Showing papers in "Health Affairs in 2008"
TL;DR: Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.
Abstract: Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health car...
4,276 citations
TL;DR: With the exception of black males, all recent gains in life expectancy at age twenty-five have occurred among better-educated groups, raising educational differentials in life life expectancy by 30 percent.
Abstract: In this paper we examine educational disparities in mortality and life expectancy among non-Hispanic blacks and whites in the 1980s and 1990s. Despite increased attention and substantial dollars directed to groups with low socioeconomic status, within race and gender groups, the educational gap in life expectancy is rising, mainly because of rising differentials among the elderly. With the exception of black males, all recent gains in life expectancy at age twenty-five have occurred among better-educated groups, raising educational differentials in life expectancy by 30 percent. Differential trends in smoking-related diseases explain at least 20 percent of this trend.
715 citations
TL;DR: In a large health plan, 377,048 patients underwent 4.9 million diagnostic tests from 1997 through 2006, and the annual per enrollee cost of radiology imaging more than doubled.
Abstract: Little has been published characterizing specific patterns of the dramatic rise in diagnostic imaging during the past decade. In a large health plan, 377,048 patients underwent 4.9 million diagnostic tests from 1997 through 2006. Cross-sectional imaging nearly doubled over those years, rising from 260 to 478 examinations per thousand enrollees per year. Imaging with computed tomography (CT) doubled, and imaging with magnetic resonance imaging (MRI) tripled. Cross-sectional studies added to existing studies instead of replacing them, and the annual per enrollee cost of radiology imaging more than doubled. The dramatic rise in imaging raises both costs and radiation exposure.
536 citations
TL;DR: In this paper, the authors reviewed the evidence for mental health and mental health care disparities, comparing them to patterns in health and found that minorities have equal or better mental health than white Americans.
Abstract: Minorities have, in general, equal or better mental health than white Americans, yet they suffer from disparities in mental health care. This paper reviews the evidence for mental health and mental health care disparities, comparing them to patterns in health. Strategies for addressing disparities in health care, such as improving access to and quality of care, should also work to eliminate mental health care disparities. In addition, a diverse mental health workforce, as well as provider and patient education, are important to eliminating mental health care disparities.
482 citations
TL;DR: If the United States could reduce amenable mortality to the average rate achieved in the three top-performing countries, there would have been 101,000 fewer deaths per year by the end of the study period.
Abstract: We compared trends in deaths considered amenable to health care before age seventy-five between 1997–98 and 2002–03 in the United States and in eighteen other industrialized countries. Such deaths account, on average, for 23 percent of total mortality under age seventy-five among males and 32 percent among females. The decline in amenable mortality in all countries averaged 16 percent over this period. The United States was an outlier, with a decline of only 4 percent. If the United States could reduce amenable mortality to the average rate achieved in the three top-performing countries, there would have been 101,000 fewer deaths per year by the end of the study period.
475 citations
TL;DR: The authors present a framework for categorizing and developing business models in health care, followed by a discussion of some of the reasons why disruptive innovation in health Care delivery has been slow.
Abstract: Disruptive innovation has brought affordability and convenience to customers in a variety of industries. However, health care remains expensive and inaccessible to many because of the lack of business-model innovation. This paper explains the theory of disruptive innovation and describes how disruptive technologies must be matched with innovative business models. The authors present a framework for categorizing and developing business models in health care, followed by a discussion of some of the reasons why disruptive innovation in health care delivery has been slow.
451 citations
TL;DR: It is argued that unless China tackles the root cause of unaffordable health care--rapid cost inflation caused by an irrational and wasteful health care delivery system--much of the new money is likely to be captured by providers as higher income and profits.
Abstract: The Chinese government has committed to increasing government funding for health care by directing 1–1.5 percent of its gross domestic product to universal basic health care. However, China is at a...
433 citations
TL;DR: This 2008 survey of chronically ill adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States finds major differences among countries in access, safety, and care efficiency.
Abstract: This 2008 survey of chronically ill adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States finds major differences among countries in access, safety, and care efficiency. U.S. patients were at particularly high risk of forgoing care because of costs and of experiencing inefficient, poorly organized care, or errors. The Dutch, who have a strong primary care infrastructure, report notably positive access and coordination experiences. Still, deficits in care management during hospital discharge or when seeing multiple doctors occurred in all countries. Findings highlight the need for system innovations to improve outcomes for patients with complex chronic conditions.
420 citations
TL;DR: The Geisinger Health System's innovation strategy for care model redesign is described, showing how clinical leadership, dedicated innovation team, electronic health information systems, and financial incentive alignment each contribute to its innovation record.
Abstract: To achieve the diverse health care goals of the United States, health care value must increase. The capacity to create value through innovation is facilitated by an integrated delivery system focused on creating value, measuring innovation returns, and receiving market rewards. This paper describes the Geisinger Health System’s innovation strategy for care model redesign. Geisinger’s clinical leadership, dedicated innovation team, electronic health information systems, and financial incentive alignment each contribute to its innovation record. Although Geisinger’s characteristics raise serious questions about broad applicability to nonintegrated health care organizations, its experience can provide useful insights for health system reform.
311 citations
TL;DR: As the medical home concept is further developed, it will be important to not overemphasize redesign of practices at the expense of patient-centered care, which is the hallmark of excellent primary care.
Abstract: The “patient-centered medical home” has been promoted as an enhanced model of primary care. Based on a literature review and interviews with practicing physicians, we find that medical home advocates and physicians have somewhat different, although not necessarily inconsistent, expectations of what the medical home should accomplish—from greater responsiveness to the needs of all patients to increased focus on care management for patients with chronic conditions. As the medical home concept is further developed, it will be important to not overemphasize redesign of practices at the expense of patient-centered care, which is the hallmark of excellent primary care.
285 citations
TL;DR: The results demonstrate the potential for copayment reductions for highly valued services to increase medication adherence above the effects of existing DM programs.
Abstract: This paper estimates the effects of a large employer’s value-based insurance initiative designed to improve adherence to recommended treatment regimens. The intervention reduced copayments for five chronic medication classes in the context of a disease management (DM) program. Compared to a control employer that used the same DM program, adherence to medications in the value-based intervention increased for four of five medication classes, reducing nonadherence by 7–14 percent. The results demonstrate the potential for copayment reductions for highly valued services to increase medication adherence above the effects of existing DM programs.
TL;DR: The happiness-health relationship from an economics perspective is reviewed, highlighting the role of adaptation and how happiness surveys can-and cannot-inform public health policy.
Abstract: This paper reviews the happiness-health relationship from an economics perspective, highlighting the role of adaptation People’s expectations for health standards influence their reported health and associated happiness, a finding that roughly mirrors the Easterlin paradox in income and happiness Research on unhappiness and obesity shows that norms and stigma vary a great deal across countries and cohorts, mediating the related well-being costs Better understanding this variance and its effects on incentives for addressing the condition is important to policy design More generally, the paper discusses how happiness surveys can—and cannot—inform public health policy
TL;DR: The authors predicts that population growth and aging will increase family physicians and general internists' workloads by 29 percent between 2005 and 2025, which will threaten the nation's foundation of primary care for adults.
Abstract: We predict that population growth and aging will increase family physicians’ and general internists’ workloads by 29 percent between 2005 and 2025. We expect a 13 percent increased workload for care of children by pediatricians and family physicians. However, the supply of generalists for adult care, adjusted for age and sex, will increase 7 percent, or only 2 percent if the number of graduates continues to decline through 2008. We expect deficits of 35,000–44,000 adult care generalists, although the supply for care of children should be adequate. These forces threaten the nation’s foundation of primary care for adults.
TL;DR: In this paper, the authors surveyed primary care physicians to assess variability in discretionary decision making and evaluate its relationship to the cost of health care, and found that physicians in high-spending regions see patients back more frequently and are more likely to recommend screening tests of unproven benefit and discretionary interventions compared with physicians in low spending regions.
Abstract: Efforts to improve the quality and costs of U.S. health care have focused largely on fostering physician adherence to evidence-based guidelines, ignoring the role of clinical judgment in more discretionary settings. We surveyed primary care physicians to assess variability in discretionary decision making and evaluate its relationship to the cost of health care. Physicians in high-spending regions see patients back more frequently and are more likely to recommend screening tests of unproven benefit and discretionary interventions compared with physicians in low-spending regions; however, both appear equally likely to recommend guideline-supported interventions. Greater attention should be paid to the local factors that influence physicians’ clinical judgment in discretionary settings.
TL;DR: The Netherlands health system is a possible model for the United States because all Dutch citizens have to buy standardized individual health insurance coverage from a private insurer, and consumers have an annual choice among insurers.
Abstract: Policy analysts consider the Netherlands health system a possible model for the United States. Since 2006 all Dutch citizens have to buy standardized individual health insurance coverage from a private insurer. Consumers have an annual choice among insurers, and insurers can selectively contract or integrate with health care providers. Subsidies make health insurance affordable for everyone. A Risk Equalization Fund compensates insurers for enrollees with predictably high medical expenses. The reform is a work in progress. So far the emphasis has been on the health insurance market. The challenge is now to successfully reform the market for the provision of health care.
TL;DR: This approach identifies how specific social environments "get under the skin" to cause disease, illustrated with the disparity in mortality from aggressive premenopausal breast cancer suffered by black women.
Abstract: Certain social/environmental factors put some groups at extraordinary risk for adverse health outcomes, creating health disparities. We present a downward causal model, originating at the population level and ending at disease, with psychological and behavioral responses linking the two. This approach identifies how specific social environments “get under the skin” to cause disease, illustrated with the disparity in mortality from aggressive premenopausal breast cancer suffered by black women. Broadening our lens to consider the entire chain of causal factors, spanning multiple levels and interacting across the life span, heightens our ability to craft specific interventions to address group differences in health.
TL;DR: Public investments are needed to head off a huge increase in the morbidity, disability, absenteeism, and medical care costs linked with this nutritional shift in China.
Abstract: Rapid social and economic change is transforming China, with enormous implications for its population and economy. More than a fifth of China’s adult population is overweight, related to changing d...
TL;DR: Policy-makers need to move beyond conventional public health and health care approaches to consider policies to improve access to opportunity-rich neighborhoods through enhanced housing mobility, and to increase the opportunities for healthy living in disadvantaged neighborhoods.
Abstract: Extreme racial/ethnic disparities exist in children’s access to “opportunity neighborhoods.” These disparities arise from high levels of residential segregation and have implications for health and...
TL;DR: Food availability and prices in large and small stores across neighborhoods of varying income levels in New Haven, Connecticut suggest that supermarket access in lower-income neighborhoods has improved since 1971, and average food prices are comparable across income areas.
Abstract: Two studies compared food availability and prices in large and small stores across neighborhoods of varying income levels in New Haven, Connecticut. The findings suggest that supermarket access in lower-income neighborhoods has improved since 1971, and average food prices are comparable across income areas. Despite this progress, stores in lower-income neighborhoods (compared to those in higher-income neighborhoods) stock fewer healthier varieties of foods and have fresh produce of much lower quality. Policies are needed not only to improve access to supermarkets, but also to ensure that stores in lower-income neighborhoods provide high-quality produce and healthier versions of popular foods.
TL;DR: The outlook for national health spending calls for continued steady growth, with the health share of gross domestic product (GDP) expected to increase to 16.3 percent in 2007 and then rise throughout the projection period, reaching 19.5 percent of GDP by 2017.
Abstract: The outlook for national health spending calls for continued steady growth. Spending growth is projected to be 6.7 percent in 2007, similar to its rate in 2006. Average annual growth over the projection period is expected to be 6.7 percent. Slower growth in private spending toward the end of the period is expected to be offset by stronger growth in public spending. The health share of gross domestic product (GDP) is expected to increase to 16.3 percent in 2007 and then rise throughout the projection period, reaching 19.5 percent of GDP by 2017.
TL;DR: It is found that education is a more powerful determinant of health behaviors and outcomes for some groups than it is for others, and any intervention for eliminating health disparities must take these patterns into account.
Abstract: Using pooled data from the 2000-2006 National Health Interview Survey, we document how the relationship between education and a broad range of health measures varies by race/ethnicity and nativity. We found that education is a more powerful determinant of health behaviors and outcomes for some groups than it is for others. In addition, the education differentials for foreign-born groups are typically more modest than those for corresponding native-born populations. We also show how the education-health relationship varies across Hispanic and Asian subgroups. We argue that any intervention for eliminating health disparities must take these patterns into account.
TL;DR: Black, Hispanics, women, and patients seen in urban EDs waited longer than other patients did and were especially pronounced for patients with AMI, for whom waits increased 11.2 percent per year.
Abstract: As emergency department (ED) patient volumes increase throughout the United States, are patients waiting longer to see an ED physician? We evaluated the change in wait time to see an ED physician from 1997 to 2004 for all adult ED patients, patients diagnosed with acute myocardial infarction (AMI), and patients whom triage personnel designated as needing “emergent” attention. Increases in wait times of 4.1 percent per year occurred for all patients but were especially pronounced for patients with AMI, for whom waits increased 11.2 percent per year. Blacks, Hispanics, women, and patients seen in urban EDs waited longer than other patients did.
TL;DR: In this paper, the authors compared health status, risk factors, and chronic diseases among people age forty-five and older in China and India, and found that smoking and inadequate physical activity are highly prevalent among older adults.
Abstract: China and India are home to two of the world’s largest populations, and both populations are aging rapidly. Our data compare health status, risk factors, and chronic diseases among people age forty-five and older in China and India. By 2030, 65.6 percent of the Chinese and 45.4 percent of the Indian health burden are projected to be borne by older adults, a population with high levels of noncommunicable diseases. Smoking (26 percent in both China and India) and inadequate physical activity (10 percent and 17.7 percent, respectively) are highly prevalent. Health policy and interventions informed by appropriate data will be needed to avert this burden.
TL;DR: This article made a strong case for diversity in the health care field on the grounds of civil rights, public health and educational benefit, and business gains, emphasizing that African Americans, Latinos, and American Indians are severely underrepresented in health care.
Abstract: African Americans, Latinos, and American Indians are severely underrepresented in the health professions. A strong case for diversity may be made on the grounds of civil rights, public health and educational benefit, and business gains. Improving the diversity of the health professions requires multiprong strategies addressing the educational pipeline, admissions policies and the institutional culture at health professions schools, and the broader policy environment.
TL;DR: With health insurance moving toward greater patient cost sharing, this study finds a sharp increase in the number of underinsured people, and the need for policy attention to benefit design, to assure care and affordability.
Abstract: With health insurance moving toward greater patient cost sharing, this study finds a sharp increase in the number of underinsured people. Based on indicators of cost exposure relative to income, as of 2007 an estimated twenty-five million insured people ages 19–64 were underinsured—a 60 percent increase since 2003. The rate of increase was steepest among those with incomes above 200 percent of poverty, where underinsurance rates nearly tripled. In total, 42 percent of U.S. adults were underinsured or uninsured. The underinsured report high levels of access problems and financial stress. The findings underscore the need for policy attention to benefit design, to assure care and affordability.
TL;DR: It is suggested that money alone, channeled through insurance and infrastructure strengthening, is inadequate to address the current problems of unaffordable health care and heavy financial risk, and the future challenges posed by aging populations that are increasingly affected by noncommunicable diseases.
Abstract: Both China and India have recently committed to injecting new public funds into health care. Both countries are now deciding how best to channel the additional funds to produce benefits for their populations. In this paper we analyze how well the health care systems of China and India have performed and what determines their performance. Based on the analysis, we suggest that money alone, channeled through insurance and infrastructure strengthening, is inadequate to address the current problems of unaffordable health care and heavy financial risk, and the future challenges posed by aging populations that are increasingly affected by noncommunicable diseases.
TL;DR: Wang et al. as discussed by the authors argue that China's pharmaceutical policy has distorted market incentives, increased consumers' costs, and financially rewarded inappropriate prescribing, thus undermining public health, and they propose a solution to solve the problem.
Abstract: Contradictory goals plague China’s pharmaceutical policy. The government wants to develop the domestic pharmaceutical industry and has used drug pricing to cross-subsidize public hospitals. Yet the government also aims to control drug spending through price caps and profit-margin regulations to guarantee access even for poor patients. The resulting system has distorted market incentives, increased consumers’ costs, and financially rewarded inappropriate prescribing, thus undermining public health. Pharmaceuticals account for about half of total health spending in China, representing 43 percent of spending per inpatient episode and 51 percent of spending per outpatient visit. Yet some essential medicines are unavailable or of questionable quality.
TL;DR: The implementation of Medicare Part D caused a major shift in the distribution of payers for prescription drugs, as Medicare played a larger role in drug purchases than it had before.
Abstract: In 2006, U.S. health care spending increased 6.7 percent to $2.1 trillion, or $7,026 per person. The health care portion of gross domestic product (GDP) was 16.0 percent, slightly higher than in 2005. Prescription drug spending growth accelerated in 2006 to 8.5 percent, partly as a result of Medicare Part D’s impact. Most of the other major health care services and public payers experienced slower growth in 2006 than in prior years. The implementation of Medicare Part D caused a major shift in the distribution of payers for prescription drugs, as Medicare played a larger role in drug purchases than it had before.
TL;DR: Examination of China's health care from a system perspective is examined, describing its health services delivery, access, outcomes, and population health in the post-reform era and identifying the main issues in the current system.
Abstract: No other country has undergone health care reforms as dramatic as China’s. Starting in 1978, China reformed its health system from a governmental, centrally planned, and universal system to a heavily market-based one. Now, three decades later, the Chinese government openly acknowledges that the reforms failed and seeks new directions. This paper adds to the literature by examining China’s health care from a system perspective, describing its health services delivery, access, outcomes, and population health in the post-reform era. It also identifies the main issues in the current system and highlights the key lessons learned from China’s reform process.
TL;DR: In this article, the authors compared the demographics of and reasons for visits in national samples of visits to retail clinics, primary care physicians (PCPs), and emergency departments (EDs), and found that retail clinics appear to be serving a patient population that is underserved by PCPs.
Abstract: In this study we compared the demographics of and reasons for visits in national samples of visits to retail clinics, primary care physicians (PCPs), and emergency departments (EDs). We found that retail clinics appear to be serving a patient population that is underserved by PCPs. Ten clinical problems such as sinusitis and immunizations encompass more than 90 percent of retail clinic visits. These same ten clinical problems make up 13 percent of adult PCP visits, 30 percent of pediatric PCP visits, and 12 percent of ED visits. Whether there will be a future shift of care from EDs or PCPs to retail clinics is unknown.