Showing papers in "Health Affairs in 2009"
TL;DR: This analysis presents updated estimates of the costs of obesity for the United States across payers (Medicare, Medicaid, and private insurers), in separate categories for inpatient, non-inpatient, and prescription drug spending.
Abstract: In 1998 the medical costs of obesity were estimated to be as high as $78.5 billion, with roughly half financed by Medicare and Medicaid. This analysis presents updated estimates of the costs of obesity for the United States across payers (Medicare, Medicaid, and private insurers), in separate categories for inpatient, non-inpatient, and prescription drug spending. We found that the increased prevalence of obesity is responsible for almost $40 billion of increased medical spending through 2006, including $7 billion in Medicare prescription drug costs. We estimate that the medical costs of obesity could have risen to $147 billion per year by 2008.
2,816 citations
TL;DR: Accumulated evidence appears to support the Chronic Care Model as an integrated framework to guide practice redesign, and studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes.
Abstract: Developed more than a decade ago, the Chronic Care Model (CCM) is a widely adopted approach to improving ambulatory care that has guided clinical quality initiatives in the United States and around the world. We examine the evidence of the CCM’s effectiveness by reviewing articles published since 2000 that used one of five key CCM papers as a reference. Accumulated evidence appears to support the CCM as an integrated framework to guide practice redesign. Although work remains to be done in areas such as cost-effectiveness, these studies suggest that redesigning care using the CCM leads to improved patient care and better health outcomes.
1,418 citations
TL;DR: If you want a glimpse of what health care could look like a few years from now, consider "Hello Health," the Brooklyn-based primary care practice that is fast becoming an emblem of modern medicine.
Abstract: If you want a glimpse of what health care could look like a few years from now, consider “Hello Health,” the Brooklyn-based primary care practice that is fast becoming an emblem of modern medicine....
777 citations
TL;DR: Patient-centeredness is a dimension of health care quality in its own right, not just because of its connection with other desired aims, like safety and effectiveness as discussed by the authors. But its proper incorporation into new health care designs will involve some radical, unfamiliar, and disruptive shifts in control and power, out of the hands of those who give care and into the hands who receive it.
Abstract: Patient-centeredness" is a dimension of health care quality in its own right, not just because of its connection with other desired aims, like safety and effectiveness. Its proper incorporation into new health care designs will involve some radical, unfamiliar, and disruptive shifts in control and power, out of the hands of those who give care and into the hands of those who receive it. Such a consumerist view of the quality of care, itself, has im- portant differences from the more classical, professionally dominated definitions of "qual- ity." New designs, like the so-called medical home, should incorporate that change. (Health Affairs 28, no. 4 (2009): w555-w565 (published online 19 May 2009; 10.1377/hlthaff .28.4.w555))
690 citations
TL;DR: To prepare for the growing chronic disease burden, a larger interdisciplinary primary care workforce is needed, and payment for primary care should reward practices that incorporate multidisciplinary teams.
Abstract: The U.S. chronic illness burden is increasing and is felt more strongly in minority and low-income populations: in 2005, 133 million Americans had at least one chronic condition. Prevention and management of chronic disease are best performed by multidisciplinary teams in primary care and public health. However, the future health care work-force is not projected to include an appropriate mix of personnel capable of staffing such teams. To prepare for the growing chronic disease burden, a larger interdisciplinary primary care workforce is needed, and payment for primary care should reward practices that incorporate multidisciplinary teams.
575 citations
TL;DR: It was found that 27.7 percent who saw calorie labeling in New York said the information influenced their choices, however, it did not detect a change in calories purchased after the introduction of calorie labeling.
Abstract: We examined the influence of menu calorie labels on fast food choices in the wake of New York City’s labeling mandate. Receipts and survey responses were collected from 1,156 adults at fast-food restaurants in low-income, minority New York communities. These were compared to a sample in Newark, New Jersey, a city that had not introduced menu labeling. We found that 27.7 percent who saw calorie labeling in New York said the information influenced their choices. However, we did not detect a change in calories purchased after the introduction of calorie labeling. We encourage more research on menu labeling and greater attention to evaluating and implementing other obesity-related policies.
501 citations
TL;DR: Registered nurse (RN) employment has increased during the current recession, and the recent increase in employment is improving projections of the future supply of RNs, yet large shortages are still expected in the next decade.
Abstract: Registered nurse (RN) employment has increased during the current recession, and we may soon see an end to the decade-long nurse shortage. This would give hospitals welcome relief and an opportunity to strengthen the nurse workforce by addressing issues associated with an increasingly older and foreign-born workforce. The recent increase in employment is also improving projections of the future supply of RNs, yet large shortages are still expected in the next decade. Until nursing education capacity is increased, future imbalances in the nurse labor market will be unavoidable.
486 citations
TL;DR: The nurse work environment was significantly related to all HCAHPS patient satisfaction measures and patient-to-nurse workloads were significantly associated with patients' ratings and recommendation of the hospital to others, and with their satisfaction with the receipt of discharge information.
Abstract: Patient satisfaction is receiving greater attention as a result of the rise in pay-for-performance (P4P) and the public release of data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. This paper examines the relationship between nursing and patient satisfaction across 430 hospitals. The nurse work environment was significantly related to all HCAHPS patient satisfaction measures. Additionally, patient-to-nurse workloads were significantly associated with patients’ ratings and recommendation of the hospital to others, and with their satisfaction with the receipt of discharge information. Improving nurses’ work environments, including nurse staffing, may improve the patient experience and quality of care.
403 citations
TL;DR: A systematic review of health IT with studies published during 2004-2007 identified a proliferation of patient-focused applications although little formal evaluation in this area; more descriptions of commercial electronic health records (EHRs) and health IT systems designed to run independently from EHRs; and proportionately fewer relevant studies from the health IT leaders.
Abstract: To understand what is new in health information technology (IT), we updated a systematic review of health IT with studies published during 2004-2007. From 4,683 titles, 179 met inclusion criteria. We identified a proliferation of patient-focused applications although little formal evaluation in this area; more descriptions of commercial electronic health records (EHRs) and health IT systems designed to run independently from EHRs; and proportionately fewer relevant studies from the health IT leaders. Accelerating the adoption of health IT will require greater public-private partnerships, new policies to address the misalignment of financial incentives, and a more robust evidence base regarding IT implementation.
387 citations
TL;DR: This 2009 survey of primary care doctors in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States finds wide differences in practice systems, incentives, perceptions of access to care, use of health information technology (IT), and programs to improve quality.
Abstract: This 2009 survey of primary care doctors in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States finds wide differences in practice systems, incentives, perceptions of access to care, use of health information technology (IT), and programs to improve quality. Response rates exceeded 40 percent except in four countries: Canada, France, the United Kingdom, and the United States. U.S. and Canadian physicians lag in the adoption of IT. U.S. doctors were the most likely to report that there are insurance restrictions on obtaining medication and treatment for their patients and that their patients often have difficulty with costs. We believe that opportunities exist for cross-national learning in disease management, use of teams, and performance feedback to improve primary care globally.
386 citations
TL;DR: The results suggest that implementing mental health parity nationally will reduce some but not all of the barriers to mental health care, as well as the probability of having mental health access problems for patients.
Abstract: About two-thirds of primary care physicians (PCPs) reported in 2004-05 that they could not get outpatient mental health services for patients-a rate that was at least twice as high as that for other services. Shortages of mental health care providers, health plan barriers, and lack of coverage or inadequate coverage were all cited by PCPs as important barriers to mental health care access. The probability of having mental health access problems for patients varied by physician practice, health system, and policy factors. The results suggest that implementing mental health parity nationally will reduce some but not all of the barriers to mental health care.
TL;DR: This paper examined the prevalence of self-reported chronic conditions and out-of-pocket spending using the 2005 Medical Expenditure Panel Survey (MEPS) and made comparisons to previously published MEPS data.
Abstract: We examined the prevalence of self-reported chronic conditions and out-of-pocket spending using the 2005 Medical Expenditure Panel Survey (MEPS) and made comparisons to previously published MEPS data. Our study found that the prevalence of self-reported chronic conditions is increasing among not only the old-old but also people in midlife and earlier old age. The greatest growth occurred in the number of people affected by multiple chronic diseases, a group with sizable out-of-pocket spending. Policymakers should be aware that cost sharing at the point of care can disproportionately burden people with chronic conditions and discourage adherence to drugs that prevent disease progression.
TL;DR: This work proposes a new approach to help achieve more integrated and efficient care by fostering local organizational accountability for quality and costs through performance measurement and "shared savings" payment reform.
Abstract: To succeed, health care reform must slow spending growth while improving quality. We propose a new approach to help achieve more integrated and efficient care by fostering local organizational accountability for quality and costs through performance measurement and “shared savings” payment reform. The approach is practical and feasible: it is voluntary for providers, builds on current referral patterns, requires no change in benefits or lock-in for beneficiaries, and offers the possibility of sustained provider incomes even as total costs are constrained. We simulate the potential expenditure impact and show that significant Medicare savings are possible.
TL;DR: Two proposed methods of payment, "episode-of-care payment" and "comprehensive care payment" (condition-adjusted capitation), could facilitate higher quality and lower cost by avoiding the problems of both fee-for-service payment and traditional capitation.
Abstract: Payment systems for health care today are based on rewarding volume, not value for the money spent. Two proposed methods of payment, “episode-of-care payment” and “comprehensive care payment” (condition-adjusted capitation), could facilitate higher quality and lower cost by avoiding the problems of both fee-for-service payment and traditional capitation. The most appropriate payment systems for different types of patient conditions and some methods of addressing design and implementation issues are discussed. Although the new payment systems are desirable, many providers are not organized to accept or use them, so transitional approaches such as “virtual bundling,” described in this paper, will be needed.
TL;DR: The impact of implementing a comprehensive electronic health record (EHR) system on ambulatory care use in an integrated health care delivery system with more than 225,000 members decreased between 2004 and 2007 and scheduled telephone visits increased more than eightfold.
Abstract: We examined the impact of implementing a comprehensive electronic health record (EHR) system on ambulatory care use in an integrated health care delivery system with more than 225,000 members. Between 2004 and 2007, the annual age/sex-adjusted total office visit rate decreased 26.2 percent, the adjusted primary care office visit rate decreased 25.3 percent, and the adjusted specialty care office visit rate decreased 21.5 percent. Scheduled telephone visits increased more than eightfold, and secure e-mail messaging, which began in late 2005, increased nearly sixfold by 2007. Introducing an EHR creates operational efficiencies by offering nontraditional, patient-centered ways of providing care.
TL;DR: It is estimated that medical technology explains 27-48 percent of health spending growth since 1960-a smaller percentage than earlier estimates.
Abstract: A broad consensus holds that increased medical capability—technology—is the primary driver of health spending growth. However, technology does not expand independently of historical context; it is fueled by rising incomes and more generous insurance coverage. We estimate that medical technology explains 27–48 percent of health spending growth since 1960—a smaller percentage than earlier estimates. Income (gross domestic product, or GDP) growth plays a critical role, primarily through the actions of governments and employers on behalf of pools of consumers. The contribution of insurance is likely to differ, with less of a push from increasing generosity of coverage and more of a push from changes in provider payment.
TL;DR: This study pooled and reanalyzed data from ten randomized clinical trials of heart failure care management programs to discern how program delivery methods contribute to patient outcomes to offer policymakers and health plan administrators important guideposts for developing an evidence base on which to build effective policy and programmatic initiatives for chronic care management.
Abstract: The evidence base of what works in chronic care management programs is underdeveloped. To fill the gap, we pooled and reanalyzed data from ten randomized clinical trials of heart failure care management programs to discern how program delivery methods contribute to patient outcomes. We found that patients enrolled in programs using multi-disciplinary teams and in programs using in-person communication had significantly fewer hospital readmissions and readmission days than routine care patients had. Our study offers policymakers and health plan administrators important guideposts for developing an evidence base on which to build effective policy and programmatic initiatives for chronic care management.
TL;DR: Perceptions about communicating with practitioners about generics, generic substitution, and policymakers' role in influencing generic use are discussed.
Abstract: Insurers and policymakers encourage the use of generic drugs to reduce costs, but generics remain underused. We conducted a national survey of commercially insured adults to evaluate their perceptions about generic drugs. Patients agreed that generics are less expensive and a better value than brand-name drugs, and are just as safe. However, although 56 percent reported that Americans should use more generics, only 37.6 percent prefer to take generics. We discuss perceptions about communicating with practitioners about generics, generic substitution, and policymakers' role in influencing generic use. These findings underscore the challenge that providers, insurers, and policymakers face in stimulating the cost-effective use of medications.
TL;DR: Challenges for health care systems, regulators, and policymakers include developing the evidence base on comparative risks and benefits; defining measures of treatment quality; and implementing policies that encourage evidence-based practices while avoiding unduly burdensome restrictions.
Abstract: Atypical antipsychotic medications are increasingly used for a wide range of clinical indications in diverse populations, including privately and publicly insured youth and elderly nursing home residents. These trends heighten policy challenges for payers, patients, and clinicians related to appropriate prescribing and management, patient safety, and clinical effectiveness. For clinicians and patients, balancing risks and benefits is challenging, given the paucity of effective alternative treatments. For health care systems, regulators, and policymakers, challenges include developing the evidence base on comparative risks and benefits; defining measures of treatment quality; and implementing policies that encourage evidence-based practices while avoiding unduly burdensome restrictions.
TL;DR: The frequency of borrowing money or selling assets to buy health services in forty low- and middle-income countries and how various factors are associated with these coping strategies were calculated.
Abstract: Many families around the world make sizable out-of-pocket payments for health care. We calculated the frequency of borrowing money or selling assets to buy health services in forty low- and middle-income countries and estimated how various factors are associated with these coping strategies. The data represented a combined population of 3.66 billion, or 58 percent of the world’s population. On average, 25.9 percent of households borrowed money or sold items to pay for health care. The risk was higher among the poorest households and in countries with less health insurance. Health systems in developing countries are failing to protect families from the financial risks of seeking health care.
TL;DR: There is a gap between today's personal health records and what patients say they want and need from this electronic tool for managing their health information, and until that gap is bridged, it is unlikely that PHRs will be widely adopted.
Abstract: There is a gap between today’s personal health records (PHRs) and what patients say they want and need from this electronic tool for managing their health information. Until that gap is bridged, it is unlikely that PHRs will be widely adopted. Current barriers to PHR adoption among patients include cost, concerns that information is not protected or private, inconvenience, design shortcomings, and the inability to share information across organizations. However, in the future, when these concerns are addressed, and health data are portable and understandable (in both content and format), PHRs will likely prove to be invaluable.
TL;DR: In this paper, the authors conducted a survey of physicians and practice administrators and found that physicians reported spending three hours weekly interacting with plans; nursing and clerical staff spent much larger amounts of time, and the national time cost to practices of interactions with plans is at least $23 billion to $31 billion each year.
Abstract: Physicians have long expressed dissatisfaction with the time they and their staffs spend interacting with health plans. However, little information exists about the extent of these interactions. We conducted a national survey on this subject of physicians and practice administrators. Physicians reported spending three hours weekly interacting with plans; nursing and clerical staff spent much larger amounts of time. When time is converted to dollars, we estimate that the national time cost to practices of interactions with plans is at least $23 billion to $31 billion each year.
TL;DR: A near-doubling in hospitalizations with a diagnosis of obesity between 1999 and 2005 and an increase in costs from $125.9 million to 237.6 million (in 2005 dollars) between 2001 and 2005 are detected.
Abstract: Childhood obesity is increasingly recognized as an epidemic, but the economic consequences have not been well quantified. We evaluated trends in obesity-associated hospitalizations, charges, and costs using 1999–2005 data from a nationally representative sample of admissions to U.S. hospitals. We detected a near-doubling in hospitalizations with a diagnosis of obesity between 1999 and 2005 and an increase in costs from $125.9 million to 237.6 million (in 2005 dollars) between 2001 and 2005. Medicaid appears to bear a large burden of hospitalizations for conditions that occur along with obesity, while private payers pay a greater portion of hospitalization costs to treat obesity itself.
TL;DR: It is found that electronic medical records have a small, positive effect on patient safety, and it is suggested that investment in health IT should be accompanied by investment in the evidence base needed to evaluate it.
Abstract: The potential of health information technology (IT) to transform health care delivery has spurred health IT adoption and will likely contribute to increased investments in coming years. Although an extensive literature shows the value of health IT at leading academic institutions, its broader value remains unknown. We sought to estimate IT's effect on key patient safety measures in a national sample. Using four years of Medicare inpatient data, we found that electronic medical records have a small, positive effect on patient safety. Although these results are encouraging, we suggest that investment in health IT should be accompanied by investment in the evidence base needed to evaluate it.
TL;DR: In this article, the authors highlight the importance of nurses in the delivery of high-quality, efficient care in hospitals and demonstrate how nurses and staff, supported by leadership, can be actively involved in improving both the quality and efficiency of hospital care.
Abstract: Discussions of hospital quality, efficiency, and nursing care often taken place independent of one another. Activities to assure the adequacy and performance of hospital nursing, improve quality, and achieve effective control of hospital costs need to be harmonized. Nurses are critical to the delivery of high-quality, efficient care. Lessons from Magnet program hospitals and hospitals implementing front-line staff–driven performance improvement programs such as Transforming Care at the Bedside illustrate how nurses and staff, supported by leadership, can be actively involved in improving both the quality and the efficiency of hospital care.
TL;DR: Medicaid physician fees increased 15.1 percent, on average, between 2003 and 2008, but the increase in Medicaid fees relative to Medicare fees resulted from relative increases for primary care and obstetrical services, but not for other services.
Abstract: Medicaid physician fees increased 15.1 percent, on average, between 2003 and 2008. This was below the general rate of inflation, resulting in a reduction in real fees. Only primary care fees grew at the rate of inflation—20 percent between 2003 and 2008. However, because of slow growth in Medicare fees, Medicaid fees closed a small portion of their ongoing gap relative to Medicare—growing from 69 percent to 72 percent of Medicare. The increase in Medicaid fees relative to Medicare fees resulted from relative increases for primary care and obstetrical services, but not for other services.
TL;DR: In this article, the average annual growth in national health spending is projected to be 6.2 percent during the projection period (2008-2018), which is 2.1 percentage points faster than the growth in gross domestic product (GDP).
Abstract: During the projection period (2008–2018), average annual growth in national health spending is projected to be 6.2 percent—2.1 percentage points faster than average annual growth in gross domestic product (GDP). The health share of GDP is anticipated to rise rapidly from 16.2 percent in 2007 to 17.6 percent in 2009, largely as a result of the recession, and then climb to 20.3 percent by 2018. Public payers are expected to become the largest source of funding for health care in 2016 and are projected to pay for more than half of all national health spending in 2018.
TL;DR: Careful choices about frequency, groups to target, and component costs can increase the likelihood that interventions will be highly cost-effective or even cost-saving.
Abstract: Over the four decades since cost-effectiveness analysis was first applied to health and medicine, hundreds of studies have shown that prevention usually adds to medical costs instead of reducing them. Medications for hypertension and elevated cholesterol, diet and exercise to prevent diabetes, and screening and early treatment for cancer all add more to medical costs than they save. Careful choices about frequency, groups to target, and component costs can increase the likelihood that interventions will be highly cost-effective or even cost-saving.
TL;DR: Although the number of operational RHIOs is growing, their scope remains limited and their viability uncertain, and most were focused on exchanging test results.
Abstract: We surveyed regional health information organizations (RHIOs) to assess the state of electronic health information exchange in the United States. We found fifty-five operational RHIOs, and most were focused on exchanging test results. Forty-one percent of operational RHIOs reported receiving sufficient revenue from participating entities to cover operating costs. Of the remainder, only 28 percent expected to ever do so. RHIOs in the planning stage were far more optimistic. Operational RHIOs from our 2007 survey had made little progress in expanding the breadth of their activities. Although the number of operational RHIOs is growing, their scope remains limited and their viability uncertain.
TL;DR: An agenda for research is described for research to guide broader use of patient-targeted financial incentives, either in conjunction with provider- targeted financial incentives (pay-for-performance, or P4P) or in clinical contexts where provider- targeted approaches are unlikely to be effective.
Abstract: Unhealthy behavior is a major cause of poor health outcomes and high health care costs. In this paper we describe an agenda for research to guide broader use of patient-targeted financial incentives, either in conjunction with provider-targeted financial incentives (pay-for-performance, or P4P) or in clinical contexts where provider-targeted approaches are unlikely to be effective. We discuss evidence of proven effectiveness and limitations of the existing evidence, reasons for underuse of these approaches, and options for achieving wider use. Patient-targeted incentives have great potential, and systematic testing will help determine how they can best be used to improve population health.