substance abuse
treatment.
Huskamp, H. A. 1999. Episodes of mental health and substance
abuse treatment under a managed behavioral health care carve-out. Inquiry 36
(2):147-61.
Little is known about the effect of a managed behavioral
health care (MBHC) carve-out on treatment episodes for a mental health/substance
abuse (MHSA) condition. This study found adoption of a carve-out for
Massachusetts state employees associated with a dramatic drop in total MHSA
costs per episode (particularly for individuals with certain severe MHSA
conditions). The carve-out also was associated with a shift away from the use of
facility care toward the use of outpatient care for enrollees with a diagnosis
of unipolar depression.
Huskamp, H. A., M. B. Rosenthal, R. G. Frank, and J. P.
Newhouse. 2000. The Medicare prescription drug benefit: how will the game be
played? [see comments]. Health Aff (Millwood) 19 (2):8-23.
Most
recent proposals to add a prescription drug benefit to the Medicare program
suggest using pharmacy benefit managers (PBMs) to control costs and promote
quality. However, the proposals give little detail on the institutional
arrangements that would govern PBM operations and drug procurement. The recent
Congressional Budget Office cost estimate of the Clinton administration's
proposal reflects this lack of detail on how PBMs would function. We sketch an
approach for structuring PBM operations that focuses on competition among PBMs,
manufacturers, and distributors; incentive pricing; and risk sharing with
PBMs.
Kao, A. C., D. C. Green, N. A. Davis, J. P. Koplan, and P.
D. Cleary. 1998a. Patients' trust in their physicians: effects of choice,
continuity, and payment method. J Gen Intern Med 13 (10):681-6.
OBJECTIVE: To evaluate the extent to which physician choice,
length of patient-physician relationship, and perceived physician payment method
predict patients' trust in their physician. DESIGN: Survey of patients of
physicians in Atlanta, Georgia. PATIENTS: Subjects were 292 patients aged 18
years and older. MEASUREMENTS AND MAIN RESULTS: Scale of patients' trust in
their physician was the main outcome measure. Most patients completely trusted
their physicians "to put their needs above all other considerations" (69%).
Patients who reported having enough choice of physician (p .05), a longer
relationship with the physician (p .001), and who trusted their managed care
organization (p .001) were more likely to trust their physician. Approximately
two thirds of all respondents did not know the method by which their physician
was paid. The majority of patients believed paying a physician each time a test
is done rather than a fixed monthly amount would not affect their care (72.4%).
However, 40.5% of all respondents believed paying a physician more for ordering
fewer than the average number of tests would make their care worse. Of these
patients, 53.3% would accept higher copayments to obtain necessary medical
tests. CONCLUSIONS: Patients' trust in their physician is related to having a
choice of physicians, having a longer relationship with their physician, and
trusting their managed care organization. Most patients are unaware of their
physician's payment method, but many are concerned about payment methods that
might discourage medical use.
Kao, A. C., D. C. Green, A. M. Zaslavsky, J. P. Koplan, and
P. D. Cleary. 1998b. The relationship between method of physician payment and
patient trust [see comments]. JAMA 280 (19):1708-14.
CONTEXT: Trust is the cornerstone of the patient-physician
relationship. Payment methods that place physicians at financial risk have
raised concerns about patients' trust in physicians to act in patients' best
interests. OBJECTIVE: To evaluate the extent to which methods of physician
payment are related to patient trust. DESIGN: Cross-sectional telephone
interview survey done between January and June 1997. SETTING: Health plans of a
large national insurer in Atlanta, Ga, the Baltimore, Md-Washington, DC, area,
and Orlando, Fla. PARTICIPANTS: A total of 2086 adult managed care and indemnity
patients. MAIN OUTCOME MEASURE: A 10-item scale (alpha = .94) assessing
patients' trust in physicians. RESULTS: More fee-for-service (FFS) indemnity
patients (94%) completely or mostly trust their physicians to "put their health
and well-being above keeping down the health plan's costs" than salary (77%),
capitated (83%), or FFS managed care patients (85%) (P.001 for pairwise
comparisons). In multivariate analyses that adjusted for potentially confounding
factors, FFS indemnity patients also had higher scores on the 10-item trust
scale than salary (P.001), capitated (P.001), or FFS managed care patients
(P.01). The effects of payment method on patient trust were reduced when a
measure based on patients' reports about physician behavior (eg, Does your
physician take enough time to answer your questions?) was included in the
regression analyses, but the differences remained statistically significant,
except for the comparison between FFS managed care and FFS indemnity patients
(P=.08). Patients' perceptions of how their physicians were paid were not
independently associated with trust, but the 37.7% who said they did not know
how their physicians were paid had higher levels of trust than other patients
(P.01). A total of 30.2% of patients were incorrect about their physicians'
method of payment. CONCLUSIONS: Most patients trusted their physicians, but FFS
indemnity patients have higher levels of trust than salary, capitated, or FFS
managed care patients. Patients' reports of physician behavior accounted for
part of the variation in patients' trust in physicians who are paid differently.
The impact of payment methods on patient trust may be mediated partly by
physician behavior.
Keating, N. L., P. D. Cleary, A. S. Rossi, A. M. Zaslavsky,
and J. Z. Ayanian. 1999. Use of hormone replacement therapy by postmenopausal
women in the United States [see comments]. Ann Intern Med 130
(7):545-53.
BACKGROUND: The benefits and risks of hormone replacement
therapy (HRT) in postmenopausal women are not fully defined, and individual
characteristics and preferences may influence decisions to use this therapy.
Previous studies of postmenopausal women who use HRT have been conducted in
local or highly selected cohorts or have not focused on current use. OBJECTIVE:
To examine sociodemographic, clinical, and psychological factors associated with
current use of HRT in a national population-based cohort. DESIGN: Random-digit
telephone survey. SETTING: Probability sample of U.S. households with a
telephone. PARTICIPANTS: 495 postmenopausal women 50 to 74 years of age in 1995.
MEASUREMENTS: Current use of HRT. RESULTS: Current use of HRT was reported by
37.6% of women (58.7% of those who underwent hysterectomy and 19.6% of those who
did not undergo hysterectomy; P = 0.001). In multivariable analyses, use of HRT
was more common among women in the South (adjusted odds ratio, 2.67 [95% CI,
1.08 to 6.59]) and West (odds ratio, 2.76 [CI, 1.01 to 7.53]) than the
Northeast. Use was more common among college graduates (odds ratio, 3.72 [CI,
1.29 to 10.71]) and less common among women with diabetes mellitus (odds ratio,
0.17 [CI, 0.05 to 0.51]). Other cardiac risk factors and most psychological
characteristics were not associated with HRT use. CONCLUSIONS: Sociodemographic
factors, such as region and education, may be more strongly associated with use
of HRT than clinical factors, such as risk for cardiovascular disease. Future
efforts should focus on understanding sociodemographic variations, defining
which women are most likely to benefit, and targeting therapy to them.
Keating, N. L., A. M. Zaslavsky, and J. Z. Ayanian. 1998.
Physicians' experiences and beliefs regarding informal consultation [see
comments]. JAMA
280 (10):900-4.
CONTEXT: Efforts to control medical expenses by emphasizing
primary care and limiting specialty care may influence how physicians use
informal or "curbside" consultation. OBJECTIVE: To understand physicians' use of
and beliefs about informal consultation. DESIGN: Survey mailed in July 1997.
PARTICIPANTS: Of a random sample of Massachusetts general internists,
pediatricians, cardiologists, orthopedic surgeons (n=300 each), and infectious
disease specialists (n=200) surveyed, 1225 were eligible and 705 (58%)
responded. MAIN OUTCOME MEASURES: Self-reported use of and beliefs about
informal consultation. RESULTS: Generalist physicians requested more informal
consultations than specialists (median, 3 vs 1 per week; P.001) and were asked
to provide fewer (2 vs 5 per week; P.001). In multivariate analyses, physicians
in a health maintenance organization, multispecialty group, or single-specialty
group requested more informal consultations than those in solo practice (82%,
40%, and 28% more, respectively; all P.001) and were more often asked to provide
them (43%, 63%, and 14% more, respectively; all P.05). Physicians with at least
30% of their income from capitation requested 38% more and were asked to provide
46% more informal consultations than those with little or no income from
capitation (both P.001). Generalists' overall approval of informal consultation
was greater than specialists' (mean 5.9 vs 5.1 on a 7-point Likert scale;
P.001), and approval was strongly associated with beliefs about how informal
consultation affects quality of care (P.001). CONCLUSIONS: Use of informal
consultation is common, varies by specialty, practice setting, and capitation,
and therefore may increase with current trends toward group practice and managed
care. Because overall approval of informal consultation is strongly associated
with beliefs about how it affects quality of care, this issue should be
carefully considered by physicians who participate in informal consultation.
Keeler, E. B., G. Carter, and J. P. Newhouse. 1998. A model
of the impact of reimbursement schemes on health plan choice. Journal of Health
Economics 17:297-320.
Flat capitation (uniform prospective payments) makes enrolling healthy enrollees profitable to health plans. Plans with relatively generous benefits may attract the sick and fail through a premium spiral. We simulate a model of idealized managed competition to explore the effect on market performance of alternatives to flat capitation such as severity-adjusted capitation and reduced supply-side cost-sharing. In our model flat capitation causes severe market problems. Severity adjustment and to a lesser extent reduced supply-side cost-sharing improve market performance, but outcomes are efficient only in cases in which people bear the marginal costs of their choices.
Landon, B. E., C. Tobias, and A. M. Epstein. 1998. Quality
management by state Medicaid agencies converting to managed care: plans and
current practice. JAMA 279 (3):211-6.
CONTEXT: Enrollment in Medicaid managed care plans has
increased more than 5-fold in this decade, but how states monitor and encourage
quality of care in these programs is not known. OBJECTIVE: To characterize the
quality monitoring and assurance activities of state Medicaid agencies for
Medicaid beneficiaries enrolled in comprehensive prepaid managed care programs.
DESIGN: Structured telephone survey conducted between October 1996 and January
1997. SETTING: State Medicaid agencies. PARTICIPANTS: Representatives from all
state Medicaid agencies, including the District of Columbia, with beneficiaries
enrolled in comprehensive prepaid managed care plans as of July 1, 1996. MAIN
OUTCOME MEASURES: Proportion of states with specific quality monitoring and
assurance activities for Medicaid managed care. RESULTS: We surveyed all 34
states enrolling beneficiaries in comprehensive managed care programs. In 1996,
all 34 states enrolled the population receiving assistance from the Aid to
Families With Dependent Children (AFDC) program, while only 21 (62%) and 15
(44%) enrolled the disabled and elderly populations, respectively. In the period
1995 to 1996, 19 states (63%) collected data on satisfaction with care, and 25
states (83%) collected data on childhood immunizations. No more than half of the
states collected data on other selected measures of access and quality, but a
substantial number planned to collect such data in 1997. While at most 37% of
states were providing comparative data to health plans, up to 80% were planning
to provide such information in 1997. Similarly, while at most 10% of states
provided beneficiaries with such information, up to 38% planned to do so in
1997. The breadth of contracting requirements designed to assure quality varied
substantially across states. CONCLUSIONS: State Medicaid agencies have already
begun adapting to their new roles as purchasers of health care. Continued
monitoring is essential to ensure that state agencies implement planned programs
and that quality of care for Medicaid enrollees is preserved or improved.
Landon, B. E., I. B. Wilson, and P. D. Cleary. 1998. A
conceptual model of the effects of health care organizations on the quality of
medical care. JAMA 279 (17):1377-82.
There has been a great deal of interest in recent years in
developing measures of health care quality that can be used to characterize and
study the effects of health plans. However, because of the recent emergence of
diverse types of health care organizations, it is often difficult to know which
parts of a plan should be combined for analysis purposes. Also, simple
taxonomies of health maintenance organizations (eg, staff, independent practice
associations, group, and network) no longer adequately describe the diverse
types of organizations that have become common. In this article we describe
these trends, explain why older taxonomies of health care plans are not
adequate, and present a new framework for characterizing and studying the
effects of diverse types of plans.
Marquis, M. S., and J. L. Buchanan. 1999. Simulating the
effects of employer contributions on adverse selection and health plan choice.
Health Serv Res
34 (4):813-37.
OBJECTIVE: To investigate the effect of employer contribution policy and adverse selection on employees' health plan choices. STUDY DESIGN: Microsimulation methods to predict employees' choices between two health plan options and to track changes in those choices over time. The simulation predicts choice given premiums, healthcare spending by enrollees in each plan, and premiums for the next period. DATA SOURCES: The simulation model is based on behavioral relationships originally estimated from the RAND Health Insurance Experiment (HIE). The model has been updated and recalibrated. The data processed in the simulation are from the 1993 Current Population Employee Benefits Supplement sample. PRINCIPAL FINDINGS: A higher fraction of employees choose a high-cost, high-benefit plan if employers contribute a proportional share of the premium or adjust their contribution for risk selection than if employees pay the full cost difference out-of-pocket. When employees pay the full cost difference, the extent of adverse selection can be substantial, which leads to a collapse in the market for the high-cost plan. CONCLUSIONS: Adverse selection can undermine the managed competition strategy, indicating the importance of good risk adjusters. A fixed employer contribution policy can encourage selection of more efficient plans. Ironically, however, it can also further adverse selection in the absence of risk adjusters.
Normand, S. L., B. J. McNeil, L. E. Peterson, and R. H.
Palmer. 1998. Eliciting expert opinion using the Delphi technique: identifying
performance indicators for cardiovascular disease. Int J Qual Health
Care 10 (3):247-60.
Combining opinion from expert panels is becoming a more
common method of selecting criteria to define quality of health care. The Rand
Corporation pioneered this method is the 1950s and 1960s in the context of
forecasting technological events. Since then, numerous organizations have
adopted the methodology to develop local and national policy. In the context of
quality of care, opinion is typically elicited from a sample of experts
regarding the appropriateness or importance of a medical treatment for several
well-defined clinical cohorts. The information from the experts is then combined
in order to create a standard or performance measure of care. This article
describes how to use the panel process to elicit information from diverse panels
of experts. Methods are demonstrated using the data from five distinct panels
convened as part of the Harvard Q-SPAN-CD study, a nationally- funded project
whose goal is to identify a set of cardiovascular- related performance
measures.
Palmer, R. H. 1998. Using health outcomes data to compare
plans, networks and providers [see comments]. Int J Qual Health
Care 10 (6):477-83.
PURPOSE: To analyze the challenge of using health outcomes
data to compare plans, networks and providers. ANALYSIS: Different questions
require different designs for collecting and interpreting health outcomes data.
When evaluating effectiveness of treatments, tests or other technologies, the
question is what processes improve health outcomes? For this purpose, the
strongest evidence comes from a double- blind randomized controlled trial. In
program evaluations, the question is 'what is the impact of this policy and
related programs on health outcomes?' For this purpose, we may be able to
randomize subjects, but are more likely to have a quasi-experimental or an
epidemiological design. When we compare plans, networks and providers for
quality improvement purposes the question is 'do these specific plans perform
differently from one another?', or, 'are these specific plans improving their
performance over time?' We want to isolate for study the effects attributable to
specific plans. Designs that yield strong evidence cannot be applied because we
lack experimental control. CONCLUSIONS: When we already have strong evidence
linking specific processes of care with specific outcomes, comparing process
data may reveal more about performance of plans, networks and providers than
comparing outcomes data. Comparisons of process data are easier to interpret and
more sensitive to small differences than comparisons of outcomes data. Outcomes
data are most useful for tracking care given by high volume providers over long
periods of time, targeting areas for quality improvement and for detecting
problems in implementation of processes of care.
Remler, D. K., K. Donelan, R. J. Blendon, G. D. Lundberg, L.
L. Leape, D. R. Calkins, K. Binns, and J. P. Newhouse. 1997. What do managed
care plans do to affect care? Results from a survey of physicians. Inquiry 34
(3):196-204.
Little is known about physicians' exposure to managed care
techniques that affect clinical practice. In 1995, we conducted a survey of
2,003 U.S. physicians asking them about their share of patients subject to a
variety of managed care techniques. Nationally, 24% of physicians received some
form of capitation payment for their patients. The two most widely used
techniques were utilization review (UR), applied to an average of 59% of
patients, and discounted fees, applied to an average of 38% of patients.
Although UR was common, ultimate denial rates of coverage were very low: at most
3% for the types of care studied. Use of managed care techniques varied more
within states than between states. Conventional measures of HMO market
penetration revealed little about how managed care affects physicians.
Reuben, D. B., J. F. Schnelle, J. L. Buchanan, R. S.
Kington, G. L. Zellman, D. O. Farley, S. H. Hirsch, and J. G. Ouslander. 1999.
Primary care of long-stay nursing home residents: Approaches of three health maintenance
organizations. Journal of the American Geriatrics Society
47:131-138.
OBJECTIVE: To describe
the innovative programs of three health maintenance organizations (HMOs) for
providing primary care for long-stay nursing home (NH) residents and to
compare this care with that of fee-for-service (FFS) residents at the same
NHs. DESIGN:
Cross-sectional interviews and case-studies, including retrospective chart
reviews for 1 year.
SETTING: The programs were based in 20 communitybased nursing homes
in three regions (East, West, Far West).
PARTICIPANTS: Administrative
and professional staff of HMOs in three regions and 20 NHs; 215 HMO and 187 FFS
residents at these homes were studied. MAIN OUTCOME MEASURES: Emergency
department (ED) and hospital utilization. RESULTS: All HMO programs utilized nurse
practitioner/ physician's assistants (NP/PA), but the structural
configuration of physicians' (MD) practices differed substantially. At
nursing homes within each region, all three HMO programs provided more total (MD
plus NP/PA) visits per month than did FFS care (2.0 vs 1.1, 1.3 vs .6, and 1.4
vs .8 visits per month; all P < .05). The HMO that provided the most total
visits had a significantly lower percentage of residents transferred to EDs
(6°/a vs 16%, P = .048), fewer ED visits per resident (0.1 vs .4 per year, P =
.027), and fewer hospitalizations per resident (0.1 vs .5 per year, P =
.038) than FFS residents; these differences remained significant in
multivariate analyses. However, the other two programs did not achieve the
same benefits on healthcare utilization. CONCLUSIONS: HMO programs for NH residents
provide more primary care and have the potential to reduce ED and hospital use
compared with FFS care. However, not all programs have been associated with
decreased ED and hospital utilization, perhaps because of differences in
structure or implementation problems.
Rosenthal, M. B. 1999. Risk sharing in managed behavioral
health care. Health
Aff (Millwood) 18 (5):204-13.
While policymakers have expressed concern over the impact of
risk sharing with providers on treatment patterns, the literature lacks decisive
evidence on which to base policy. This paper evaluates the impact of a
contracting change within a managed behavioral health organization from a
fee-for-service system to a case-rate system with utilization management
delegated to providers. The contracting change resulted in a 25 percent
reduction in mental health visits per episode. This effect varies with the
dollar amount of the case rate and is more pronounced for providers with a
larger share of revenue from risk contracts and with intensive utilization
management programs.
Schnelle, J. F., J. G. Ouslander, J. Buchanan, G. Zellman,
D. Farley, S. H. Hirsch, and D. B. Reuben. 1999. Objective and subjective
measures of the quality of managed care in nursing homes. Med Care 37
(4):375-83.
BACKGROUND: The number of nursing home (NH) residents
enrolled in managed care plans (HMO) will increase, and there is concern that
the quality of their medical care may be compromised by cost-containment
pressures. In this study, we evaluated the medical care of residents enrolled in
3 health maintenance organizations (HMO) that developed specific long-term care
programs. OBJECTIVES: To compare the medical care received by NH residents
enrolled in HMO and Fee-for-Service (FFS) plans with both objective process of
care and consumer perception (subjective) measures. To describe the relationship
between the objective and subjective measures. MEASURES: Number of primary care
visits per month; process of medical care for 2 geriatric tracer conditions
(falls, fevers); family and residents' perceptions of the adequacy of sickness
episode management; and the frequency of primary provider visits. DESIGN:
Quasi-experimental. RESULTS: HMO residents received more timely and appropriate
responses to falls and fevers than did FFS residents. HMO residents also
received more frequent routine visits by a primary care provider team consisting
of a physician and nurse practitioner. Consumer perceptions of quality did not
differ between the HMO and FFS groups. Families within both groups were
significantly more positive than were residents about the frequency of visits by
both physicians and nurse practitioners. Within the HMO group, both families and
residents were more positive about the frequency of nurse practitioner visits
than were physician visits even when the frequency of visits by the 2 providers
were similar. CONCLUSIONS: Although the medical care received by HMO residents
was better on most objective process measures than that received by FFS
residents, consumer perceptions of care did not detect those differences. NH
residents and families have different perceptions about the adequacy of visits
by physicians and nurse practitioners, and both families and residents appear to
have different expectations concerning how often they want physicians to visit
as compared with nurse practitioners.
Shaul, J. A., F. J. Fowler, Jr., A. M. Zaslavsky, C. J.
Homer, P. M. Gallagher, and P. D. Cleary. 1999. The impact of having parents
report about both their own and their children's experiences with health
insurance plans. Med
Care 37 (3 Suppl):MS59-68.
OBJECTIVES: The aim of this study was to determine whether
parents rate their children's care differently when they also rate their own
care than when they do not. METHODS: Subjects were employees of Washington State
who had been enrolled in a health plan for at least 6 months and who had at
least one covered child. Subjects were randomly assigned to four study groups
that were surveyed using different protocols. To assess the stability of
responses over time, a follow-up telephone interview was conducted with
individuals in two of the groups. RESULTS: Parents or guardians who received
both the Adult and Child Surveys were less likely to complete a survey than
those who received only one survey. Responses to selected survey questions were
quite stable between survey administrations. Parents who rated only their
child's health care experiences generally gave more positive responses than
those who also rated their own care, although few of these differences were
statistically significant. This may have been due, in part, to the lower
response rates in the latter group. The pairs of survey questions that ask about
the adult's and child's experiences with the same aspects of care had moderate
to high levels of association. The pair with the weakest association asked how
clearly the doctor or nurse explained things to the adult or the child.
CONCLUSIONS: Sending both an adult and child survey to an adult could have an
effect on the pattern of responses and result in lower response rates, but this
might be a cost-effective way to collect reports about both adult and child
health care.
Thomas, E. J., D. M. Studdert, J. P. Newhouse, B. I. Zbar,
K. M. Howard, E. J. Williams, and T. A. Brennan. 1999. Costs of medical injuries
in Utah and Colorado. Inquiry 36 (3):255-64.
Patient injuries are thought to have a substantial financial
impact on the health care system, but recent studies have been limited to
estimating the costs of adverse drug events in teaching hospitals. This analysis
estimated the costs of all types of patient injuries from a representative
sample of hospitals in Utah and Colorado. We detected 459 adverse events (of
which 265 were preventable) by reviewing the medical records of 14,732 randomly
selected 1992 discharges from 28 hospitals. The total costs (all results are
discounted 1996 dollars) were $661,889,000 for adverse events, and $308,382,000
for preventable adverse events. Health care costs totaled $348,081,000 for all
adverse events and $159,245,000 for the preventable adverse events. Fifty-seven
percent of the adverse event health care costs, and 46% of the preventable
adverse event costs were attributed to outpatient medical care. Surgical
complications, adverse drug events, and delayed or incorrect diagnoses and
therapies were the most expensive types of adverse events. The costs of adverse
events were similar to the national costs of caring for people with HIV/AIDS,
and totaled 4.8% of per capita health care expenditures in these states.
vom Eigen, K. A., J. D. Walker, S. Edgman-Levitan, P. D.
Cleary, and T. L. Delbanco. 1999. Carepartner experiences with hospital care. Med Care 37
(1):33-8.
OBJECTIVES: Family members and other "carepartners" often
play an important role in the care and support of patients during and after
hospitalization, yet little is known about how they assess their hospital
experience or the factors that may influence their perceptions. METHODS: A
nationwide telephone survey of 1,800 recently discharged patients and their
carepartners about their hospital experience was conducted. Carepartner
responses in six domains of care were summarized, and multivariable regression
analysis was used to detect independent predictors of more frequent problem
reports by carepartners. RESULTS: Carepartners reported problems most frequently
in the domains of emotional support (23.9%), discharge planning (20.3%), and
family participation (17.6%). Independent predictors of more frequent
carepartner problem reports included poor subjective patient health status,
emergency hospitalization, nonsurgical admission, carepartner income less than
$7,500/year, younger carepartner age, noninvolvement of the patient's regular
doctor, less frequent carepartner visits during the hospitalization, and less
time spent with the patient after discharge. CONCLUSIONS: Better awareness of
the problems carepartners experience and attention to improving quality in these
areas may facilitate family involvement in patient care and enhance carepartner
and patient satisfaction.
Weissman, J. S., J. Z. Ayanian, S. Chasan-Taber, M. J.
Sherwood, C. Roth, and A. M. Epstein. 1999a. Hospital readmissions and quality
of care. Med Care
37 (5):490-501.
BACKGROUND: Readmission rates are often proposed as markers
for quality of care. However, a consistent link between readmissions and quality
has not been established. OBJECTIVE: To test the relation of readmission to
quality and the utility of readmissions as hospital quality measures. SUBJECTS:
One thousand, seven hundred and fifty-eight Medicare patients hospitalized in
four states between 1991 to 1992 with pneumonia or congestive heart failure
(CHF). DESIGN: Case control. MEASURES: Related adverse readmissions (RARs),
defined as readmissions that indicate potentially sub-optimal care during
initial hospitalization, were identified from administrative data using
readmission diagnoses and intervening time periods designated by physician
panels. We used linear regression to estimate the association between implicit
and explicit quality measures and readmission status (RARs, non-RAR
readmissions, and nonreadmissions), adjusting for severity. We tested whether
RARs were associated with inferior care and performed simulations to determine
whether RARs discriminated between hospitals on the basis of quality. RESULTS:
Compared with nonreadmitted pneumonia patients, patients with RARs had lower
adjusted quality measured both by explicit (0.25 standardized units, P = 0.004)
and implicit methods (0.17, P = 0.047). Adjusted differences for CHF patients
were 0.17 (P = 0.048) and 0.20 (P = 0.017), respectively. In some analyses,
patients with non-RAR readmissions also experienced lower quality. However,
rates of inferior quality care did not differ significantly by readmission
status, and simulations identified no meaningful relationship between RARs and
hospital quality of care. CONCLUSIONS: RARs are statistically associated with
lower quality of care. However, neither RARs nor other readmissions appear to be
useful tools for identifying patients who experience inferior care or for
comparing quality among hospitals.
Weissman, J. S., J. S. Haas, F. J. Fowler, Jr., C. Gatsonis,
M. P. Massagli, G. R. Seage, 3rd, and P. Cleary. 1999b. The stability of
preferences for life-sustaining care among persons with AIDS in the Boston
Health Study. Med
Decis Making 19 (1):16-26.
BACKGROUND: Clinicians recognize the importance of eliciting
patient preferences for life-sustaining care, yet little is known about the
stability of those preferences for patients with serious disease. OBJECTIVES: To
examine the stability of preferences for life-sustaining care among persons with
AIDS and to assess factors associated with changes in preferences. DESIGN: Two
patient surveys and medical record reviews, administered four months apart in
1990-1991. SETTING: Three health care settings in Boston. PATIENTS: 252 of 505
eligible persons with AIDS who participated in both baseline and follow-up
surveys. MAIN OUTCOME MEASURES: A single question assessing desire for cardiac
resuscitation and a scale of preferences for life-extending treatment
conditional on hypothetical health states. RESULTS: Approximately one- fourth of
the respondents changed their minds about life-sustaining care during a
four-month period. Of patients who initially desired cardiac resuscitation, 23%
decided to forego it four months later, and of those who initially said they
would decline care, 34% later said they would accept it. Of those who initially
desired any of the life- extending treatments, 25% decided to forego them four
months later, and of those who initially said they would decline life-extending
care, 24% later said they would accept some treatment. Patients reporting
changes in physical function, pain, or suicide ideation were more likely to
modify their desires to be resuscitated (all p or =0.05). Patients lacking an
advance directive, not completing high school, or becoming more severely ill
were more likely to change their preferences on the Life Extension scale (p or
=0.05). Patients who discussed their preferences with at least one physician
were just as likely as others to change desires for cardiac resuscitation. Age,
gender, race, emotional health, clinical severity, social support, and site of
care were not significant correlates of change for either measure. CONCLUSIONS:
Health care providers should periodically reassess preferences for
life-sustaining care, particularly for patients with progressive disease, given
the instability in patient preferences. However, predictors of instability may
vary with how preferences are measured. In particular, changes in health status
may be related to instability of preferences for certain types of treatments.
Weissman, J. S., D. Saglam, E. G. Campbell, N. Causino, and
D. Blumenthal. 1999c. Market forces and unsponsored research in academic health
centers [see comments]. JAMA 281 (12):1093-8.
CONTEXT: Increased competitive pressures on academic health
centers may result in reduced discretionary funds from patient care revenues to
support the performance of unsponsored research, including institutionally
funded and faculty-supported activities. OBJECTIVE: To measure the amount and
distribution of unsponsored research activities and their outcomes. DESIGN AND
SETTING: Survey conducted in academic year 1996-1997 of 2336 research faculty in
117 medical schools. Responses were weighted to provide national estimates. MAIN
OUTCOME MEASURES: Institutionally funded research as a proportion of total
direct costs of research was compared across stages of market competition.
Logistic regression was used to assess the relationship of performing
unsponsored research to faculty characteristics and market stage. RESULTS:
Overall, 43% of faculty received institutional funding for research. Young
faculty were more likely than others to receive institutional support (adjusted
odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1-1.9; P = .004). The
amount of institutional support as a proportion of total funding was more than
twice as high in less competitive markets (6.1%) compared with the most
competitive markets (2.5%; P = .05). Most faculty (55%) performed
faculty-supported research. Clinical researchers (OR, 1.6; 95% CI, 1.1-2.3),
principal investigators (OR, 4.3; 95% CI, 2.8-7.0), faculty with high levels of
research effort (OR, 6.2; 95% CI, 4.0-9.5) or institutional funding (OR, 1.9;
95% CI, 1.4-2.6), and faculty in the most competitive markets (OR, 1.9; 95% CI,
1.4-2.5) were more likely than others to conduct faculty-supported research.
When undertaken by clinical researchers, these activities were supported by
clinical income, extra hours worked, and discretionary funds, and often led to
publications (76%) or grant awards (51%). CONCLUSIONS: Many academic health
center faculty receive institutional support to conduct their research or fund
the research themselves. Market pressures may be affecting the level of
institutional funding available to faculty.
Williams, T. V., A. M. Zaslavsky, and P. D. Cleary. 1999.
Physician experiences with, and ratings of, managed care organizations in
Massachusetts. Med
Care 37 (6):589-600.
BACKGROUND: Physicians can provide important information
about how managed care plans affect the delivery of health care. Assessments of
the quality of managed care plans have rarely used physician evaluations.
OBJECTIVES: To elicit physician evaluations of managed care plans and to
determine factors associated with those evaluations. RESEARCH DESIGN: Physicians
were asked in a mail survey to evaluate a managed care plan they were associated
with. SUBJECTS: Probability sample of 1,336 physicians associated with the five
largest managed care health plans in Massachusetts. MEASURES: Physicians were
asked about the extent to which the management strategies used by a plan
influenced their clinical behavior and about the quality of care available to
their patients. RESULTS: Evaluations of the plans were significantly different
among the eight units evaluated. Some differences between divisions within plans
were as large as differences among plans. Physicians reported that the use of
education and peer influence influenced their clinical behavior and facilitated
the provision of high quality care more than did rules and regulations or
financial incentives. Physicians evaluated most positively plans, which they
said used educational strategies more than other plans and which used rules and
regulations and financial incentives less. Physicians tended to rate staff and
group model plans more positively than did other plans. CONCLUSIONS: Physicians
can provide important information about the extent to which the organization and
operation of managed care plans affect the provision of high quality care.
Zaslavsky, A. M., N. D. Beaulieu, B. E. Landon, and P. D.
Cleary. 2000a. Dimensions of consumer-assessed quality of Medicare managed-care
health plans. Med
Care 38 (2):162-74.
OBJECTIVES: We investigated relationships at the health-plan
level among member ratings of and reports on plans in the Consumer Assessment of
Health Plans Survey (CAHPS). We sought a more parsimonious description of the
reports that can be used in analyses of the distribution and correlates of
consumer-assessed quality. SUBJECTS: There were 89,419 Medicare beneficiaries
enrolled in 212 Medicare managed-care health plans who responded to CAHPS in
1998. MEASURES: There were 39 survey items measuring consumer ratings of and
reports on care. METHODS: We adjusted correlations for sampling variability in
the plan means and performed a principal factor analysis of the report items
with oblique rotation. We grouped items that loaded heavily on the different
factors, formed composites, and regressed rating items on the report composites.
RESULTS: Four factors explained 75% of the variance in the reports. The
corresponding groups of items were concerned with the following subjects: (1)
interactions around delivery of care in the doctor's office; (2) customer
service from the plan; (3) access to medical services provided by the plan, such
as specialist care, equipment, therapy, or drugs; and (4) advice on
health-promoting activities. Corrected Cronbach alpha for composites were 0.97,
0.93, 0.86, and 0.60. The "delivery" composite was strongly predictive of
overall ratings of care, doctor, and specialist; the "customer" composite was
strongly predictive of overall ratings of the plan. CONCLUSIONS: CAHPS
distinguishes among dimensions of between-plan variability of consumer-assessed
quality. Different global ratings are related to distinct groups of consumer
reports on their experiences.
Zaslavsky, A. M., J. N. Hochheimer, E. C. Schneider, P. D.
Cleary, J. J. Seidman, E. A. McGlynn, J. W. Thompson, C. Sennett, and A. M.
Epstein. 2000b. Impact of sociodemographic case mix on the HEDIS measures of
health plan quality. Medical Care (accepted for publication).
Background: The widely used HEDIS measures may be affected by differences among plans in sociodemographic characteristics of members. Objective: To estimate effects of geographically-linked patient sociodemographic characteristics on differential performance within and among plans on HEDIS measures. Research design: Using logistic regression, we modeled associations between age, sex, and residential area characteristics of health plan members and results on HEDIS measures. We then calculated the impact of adjusting for these associations on plan-level measures. Subjects: 92,232 commercially-insured members with individual-level HEDIS data, and an additional 20,615 members whose geographical distribution was provided. Measures: Seven measures of screening and preventive services. Results: Performance was negatively associated with percent receiving public assistance in the local area (6 of 7 measures), percent Black (5 measures) and percent Hispanic (2 measures), and positively associated with percent college educated (6 measures), percent urban (2 measures), and percent Asian (1 measure), after controlling for plan and product type. These effects were generally consistent across plans. When measures were adjusted for these characteristics, rates for most plans changed by less than 5 percentage points. The largest change in the difference between plans ranged from 1.5% for retinal exams for people with diabetes, to 20.2% for immunization of adolescents. Conclusions: Performance on quality indicators for individual members is associated with sociodemographic context. Adjustment has little impact on the measured performance of most plans, but a substantial impact for a few. Further study with more plans is required to determine the appropriateness and feasibility of adjustment.
Zaslavsky, A. M., B. E. Landon, N. D. Beaulieu, and P. D.
Cleary. 2000c. How consumer assessments of managed care vary within and among
markets [In Process Citation]. Inquiry 37 (2):146-61.
This
study investigated the extent to which the Consumer Assessments of Health Plans
Survey (CAHPS) distinguishes performance of Medicare managed care (MMC) health
plans. Results indicate that CAHPS ratings and report composites distinguish
among plans both nationally and within markets. Global ratings of a health plan
and reports on customer services varied strongly at the individual plan level,
with smaller effects seen at regional and Metropolitan Statistical Area (MSA)
levels. Ratings of doctors and health care, and reports on experiences in the
doctor's office varied more among regions and among MSAs than among plans within
the same MSA. These patterns are consonant with our hypotheses about the
determinants of these ratings: customer service is a distinct plan function, but
medical services are provided by networks that often overlap for plans in the
same area. We conclude that the CAHPS-MMC survey can inform consumers choosing
among plans as well as policymakers and researchers.
Zaslavsky, A. M., T. V. Williams, and P. D. Cleary. 1999.
Sample allocation for overlapping domains in a physician survey with a limited
population. Stat
Med 18 (8):935-46.
We
consider an analytic survey in which each survey unit can respond with respect
to one or more domains to which it belongs. In this situation, the optimal
sample allocation is constrained by the number of available units in each
stratum defined by a set of domains. We present optimal sample allocation rules
for this situation, and other rules that apply when there are additional
constraints on sample sizes or variances by domain. We apply these rules to our
motivating example, the design of a survey of physicians on their experiences
with health plans, in which each physician can only be asked about her
experience with one plan regardless of her number of affiliations.
Zaslavsky, A. M., L. Zaborski, and P. D. Cleary. 2000. Does
the effect of respondent characteristics on consumer assessments vary across
health plans? [In Process Citation]. Med Care Res Rev 57 (3):379-94.
Responses to the Consumer Assessments of Health Plans Survey (CAHPS) are related to respondent characteristics. CAHPS procedures include casemix adjustment to remove effects of difference in respondent characteristics on comparative plan ratings, under the assumption that casemix coefficients are homogeneous across plans. The authors analyzed data from the Washington state CAHPS demonstration, fitting hierarchical models in which coefficients of casemix variables and intercepts could vary by plan. They estimated the impact of variability in casemix coefficients on plan adjustments and also assessed the implications for differential effects of individual characteristics at different plans. Estimated between-plan variability of coefficients was small, but the data are consistent with substantially larger variability. The potential impact of this variability on adjustments for plans was small relative to the magnitude of the adjustments. Comparisons between plans for individuals, however, could be affected substantially. This methodology could be useful wherever casemix adjustment is applied.
Berndt ER, Cutler DM, Frank R, Griliches Z, Newhouse JP, and
Triplett JE.
Price Indexes for Medical Care Goods and Services: An Overview of
Measurement Issues.
Medical Care
Output and
Productivity, eds. Ernst Berndt and David Cutler, in press (also available
as Working Paper 6817 of the National Bureau of Economic Research, Cambridge, MA,
November 1998).
We review in considerable detail the conceptual and measurement issues that underlie construction of medical care price indexes in the U.S., particularly the medical care consumer price indexes (MCPIs) and medical-related producer price indexes (MPPIs). We outline salient features of the medical care marketplace, including the impacts of insurance, moral hazard, principal-agent relationships, technological progress and organizational changes. Since observed data are unlikely to correspond with efficient outcomes, we discuss implications of the failure of transactions data in this market to reveal reliable marginal valuations, and the consequent need to augment traditional transactions data with information based on cost-effectiveness and outcomes studies. We describe procedures currently used by the BLS in constructing MCPIs and MPPIs, including recent revisions, and then consider alternative notions of medical care output pricing that involve the price or cost of an episode of treatment, rather than prices of fixed bundles of inputs. We outline features of a proposed new experimental price index -- a medical care expenditure price index -- that is more suitable for evaluation and analyses of medical care cost changes, than are the current MCPIs and MPPIs. We conclude by suggesting future research and measurement issues that are most likely to be fruitful.
Cutler D, McClellan M, Newhouse JP, and Remler D. Pricing Heart Attack
Treatments. Medical Care Output and Productivity, eds., Ernst Berndt and David
Cutler, in press (available as Working Paper 7089 of the National Bureau of
Economic Research, Cambridge, MA, April 1999).
In
this paper, we estimate price indices for heart attack treatments, demonstrating
the techniques that are currently used in official price indices and presenting
some alternatives. We consider two types of price indices, a Service Price
Index, which prices specific treatments provided, and a
Cost of Living Index, which prices the health outcomes of
patients. Both indices are complicated by price measurement issues: list prices
and transactions prices are fundamentally different in the medical care field.
The development of new or modified medical treatments further complicates the
comparison of like' goods over time. And the Cost of Living Index is hampered by
the need to determine how much of health improvement results from medical
treatments in comparison to other factors. We describe methods to address each
of these obstacles. We conclude that whereas traditional price indices when
applied to heart attack treatments are rising at roughly 3 percent per year
above general inflation, a corrected service price index is rising at perhaps 1
to 2 percent per year above general inflation, and the cost of living index is
falling by 1 to 2 percent per year relative to general inflation. We discuss the
implications of these results for official price index calculations.