Showing papers in "Health Affairs in 2001"
TL;DR: The CCM is described, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process are described, to guide quality improvement.
Abstract: The growing number of persons suffering from major chronic illnesses face many obstacles in coping with their condition, not least of which is medical care that often does not meet their needs for effective clinical management, psychological support, and information. The primary reason for this may be the mismatch between their needs and care delivery systems largely designed for acute illness. Evidence of effective system changes that improve chronic care is mounting. We have tried to summarize this evidence in the Chronic Care Model (CCM) to guide quality improvement. In this paper we describe the CCM, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process.
3,215 citations
TL;DR: The current nursing shortage, high hospital nurse job dissatisfaction, and reports of uneven quality of hospital care are not uniquely American phenomena. as mentioned in this paper presents reports from 43,000 nurses from more than 700 hospitals in the United States, Canada, England, Scotland, and Germany in 1998-1999.
Abstract: The current nursing shortage, high hospital nurse job dissatisfaction, and reports of uneven quality of hospital care are not uniquely American phenomena. This paper presents reports from 43,000 nurses from more than 700 hospitals in the United States, Canada, England, Scotland, and Germany in 1998-1999. Nurses in countries with distinctly different health care systems report similar shortcomings in their work environments and the quality of hospital care. While the competence of and relation between nurses and physicians appear satisfactory, core problems in work design and workforce management threaten the provision of care. Resolving these issues, which are amenable to managerial intervention, is essential to preserving patient safety and care of consistently high quality.
1,539 citations
TL;DR: It is concluded that medical spending as a whole is worth the increased cost of care, and has many implications for public policy.
Abstract: When costs and benefits are weighed together, technological advances have proved to be worth far more than their costs. by David M. Cutler and Mark McClellan ABSTRACT: Medical technology is valuable if the benefits of medical advances exceed the costs. We analyze technological change in five conditions to deter- mine if this is so. In four of the conditions—heart attacks, low-birthweight infants, depression, and cataracts—the estimated benefit of technological change is much greater than the cost. In the fifth condition, breast cancer, costs and benefits are about of equal magnitude. We conclude that medical spending as a whole is worth the increased cost of care. This has many implications for public policy. I t is widely accepted that technological change has ac- counted for the bulk of medical care cost increases over time. But it does not necessarily follow that technological change is there- fore bad. Presumably, technological change brings benefits in addi- tion to costs—increased longevity, improved quality of life, less time absent from work, and so on. These benefits need to be compared with the costs of technology before welfare statements can be made. Technological change is bad only if the cost increases are greater than the benefits. In aggregate, health has improved as medical spending has in- creased. Given then prevailing medical spending by age, the average newborn in 1950 could expect to spend $8,000 in present value on medical care over his or her lifetime. The comparable amount in 1990 is $45,000. An infant born in 1990 had a life expectancy that was seven years greater than that of the one born in 1950, and lower lifetime disability as well. 1 But how much of the health improvement is a result of medical care? Is the medical component worth it? These questions capture perhaps the most critical issue in the economic
881 citations
TL;DR: This article found that one-quarter of Medicare outlays are for the last year of life, unchanged from twenty-five years ago, reflecting care for multiple severe illnesses typically present near death.
Abstract: This paper profiles Medicare beneficiaries’ costs for care in the last year of life. About one-quarter of Medicare outlays are for the last year of life, unchanged from twenty years ago. Costs reflect care for multiple severe illnesses typically present near death. Thirty-eight percent of beneficiaries have some nursing home stay in the year of their death; hospice is now used by half of Medicare cancer decedents and 19 percent of Medicare decedents overall. African Americans have much higher end-of-life costs than others have, an unexpected finding in light of their generally lower health care spending.
500 citations
TL;DR: This paper found that fewer noncitizen immigrants and their children (even U.S.-born) have Medicaid or job-based insurance, and many more are uninsured than is the case with native citizens or children of citizens.
Abstract: Recent policy changes have limited immigrants’ access to insurance and to health care. Fewer noncitizen immigrants and their children (even U.S.-born) have Medicaid or job-based insurance, and many more are uninsured than is the case with native citizens or children of citizens. Noncitizens and their children also have worse access to both regular ambulatory and emergency care, even when insured. Immigration status is an important component of racial and ethnic disparities in insurance coverage and access to care.
461 citations
TL;DR: In this paper, the authors examined out-of-pocket medical spending by persons with and without chronic conditions using data from the 1996 Medical Expenditure Panel Survey (MEPS) and found that the level of this spending also varied by age and insurance coverage, among other characteristics.
Abstract: We examined out-of-pocket medical spending by persons with and without chronic conditions using data from the 1996 Medical Expenditure Panel Survey (MEPS). Our results show that mean out-of-pocket spending increased with the number of chronic conditions. The level of this spending also varied by age and insurance coverage, among other characteristics. Out-of-pocket spending for prescription drugs was substantial for both elderly and nonelderly persons with chronic conditions. As policymakers continue to use cost sharing and design of benefit packages to contain health spending, it is important to consider the impact of these policies on persons with chronic conditions and their families.
407 citations
TL;DR: The findings show that the skewed concentration of health care expenditures has remained very stable; 5 percent of the population accounts for the majority of health expenditures.
Abstract: In two previous publications, we described the distribution of health care expenditures among the civilian, noninstitutionalized U.S. population, specifically in terms of the share of aggregate expenditures accounted for by the top spenders in the distribution. Our focus revealed considerably skewed distribution, with a relatively small proportion of the population accounting for a large share of expenditures. In this paper we update our previous tabulations (last computed using data more than a decade old) with new data from the 1996 Medical Expenditure Panel Survey (MEPS). Our findings show that the skewed concentration of health care expenditures has remained very stable; 5 percent of the population accounts for the majority of health expenditures.
342 citations
TL;DR: Using a nationally representative sample of 23,230 U.S. residents, patterns of economic burden across five chronic conditions: mood disorders, diabetes, heart disease, asthma, and hypertension are examined.
Abstract: Using a nationally representative sample of 23,230 U.S. residents, we examine patterns of economic burden across five chronic conditions: mood disorders, diabetes, heart disease, asthma, and hypertension. Almost half of U.S. health care costs in 1996 were borne by persons with one or more of these five conditions; of that spending amount, only about one-quarter was spent on treating the conditions themselves and the remainder on coexistent illnesses. Each condition demonstrated substantial economic burden but also unique characteristics and patterns of service use driving those costs. The findings highlight the differing challenges involved in understanding needs and improving care across particular chronic conditions.
315 citations
TL;DR: In response to a mail survey, 225 leading general internists provided their opinions of the relative importance to patients of thirty medical innovations, which yielded a mean score and a variability score for each innovation.
Abstract: In response to a mail survey, 225 leading general internists provided their opinions of the relative importance to patients of thirty medical innovations. They also provided information about thems...
272 citations
TL;DR: Evidence on changes in disability among the elderly and its implications is analyzed to determine whether the projected increase in medical spending resulting from technological changes in health care would be moderated, but not eliminated.
Abstract: This paper analyzes evidence on changes in disability among the elderly and considers its implications. Disability among the elderly has declined by 1 percent or more per year for the past several decades. Strong evidence relates these changes to improved medical technology and to behavioral changes. Changes in socioeconomic status, disease exposure, and use of supportive aids are likely important as well, although their magnitude is difficult to gauge. Should disability improvements continue, the projected increase in medical spending resulting from technological changes in health care would be moderated, but not eliminated. Disability change also may facilitate an increase in age of retirement.
254 citations
TL;DR: This study analyzes data on prescribed medicines from the 1996 Medical Expenditure Panel Survey to examine the association between the use of newer medicines and morbidity, mortality, and health spending.
Abstract: This study analyzes data on prescribed medicines from the 1996 Medical Expenditure Panel Survey (MEPS) to examine the association between the use of newer medicines and morbidity, mortality, and health spending. We find that people consuming newer drugs were significantly less likely to die by the end of the survey and were significantly less likely to experience work-loss days than were people consuming older drugs. Our most notable finding, however, is that use of newer drugs tends to lower all types of nondrug medical spending, resulting in a substantial net reduction in the total cost of treating a given condition.
TL;DR: Empowering older persons and their agents to make better decisions, including providing them with more structure and better consumer information; revising attitudes toward safety and protection; and developing more vigorous advocacy by and for seniors.
Abstract: Seniors’ long-term care preferences resemble those of younger persons with disabilities, but the two groups are treated differently. Younger persons with disabilities pursue the goal of social integration, whereas safety and efficiency receive undue emphasis and ageist differences prevail in the way older persons are served. Among the changes needed to help older consumers get what they want are empowering older persons and their agents to make better decisions, including providing them with more structure and better consumer information; revising attitudes toward safety and protection; and developing more vigorous advocacy by and for seniors.
TL;DR: These dimensions of patients' experience appear to be salient and relevant in each of the five countries, but attempts to develop international rankings based on this type of evidence will have to overcome a number of methodological problems.
Abstract: Analysis of patient surveys carried out in Germany, Sweden, Switzerland, the United Kingdom, and the United States in 1998–2000 revealed high rates of problems during inpatient hospital stays. Prob...
TL;DR: In this article, the authors compared the World Health Organization (WHO) rankings for seventeen industrialized countries with the perceptions of their citizens, and found that the health systems of some top WHO performers are rated poorly by their citizens.
Abstract: The World Health Organization (WHO) ranked health systems in 191 countries based on measures developed by public health experts. This paper compares the WHO rankings for seventeen industrialized countries with the perceptions of their citizens. The results show little relationship between WHO rankings and the satisfaction of the citizens who experience these health systems. The health systems of some top WHO performers are rated poorly by their citizens, including the low-income and elderly. The two rated most highly by the public rank at the bottom of the WHO ratings. These findings suggest that both public and expert views should be considered in international rankings.
TL;DR: This paper examines the current programs designed to assist persons with chronic illnesses, disabilities, and functional limitations and suggests changes in eligibility rules, coverage policies, and educational programs to provide a system more oriented to people's chronic care needs.
Abstract: Persons who are likely to be the heaviest users of medical and supportive care services—those with chronic illnesses, disabilities, and functional limitations—are often forced to navigate a system that requires them to perform most of the coordination functions themselves and is generally not organized around their needs. In 1996 an estimated 128 million Americans had at least one of these three conditions, and 9.5 million had all three. This paper examines the current programs designed to assist these persons and suggests changes in eligibility rules, coverage policies, and educational programs to provide a system more oriented to people’s chronic care needs.
TL;DR: The performance of the health care systems in twenty-nine industrialized countries in 1998 is presented and the United States is compared with the other industrialized countries for selected indicators in 1960, 1980, and 1998.
Abstract: We present data from the Organization for Economic Cooperation and Development and the World Health Organization on the performance of the health care systems in twenty-nine industrialized countries in 1998. We also compare the performance of the United States with the other industrialized countries for selected indicators in 1960, 1980, and 1998. On most indicators the U.S. relative performance declined since 1960; on none did it improve.
TL;DR: Canadian primary care has been shaped by a series of policy legacies that continue to affect the possibilities for change in primary care through their cumulative effects on the health care system and the process of health policy development.
Abstract: The development of Canadian primary care has been shaped by a series of policy legacies that continue to affect the possibilities for change in primary care through their cumulative effects on the health care system and the process of health policy development. The pursuit of radical systemwide change in the face of unfavorable circumstances (created in large part by those legacies) has resulted in missed opportunities for cumulative incremental change. While major changes in primary care policy seem unlikely in the near future, significant incremental change is possible, but it will require a reorientation of the policy development process.
TL;DR: Data from the 1995-1999 National Ambulatory Medical Care Surveys suggest that PAs and NPs are providing primary care in a way that is similar to physician care.
Abstract: Federal policies and state legislation encourage the use of physician assistants (PAs) and nurse practitioners (NPs) in primary care, although the nature of their work has not been fully analyzed. In this paper we analyze primary care physician office encounter data from the 1995–1999 National Ambulatory Medical Care Surveys. About one-quarter of primary care office based physicians used PAs and/or NPs for an average of 11 percent of visits. The mean age of patients seen by physicians was greater than that for PAs or NPs. NPs provided counseling/education during a higher proportion of visits than did PAs or physicians. Overall, this study suggests that PAs and NPs are providing primary care in a way that is similar to physician care.
TL;DR: The principles underlying evidence-based coverage policy and how they are applied by two major programs are discussed, the Technology Evaluation Center of the Blue Cross Blue Shield Association and the Medicare Coverage Advisory Committee.
Abstract: Many health plans apply evidence-based approaches to coverage decisions. The foundation of such approaches is the systematic review of information about the effectiveness of medical interventions. This paper discusses the principles underlying evidence-based coverage policy and how they are applied by two major programs: the Technology Evaluation Center of the Blue Cross Blue Shield Association and the Medicare Coverage Advisory Committee. Although such policies likely have limited effects on spending, they can help to direct medical resources toward effective care.
TL;DR: A review of data from more than 100 public opinion surveys conducted over a fifty-year period found that the American public has conflicting views about the nation's health policy as mentioned in this paper, and they report much...
Abstract: A review of data from more than 100 public opinion surveys conducted over a fifty-year period finds that the American public has conflicting views about the nation’s health policy. They report much...
TL;DR: The data show that in 1998 the aggregate prescription drug coverage rate of Medicare beneficiaries may have reached a plateau, and prescription drug use declined for beneficiaries without drug coverage and increased for those with drug coverage.
Abstract: Using data from the 1998 Medicare Current Beneficiary Survey (MCBS), we examine changes in beneficiaries’ prescription drug coverage from 1997 to 1998 and compare drug use and spending data for beneficiaries with and without drug coverage. The data show that in 1998 the aggregate prescription drug coverage rate of Medicare beneficiaries may have reached a plateau. Also, prescription drug use declined for beneficiaries without drug coverage and increased for those with drug coverage. Covered beneficiaries also paid a larger percentage of their total drug costs out of pocket in 1998 than in 1997. The result was a widening of use and spending differences between beneficiaries with and without coverage.
TL;DR: It is found that Medicaid and privately insured low-income children appear to have fairly comparable access but that Medicaid-covered children are more likely to receive services and to have more visits when they receive care.
Abstract: In this paper we assess how access to care and use of services among low-income children vary by insurance status. Although 40 percent of low-income children rely on private health insurance, little is known about how this coverage compares with Medicaid coverage in meeting their health care needs. We find that Medicaid and privately insured low-income children appear to have fairly comparable access but that Medicaid-covered children are more likely to receive services and to have more visits when they receive care. Expanding public coverage may not be sufficient to ensure that all low-income children have access to comprehensive and high-quality care. It may require improvements in preventive and dental care for children with private coverage, an area in which states have limited influence.
TL;DR: This paper offers an analysis aimed at understanding pricing patterns of brand-name prescription drugs, and focuses on the basic economic forces that enable differential pricing of products to exist and how features of the prescription drug market promote such phenomena.
Abstract: The fact that sick elderly people without prescription drug coverage pay far more for drugs than do people with private health insurance has created a call for state and federal governments to take action. Antitrust cases have been launched, state price control legislation has been enacted, and proposals for expansion of Medicare have been offered in response to price and spending levels for prescription drugs. This paper offers an analysis aimed at understanding pricing patterns of brand-name prescription drugs. I focus on the basic economic forces that enable differential pricing of products to exist and show how features of the prescription drug market promote such phenomena. The analysis directs policy attention toward how purchasing practices can be changed to better represent groups that pay the most and are most disadvantaged.
TL;DR: The results suggest that people value genetic testing for personal and financial reasons, but they also underscore the need to counsel potential recipients carefully about the accuracy and implications of test information.
Abstract: In a general population survey (N = 314), 79 percent of respondents stated that they would take a hypothetical genetic test to predict whether they will eventually develop Alzheimer’s disease. The ...
TL;DR: How the current system of regulation developed, its impact, and draws on the wider literature on regulation to outline some characteristics that may have detracted from its effectiveness and contributed to its disappointing results are described.
Abstract: The quality of care in U.S. nursing homes has been a recurrent matter of public concern and policy attention for more than thirty years. A complex regulatory system of state licensure and federal certification is in place, but problems of poor quality and neglect and abuse of patients still appear to be endemic. This paper describes how the current system of regulation developed, examines its impact, and draws on the wider literature on regulation to outline some characteristics that may have detracted from its effectiveness and contributed to its disappointing results. Future regulatory reform should pay more attention to the lessons of regulation in other settings and make more use of research and formative evaluation.