Call for Panels
Podium Presentations
Hospitals in a Reformed World
Chair: Derek DeLia, Ph.D.
Sunday, June 27 * 9:00 a.m.–10:30 a.m.
Panel Overview: Hospitals are subject to a multitude
of external pressures that affect their ability to provide
high quality care. This panel will examine how
changes in hospital reimbursement, adoption of
electronic health records (EHRs), and distance to the
nearest emergency department (ED) affect the
quality of care and patient mortality. The panel will
then discuss the implications of their findings for
proposed health reforms. The first panelist will
examine whether decreased geographical access to
the emergency department affects the health
outcomes and profiles of those who have had acute
myocardial infarctions. The second panelist will
present analysis of the impact of changes in the
generosity of payment for 21 major hospital service
lines. The third panelist will assess the use and key
clinical functions of electronic health records (EHRs)
in hospitals serving a disproportionate share of poor
patients. The panelists will reflect on how the findings
inform efforts to increase HIT use, ensure access to
care, and alter provider reimbursement in the hospital
of the 2010s.
• Effects of Decreased Emergency Department
Access on AMI Patients' Mortality Rates and
Health Profile
Yu-Chu Shen, Ph.D.; Renee Hsia M.D., M.Sc.;
Laurence Baker, Ph.D.
Presented by: Yu-Chu Shen, Ph.D., Associate
Professor of Economics, Graduate School of
Business and Public Policy, Naval Postgraduate
School, 555 Dyer Road, Code GB, Monterey, CA
93955; Phone: (831) 656-2951; Email:
yshen@nps.edu
Research Objective: We examine whether
decreased geographical access to the nearest
emergency department (ED) resulting from ED
closures affects the health profile and outcomes of
patients with acute myocardial infarction (AMI), a
group that has relatively homogenous patient
characteristics and is sensitive to the availability of
ED care.
Study Design: The primary data sources for ED
availability are the American Hospital Association
annual surveys and Medicare Provider Analysis and
Review (MedPAR) for 1995-2005. Patient data were
obtained from MedPAR. We identify the effects of ED
access by comparing mortality outcomes (1-day, 7day, 30-day) and patient health characteristics (age,
comorbidity counts) between the following groups: (1)
people who live in zip codes with no increase in
driving time to their closest ED (the control group);
and (2) people who live in zip codes that experience
<10, 10-30, or >30 minute increases in driving time.
We implement zip codes fixed-effects models and
include year dummies and full interaction of patient
demographics information. We estimate the models
on all patients as well as on sub-populations, such as
sicker patients and patients that share similar
geographical characteristics.
Population Studied: Medicare fee-for-service
patients who were admitted to hospitals for AMI
anytime between 1996-2005, excluding transfers and
those with AMI-related admissions within the
previous 12 months.
Principal Findings: We find that 91% of the study
population did not experience increased driving times
to their nearest ED during the study period. Shares of
patients that experienced <10, 10-30, and >30 minute
increases in driving time were 7, 1, and 0.4%,
respectively. In the general Medicare AMI population,
there appeared to be no differences in mortality rates
among patients in different categories of ED access.
However, the health profiles of the patients changed
if they lived in locations that experienced >30 minute
increases in driving time: they were younger (by 0.77
year, p<0.01), arrived at the hospital with higher
comorbidity counts (by 3%, p<0.05), and had a
higher probability of needing cardiac catherization or
angioplasty (by 4.6 percentage points, p<0.05)
compared to the control group. Among the sicker AMI
patients (defined as those that need angioplasty
within 1 day of admission), an increase of driving time
by 10-30 minutes had an adverse effect on mortality:
such change increased the 1-day, 7-day, and 30-day
mortality rates by 2.21, 3.5, and 4.4 percentage
points, respectively (all p<0.01). This adverse effect
disappeared by 9 months. The health profiles of the
sicker patients did not change, except that those in
areas with a > 30 minute increase arrived with higher
comorbidity counts (by 9%, p<0.05).
Conclusions: Increased driving time to the ED alters
the health profile of AMI patients who arrive at the
hospital alive and has adverse effects on the shortterm mortality of sicker AMI patients.
Implications for Policy, Delivery or Practice: Even
though ED access deterioration only affects a very
small percent of the population, policymakers
overseeing health care resource allocation should be
aware of how changes in ED availability can
adversely affect patients whose condition is sensitive
to such changes.
Funding Source(s): RWJF
• Impact of Payment Generosity on Mortality
Outcomes
Kevin Volpp, M.D., Ph.D.; R. Tamara Konetzka
Ph.D.; Jingsan Zhu, M.B.A.; Wei Chen, M.S.; Rich
Lindrooth, Ph.D.
Presented by: Kevin Volpp, M.D., Ph.D., Director,
Center for Health Incentives, Leonard Davis Institute,
Medicine and Health Care Management, University of
Pennsylvania School of Medicine and the Wharton
School, 1232 Blockley Hall, 423 Guardian Drive,
Philadelphia, PA 19104; Phone: (215) 573-0270;
Email: volpp70@exchange.upenn.edu
Research Objective: The relationship between
generosity of payment and patient outcomes has
important implications for health reform and pay for
performance programs which impact provider
payment levels. The objective of this paper is to
measure the effect of changes in service-line
payment generosity on 30-day mortality of patients in
21 major hospital service lines.
Study Design: This is an observational study using
MEDPAR claims data for 1997-2005, with a
dependent variable of risk-adjusted 30-day mortality.
Predicted mortality was calculated by creating patient
risk scores using out-of-sample data (MEDPAR 1999
and 2003) to develop betas for each comorbidity and
patient-level risk factor. These coefficients were then
applied to the patients within each study year (1997,
2001 and 2005) to predict mortality. Service-line
payment generosity is measured as the percent of
reimbursement over costs (hereafter “markup”)
calculated using cost-to-charge ratios from CMS
Hospital Cost Reports, Medicare charges, and actual
Medicare reimbursement. Risk-adjusted 30-day
mortality was regressed on the service-line markup;
service-line markup interacted with the hospital's
Medicare share; hospital*service-line and year fixed
effects; service-line volume; and service-line specific
time trends. The results are identified using variation
in markups across service lines and over time.
Service-lines with larger decreases in markups are
hypothesized to have larger increases in riskadjusted mortality, with effects hypothesized to be
increasing with a hospital's Medicare share and to be
larger in not-for-profit (NFP) hospitals.
Population Studied: We selected index admissions
to short-term, acute-care hospitals of Medicare
patients aged 65-90 excluding patients admitted from
long-term care, transferred in from other hospitals,
and with organ acquisition costs outside of PPS. The
final study data in
Principal Findings: Markups decreased from an
average across all service lines of 21% in 1997 to 3% in 2005. While the markup main effect was not
significantly different than zero (for hospitals with no
Medicare share), the interaction between
markup*Medicare share had a coefficient of -0.008
(p= 0.008). This translates into a 0.0032 percentage
point increase in mortality for each one percentage
point decrease in Medicare cost markups for a
hospital with the national average Medicare market
share of 40%. For hospitals with 40% Medicare
share, the estimated increase in deaths nationally
due to declines in the average markup relative to the
case if markups remained at the 1997 level was
13,721 between 1997 and 2001 and 36,940 between
1997 and 2005. The magnitude of the coefficient was
larger for NFP hospitals ( =-0.18 for NFP hospitals, =
0.04 among for profit hospitals; p-value for difference
0.019).
Conclusions: Decreases in Medicare payment
generosity from 1997-2005 led to significant
increases in mortality, with bigger increases in
mortality in service lines with bigger reductions in
profitability. The increases were greater at NFP
hospitals consistent with the notion that NFP
hospitals provide discretionary levels of quality that
decline as payments are reduced.
Implications for Policy, Delivery or Practice:
Policies regarding Medicare reimbursement need to
consider the effect of reimbursement levels on
quality, particularly in the context of health reform.
Funding Source(s): RWJF
• Examining the Strengths and Challenges of
Hospitals that Disproportionately Serve the Poor
Ashish Jha, M.D., M.P.H.; Catherine DesRoches
Dr.PH.; Alexandra Shields, Ph.D.; Paola Miralles,
B.S.; Jie Zheng, Ph.D., M.Stat; Sara Rosenbaum,
J.D.
Presented by: Ashish Jha, M.D., M.P.H., Associate
Professor, Health Policy and Management, Harvard
School of Public Health, 677 Huntington Avenue,
Boston, MA 02115; Phone: (617) 432-5551; Email:
ajha@hsph.harvard.edu
Research Objective: We sought to examine the use
of electronic health record (EHR) systems and their
key clinical functions among hospitals that
disproportionately serve poor patients.
Study Design: We used a hospital’s
Disproportionate Share Hospital (DSH) Index to
identify hospitals that disproportionately serve poor
patients and categorized all hospitals into quartiles by
DSH Index (e.g., high-DSH hospitals are those 25%
of hospitals with the highest DSH Index score; lowDSH hospitals are those 25% of hospitals with the
lowest DSH Index score). We used the federally
sponsored national expert panel to define a
comprehensive EHR (24 clinical functions
implemented across all major clinical units) and basic
EHR (10 clinical functions implemented in at least
one clinical units). We partnered with the American
Hospital Association to administer the hospital IT
survey to all acute care member hospitals in 2008.
We also used data from the Hospital Quality Alliance
to examine hospital performance on quality metrics
for four conditions: acute myocardial infarction (eight
process measures), congestive heart failure (four
measures), pneumonia (seven measures), and
surgical complications (five measures).
Population Studied: All non-federal acute care
American Hospital Association member hospitals in
2008.
Principal Findings: Hospitals that disproportionately
serve poor patients had significantly higher
proportions of Medicaid, black elderly, and Hispanic
elderly patients. Overall EHR adoption rates of either
a comprehensive or basic EHR were slightly lower
among hospitals that disproportionately serve poor
patients (i.e. highest DSH quartile) compared
hospitals in the lowest DSH quartile (9.7% versus
11.5%, p=0.43). We found that hospitals that
disproportionately serve poor patients had lower
rates of adoption for each of the 24 functions
examined, although the gap between high DSH and
low DSH hospitals varied widely based on the
individual clinical function examined. Fiscal concerns
were cited significantly more frequently as major
barriers to EHR adoption among high-DSH hospitals
compared low-DSH hospitals. Finally, we found that
high-DSH hospitals had lower quality of care scores
for each of the four conditions examined. However,
while this disparity in care (based on DSH index) was
present among non-EHR adopters, the adoption of
EHR systems seemed to eliminate the gap in quality
scores between high-DSH and low-DSH hospitals for
each of the conditions.
Conclusions: Hospitals that serve a higher
proportion of poor patients had slightly lower levels of
overall EHR adoption in addition to lower levels of
adoption for each of the 24 key clinical functions
examined. Furthermore, we found that the adoption
of EHRs may alleviate the gap in quality performance
between hospitals that disproportionately care for the
poor and those that don’t.
Implications for Policy, Delivery or Practice: The
nation has embarked on an ambitious and expensive
effort to promote the adoption and use of EHRs. Our
findings suggest that EHR adoption may facilitate the
reduction of disparities in care between high- and
low-DSH hospitals. It is important that current federal
health IT policies efforts are carefully crafted to
ensure that hospitals serving the most vulnerable
patients are not left behind.
Funding Source(s): RWJF
Handovers of Patient Care: What Will it Take to
Ensure Safe Outcomes?
Chair: Paul Barach, M.D., M.P.H.
Sunday, June 27 * 9:00 a.m.-10:30 a.m.
Panelists: Vineet Arora, University of Chicago;
Richard Frankel, Department of Veterans Affairs,
Indianapolis and Indiana University School of
Medicine; Julie Johnson, University of New South
Wales
Panel Overview: Handovers of patient care cut
across all care settings and all disciplines. The focus
on provider communications during patient handover
(or handoffs) is a lead patient safety and quality goal
by The Joint Commission and the WHO.
Interest in handovers has grown as
researchers, hospital administrators, educators, and
policy makers have realized that the potential breakdown in communication during patient handover
effects institutions, clinicians, and patients.
Handovers serve as the basis for transferring
responsibility and accountability for patient care from
outgoing to incoming healthcare teams across shifts,
across disciplines, and across care settings. The
complexity of the handover process presents a series
of “vulnerable gaps” in patient care that can result in
errors, near misses, and adverse patient events. Our
research shows that there is little standardisation and
great variation across disciplines and healthcare
organisations in the ways in which handovers are
performed.
The panel members (4) will present our
research findings from federally funded studies in the
US, Europe and Australia that bridge the gap
between research and practice.
Several questions will be addressed during
the panel and recommendations will be made about
local implementation and impact: What are the
clinical handovers that carry the most risk for
patients?; What are communication strategies to
ensure high reliability during patient handoffs? What
methods should we use for assessing and improving
handover communications? What are the educational
and training interventions that are the most effective?
What are the mechanisms to spread, sustain and
transfer improvements across the organization?
• Qualitative Methods for Assessing and
Improving Handover Communications
Julie Johnson, Ph.D., M.S.P.H.
Presented by: Julie Johnson, Ph.D., M.S.P.H.,
Associate Professor, Faculty of Medicine, University
of New South Wales, Sydney, 0 2052, Australia;
Phone: +6129385 1474; Email:
j.johnson@unsw.edu.au
Research Objective: Patients experience multiple
transitions and handovers as they navigate the
increasingly complex healthcare system. Ensuring
patient safety as the patient transitions in and out of
the hospital depends on communication and
coordination between the hospital-based care team
and the primary care team. Furthermore, transitions
of patient care within the hospital – across
departments, shift-to-shift, etc. – requires effective
communication strategies within and across
disciplines. While care teams often believe that
handovers of patient care could be improved, they
lack the tools to assess current practice or to use an
assessment as a way to inform improvement. Some
research methodologies are better suited to
describing the complexities of patient handovers.
Qualitative methods – specifically
observations, critical incident interviews, focus
groups, process mapping, and artifact analysis – are
especially powerful in identifying barriers and
facilitators to effective communication. For example,
interviews and focus groups can be conducted to
explore handover issues at the provider level. An
artifact analysis of documents and communication
tools (i.e. emails, phone messages, etc) from the
patient care process can demonstrate evidence of
effective and poor communication between and
among members of the care team. Process maps,
which can be accomplished from observations or
from interviews, highlight the system issues that may
be preventing an effective patient transition.
Furthermore, following initial assessment, the results
from the qualitative research can be used to fuel a
care team’s improvement strategies and help to focus
quantitative hypotheses. The goal of this presentation
will be to provide an overview of the use of qualitative
methods in research on handover communication.
The presentation will briefly summarize
qualitative methods in the context of health services
research and will discuss the complementary nature
of qualitative and quantitative research. I will present
the research strategies and methods used across our
studies in the United States and Europe. Findings
from each of the studies will highlight emerging
themes in handover communication. This
presentation will share the unique challenges in
conducting qualitative research across different care
settings, countries, languages, and cultural groups.
Maintaining accuracy and quality of the
research protocols and data collection and
management practices throughout a qualitative study
is a continual, dynamic process because the
expectations and requirements often change as the
study evolves. A focus on the generalizability and
transferability of the research methods as well as the
research findings ensures internal and external
validity. We have developed quality assurance tools
to maintain accuracy and quality of our handover
research, which will be shared during the
presentation.
Funding Source(s): European Union, EUFP7
• Communication Strategies to Ensure High
Reliability During Patient Transitions
Richard Frankel, Ph.D.
Presented by: Richard Frankel, Ph.D., Professor,
Medicine and Geriatrics, Richard L. Roudebush
VAMC, Indiana University School of Medicine,
Indianapolis, Indiana, IN; Email: rfrankel@iupui.edu
Research Objective: A handoff (also known as signout or end-of-shift report) refers to information about
a patient that is transferred by one professional or
team to another. “The primary objective of a ‘handoff’
is to provide accurate information about a patient’s
care, treatment and services, current condition and
any recent or anticipated changes.” The number and
types of handoffs for any given hospitalized patient
can vary and may involve physicians, nurses,
pharmacists, transport, and even food service.
According to the Institute of Medicine (IOM),
up to 98,000 patients die and another 15 million are
harmed in US hospitals annually due to medical
errors. Root cause analysis of reported sentinel
events from 1994 to 2004 reveals that two-thirds of
these errors were due to communication failures
associated with handoffs. Handoffs are not simply a
mechanical means for transmitting and receiving
information. In medical care, a handoff requires that
the sender consider a patient’s present condition and
his / her likely future over the next 8-12 hours;
likewise, the receiver must comprehend what is being
transmitted and feel confident about the clarity and
reliability of the message.
Thus, in addition to sheer information
exchange, handoffs also involve the transfer of rights,
duties and obligations as they relate to the meaning
and interpretation of communication from one
professional to another. Recent scholarship based on
handoffs across a variety of high reliability
organizations has produced a set of generalized
handoff strategies that are associated with improved
reliability and outcomes. These include being face to
face, choosing a location that is quiet with no
interruptions, the use of checklist procedures and
“teach backs” or “talk backs” (i.e. the receiver of the
information repeats the information back to the giver),
to ensure that the intention and effect of a message
have been heard and understood especially across
an authority or power gradient. It is only when the
content of the message has been repeated and
acknowledged by the receiver that the action
contained in a request typically takes place.
This presentation will focus on an ongoing
VA study of resident physicians’ handoffs on two
internal medicine services and a surgical ICU. In
addition, nursing handoffs during overlapping shifts
on each of the services will be studied and
compared. Both nursing and physician handoffs are
tape recorded and a research assistant “shadows”
the incoming nurse or physician for the duration of
their shift taking ethnographic field notes on how the
information that was transferred during the handoff
plays out during the shift.
My presentation will focus on 3 types of
events: 1) sub-threshold, in which a potential error is
self corrected or caught early; 2) near misses in
which the trajectory of an evolving situation is one
that that will lead to an adverse outcome if not
corrected; and 3) adverse outcomes themselves.
Illustrations of the links between the event typology
and communication will be presented along with a
description of opportunities for improvement based
on “gold standards” for handoffs established across
multiple high reliability organizations.
Funding Source(s): VA
• Educational and Training Interventions and
Their Assessment
Vineet Arora, M.D., M.P.A.
Presented by: Vineet Arora, M.D., M.P.A., Assistant
Professor and Asisstant Dean for Education,
Medicine, Univeristy of Chicago, 5405 Ellis Avenue,
Chicago, IL 60637; Email:
varora@medicine.bsd.uchicago.edu
Research Objective: We have been applying
theories from communication psychology and
process improvement working with social scientists,
physicians, educators, and trainees to examine how
best to implement and evaluate better handoff
procedures. We have developed novel ways to teach
and evaluate handovers.
My presentation will focus on illustrating the
instructional design principles and quality
improvement theories we have applied research to
teaching and evaluating patient handovers. There is
an inherent assumption that handoff communication
can be improved. However, Keysar and others have
suggested that certain communication heuristics can
systematically contribute to miscommunication.
Firstly, speakers often overestimate the effectiveness
of their communications. Secondly, senders often
assume that receivers have the same information
that they do( the ‘egocentric heuristic’) and which
suggests more communication disonance the more
familiar you are with the person you are
communicating with. We have explored these
theories in our work on handoffs.
Another key area we have studied is how
poor handoffs lead to uncertainty in clinical decision
making that can undermine care. In recent studies of
both interns and hospitalists, incomplete handoffs
were associated with uncertainty in decision making.
In addition, residents report different types of clinical
uncertainty when on-duty. These reports map nicely
to the Beresford model of clinical uncertainty
including: (1) technical (i.e., not knowing how to do a
procedure); (2) conceptual (i.e. not knowing when to
transfer a patient to the ICU); (3) personal (i.e. not
knowing a patient’s preferences).
After a patient handover, the receiver has a
high degree of personal uncertainty regarding
patient’s welfare due to lack of prior knowledge.
Receivers spend a lot of time recovering and
decoding information that should be part of a formal
handover. While optimal handover should be a
learning moment, it is unclear if improved handovers
can reduce or eliminate the personal uncertainty.
This is an area that we are still exploring in our
research and will be discussed. Based on these
theories and prior work, we are working to develop
and validate tools to teach and evaluate handoffs. To
teach handoffs, we have used –– Observed
Standardized Clinical Examination (OSCE) and
applied it to assessing patient handovers.
The Observed Standardized Handover
Examination (OSHE) models a handover by asking
trainees to incorporate static critical information (from
a history and physical) with dynamic changing
information (clinical triggers for anticipatory guidance
and to do items) into a written and verbal exchange
and perform a handover to a “standardized” resident
receiver. Resident receivers use the “Handoff CEX”
which we have developed to assess the quality of
handoffs based on domains derived from existing
literature. Efforts to validate our tools are underway
including assessing the impact of the patient
handover on the team’s preparedness and ability to
receive the patient in a safe and seemless fashion.
Funding Source(s): AHRQ
Got Electronic Health Records? Realizing the
Potential
Chair: Jane Sisk, Ph.D.
Sunday, June 27 * 9:00 a.m.-10:30 a.m.
Panel Overview: National interest in electronic
medical/electronic health record systems
(EMR/EHRs) continues to rise, as reflected in recent
legislation to promote their adoption and meaningful
use. Although these systems have the potential to
increase quality, patient safety, and efficiency, much
of this potential has not yet been realized. This
session includes four presentations that provide upto-date information about the adoption and use of
EMR/EHRs, their relationship to the quality of office
care, experience with an interoperable system, and
federal initiatives to stimulate meaningful use. Using
the latest national data, the first presentation
describes use of EMR/EHRs by office-based
physicians and a range of other ambulatory and longterm care settings, including the specific features
available. The second presentation uses nationallyrepresentative data from office-based physicians to
analyze and update research on associations
between evidence-based quality-of-care measures
and EMR/EHRs. The next presentation from a
national HMO illustrates the opportunities and
challenges that an interoperable system provides to
support improvements in quality of care and
research, including comparative effectiveness
studies. The final presentation from the Office of the
National Coordinator discusses federal strategies to
stimulate EMR/EHR adoption, the concept of
meaningful use, and approaches to track and
evaluate use over time. The session will thus convey
the latest information about EMR/EHR adoption, its
relationship to office-based quality, and private and
public initiatives to realize the potential of these
electronic systems.
• Adoption of Health Information Technology
among U.S. Ambulatory and Long-Term Care
Providers
Esther Hing, M.P.H.; Anita Bercovitz Ph.D.
Presented by: Esther Hing, M.P.H., Survey
Statistician, National Center for Health Statistics,
CDC, Division of Health Care Statistics, 3311 Toledo
Road, Hyattsville, MD 20718; Phone: (301) 4584271; Email: ehing@cdc.gov
Research Objective: To analyze adoption of
electronic medical record/electronic health record
(EMR/EHR) systems and their functionalities from the
most recently-available data across the spectrum of
U.S. ambulatory and long-term care providers.
Study Design: Nationally-representative surveys
collected data from office-based physicians (2007
and preliminary 2009 data from the National
Ambulatory Medical Care Survey (NAMCS)), hospital
emergency departments (EDs) and outpatient
departments (OPDs) (2007 National Hospital
Ambulatory Medical Care Survey (NHAMCS)),
hospital-based and freestanding ambulatory surgery
centers (ASCs ) (2006 National Survey of Ambulatory
Surgery), home and hospice care agencies (2007
National Home and Hospice Care Survey), and
nursing homes (2004 National Nursing Home
Survey). The data came from face-to-face interviews,
except for preliminary 2009 physician estimates from
a mail survey. Adoption was defined by three sets of
variables: none vs. any system, a basic system (6
functions, e.g., ordering prescriptions) and a fullyfunctional system (6 basic functions plus 8 others,
e.g., clinical reminders). Correlates of adoption and
trends were examined, when available. Provider
characteristics associated with EMR/EHR adoption
were assessed using Chi-square tests and student ttests.
Population Studied: Nationally-representative
samples of office-based physicians, hospital OPDs
and EDs, hospital-based and freestanding ASCs,
home and hospice care agencies, and nursing homes
from surveys of the National Center for Health
Statistics.
Principal Findings: In 2007, the most recent year
with comparable data, 34.8% of physicians in offices,
41.0% of home and hospice care agencies, 49.8% of
hospital OPDs, and 61.6% of EDs reported using an
EMR system. Use of EMR systems increased with
the number of physicians in the practice and with ED
hospital size. The percentages of providers with
systems meeting the criteria of a basic system were
much lower: 11.8% of physicians in offices, 19.1% of
EDs, 9.1% of OPDs, and 9.9% of home and hospice
care agencies. Only 3.8% of physicians had a fullyfunctional system. In preliminary 2009 estimates,
physician use of EMR/EHR systems had risen to
43.9%, but only 20.5% had a basic system and 6.3%
had a fully functional system (p<.05, all trends). Data
on systems’ ability to share records with other
providers (interoperability) are sparse; 14.4% of
physicians in 2009, and 8.2% of home and hospice
care agencies in 2007 reported this capability.
According to the most recent data available for other
settings, use of EMR systems extended to 22.3% of
freestanding ASCs and 62.4% of hospital-based
ASCs in 2006 and to 42.7% of nursing homes in
2004.
Conclusions: Adoption of EMR/EHR systems by
U.S. health care providers varies greatly. Few of
these providers have systems with the features of a
basic system, and even fewer have a fully-functional
system. Physician use is continuing to rise, especially
among larger practices.
Implications for Policy, Delivery or Practice:
Financial incentives for EMR/EHR adoption by
physicians and hospitals provided in the 2009
American Recovery and Reinvestment Act may
increase the pace of adoption among these
providers. Further research is needed to monitor the
effects of this legislation, with particular attention to
the ability of systems to perform the most important
functions required.
Funding Source(s): CDC
• Electronic Medical Record Use and the Quality
of Care in Physician Offices
Chun-Ju Hsiao, Ph.D., M.H.S.; Jill Marsteller Ph.D.,
M.P.P.; Alan Simon, M.D.
Presented by: Chun-Ju Hsiao, Ph.D., M.H.S.,
Service Fellow, National Center for Health Statistics,
CDC, Division of Health Care Statistics, 3311 Toledo
Road, Hyattsville, MD 20782; Phone: (301) 4584689; Email: jhsiao1@cdc.gov
Research Objective: Policymakers have raised the
potential for electronic medical record systems
(EMRs) to improve quality of care. Although regional
studies have shown some benefits of EMRs on
quality in outpatient settings, two recent national
studies found no consistent associations between
EMR use and ambulatory-care quality. EMRs in
physician offices may nevertheless have generated
quality improvements as technology has progressed
and use has expanded. This study updates previous
research using nationally-representative data, while
offering a more detailed characterization of EMR use
than one previous national study, and exploring
additional quality measures compared to the other.
Study Design: Nationally-representative samples of
primary-care office visits from the 2006 and 2007
National Ambulatory Medical Care Surveys, National
Center for Health Statistics, were used to
characterize office visits and test associations with
EMR use. EMR use was defined using three
variables: no vs. any EMR, a basic system (defined
as the presence of 6 common EMR features, e.g.,
ordering prescriptions), and a fully-functional system
(6 basic features plus 8 more advanced capabilities,
e.g., clinical reminders). Bivariate analysis and
multivariate logistic regressions were performed to
examine relationships between EMR use and
measures of quality: prescribing aspirin for ischemic
heart disease or cerebrovascular disease, blood
pressure check, blood pressure control, tobacco
counseling, and inappropriate prescribing for elderly
patients (using the updated Beers criteria).
Multivariate models adjusted for age, sex, race,
ethnicity, expected payment source, tobacco use,
presence of selected chronic conditions, physician
specialty, continuity of care, group/solo practice,
region, and metropolitan area.
Population Studied: Office visits made to primarycare providers (family/general practitioners,
pediatricians, internists, obstetricians/gynecologists)
in 2006 and 2007.
Principal Findings: Approximately 30% of primarycare visits were made to an office with an EMR, 7%
to offices with at least a basic system, and 2% to
offices with a fully-functional system. Inappropriate
prescribing for elderly patients occurred in 26% of
visits to offices with no EMR system, 20% of visits to
offices with at least a basic system, and 16% of visits
to offices with a fully-functional system. In adjusted
analyses, compared to all others, visits to offices with
at least a basic system had lower odds of
inappropriate prescribing (aOR=0.60, 95% CI= 0.420.87, p=0.006), as did visits to offices with a fullyfunctional system (aOR=0.59, 95% CI= 0.35-1.00,
p=0.054), although with weaker significance. We
found no consistent association of EMR use with
other quality measures tested.
Conclusions: Although most quality measures show
no improvement with use of EMR, having a basic or a
fully-functional EMR system was associated with
lower odds of inappropriate prescribing for elderly
patients. This finding contrasts with previous
research using national data, which showed no
association of EMR with other measures of improved
ambulatory care.
Implications for Policy, Delivery or Practice:
Implementation of EMRs has not been consistently
associated with the ambulatory quality measures
examined; this study finds a relationship in one area.
Further research should identify which aspects of
EMR may facilitate improvements in different quality
indicators.
Funding Source(s): CDC
• Implementing Clinical Decision Support in an
Electronic Medical Record System
Mark Hornbrook, Ph.D.
Presented by: Mark Hornbrook, Ph.D., Chief
Scientist, The Center for Health Research, Kaiser
Permanente Northwest, 3800 North Interstate
Avenue, Portland, OR 97227-1110; Phone: (503)
335-6746; Email: mark.c.hornbrook@kpchr.org
Research Objective: Kaiser Permanente (KP) has
installed a national electronic medical record (EMR)
system which covers all ambulatory-care facilities. KP
is in the process of installing the inpatient EMR
modules in all its hospitals. KP’s informatics strategy
has included total conversion from paper charts to
EMRs since 2003. Aims of EMRs include 1) medicolegal record of patient care; 2) physician order entry
(POE); 3) assess the patient’s health problems,
diseases, and clinical parameters; 4) immediate
access to the patient’s medical record at every
medical facility and department; 5) clinical decision
support (CDS) systems to improve quality and
effectiveness of care; and 6) population aggregate
data on case mix, utilization, costs, and outcomes.
EMR extract data files are needed for conducting
retrospective comparative effectiveness studies, for
estimating predictive models in support of clinical
decision making, and for benchmarking risk-adjusted
costs and outcomes. CDS can be purely elective and
separable, providing searchable information
resources for clinicians. They can also be integrated
into the physician order entry (POE) system to
provide real-time feedback to clinicians. CDS can be
calibrated as a patient safety net, as a costmanagement strategy, and as a guide to optimizing
quality of care in both retrospective and prospective
in applications.
Study Design: Qualitative analysis of KP’s CDS
initiatives.
Population Studied: Kaiser Permanente (KP) is an
integrated healthcare delivery system covering eight
geographic regions with nearly nine million members.
KP is a closed panel HMO. The Permanente Medical
Groups are tied exclusively to the Kaiser Foundation
Health Plan. Al
Principal Findings: CDS systems should be
evidence based. Retrospective comparative
effectiveness analyses and estimation of predictive
risk models require data from large patient samples.
EMR data storage, however, is optimized for rapid
on-line access and recording for individual patients.
EMRs are characterized by thousands of tables for
data storage, which is completely opposite of the
large rectangular files optimized for statistical
analysis. Hence, the utility of EMR data for CER and
epidemiology requires rigorous and complex data
extraction and mapping to create files for statistical
analyses. Real-time CDSs interacting with POE raise
the risk of alert overload. KP went through a process
of building alerts into the EMR up to the point when
physicians complained that they were getting so
many alerts that it was imposing significant delays in
completing their orders during patient visits, thereby
creating delays for patients and long wait times for
patients.
Conclusions: Concerns for patient safety, quality of
care, duplication of services, and care coordination
motivate development of CDS applications within
EMRs. POE-CDS systems offer the potential for
patient safety nets, and for detecting orders that
appear to be out of alignment with established
practice guidelines. The countervailing pressure is
loss of productivity associated with “dead stops” in a
CDS system that requires additional action by the
ordering physician.
Implications for Policy, Delivery or Practice: EMRbased CDS have the potential to improve the safety,
effectiveness, and cost-effectiveness of health care.
Funding Source(s): Kaiser Permanente
• Got Meaningful Use? Implementing Programs
and Policies to Achieve Widespread Use of
Health Information Technology
Yael Harris, Ph.D., M.H.S.
Presented by: Yael Harris, Ph.D., M.H.S., Director,
Division of Evaluation, Office of the National
Coordinator for Health Information Technology,
Department of Health and Human Services, 200
Independence Avenue, SW Room 717G,
Washington, DC 20201; Phone: (202) 205-3628;
Email: yael.harris@hhs.gov
Research Objective: To describe how the
Department of Health and Human Services (DHHS)
is working to help bring health information technology
(HIT) to all Americans, and what features of
electronic health records (EHRs) are needed to
transform the way care is delivered in the United
States.
Study Design: This review of the Health Information
Technology for Economic and Clinical Health
(HITECH) Act, passed in February 2009 as part of
the 2009 American Recovery and Reinvestment Act,
will focus on how programs are being implemented to
further the goal of promoting more rapid adoption of
EHR systems by providers. The underlying premise
of these programs is that HIT has the potential to
transform how U.S. health care is delivered in the
United States and is a key building block for health
reform.
Population Studied: The physicians and hospitals
that treat Medicare and Medicaid patients and are
eligible under HITECH for financial incentives to
adopt EHR systems.
Principal Findings: DHHS is closely monitoring the
interdependent Federal programs that are being
implemented to achieve widespread use of HIT. A
proposed rule outlining a detailed set of EHR features
and functionalities that providers must embrace in
order to be eligible for incentive payments under the
Medicare and Medicaid programs was recently
released. The proposed rule thus defines a draft set
of criteria for meaningful use of the technology.
These features were identified through an open and
transparent process and based on key health reform
principles: (1) improving quality, safety and efficiency
while also reducing health disparities; (2) engaging
consumers in their health care; (3) improving the
coordination of care; and (4) improving health for the
public at large. A final definition will be released in the
summer of 2010 with incentive payments beginning
in 2011. DHHS is monitoring the adoption of health
information technology, tracking adoption of a basic
set of core functionalities across all providers. It will
use the adoption of these core functions by primary
care providers to estimate of the number of
Americans with access to an EHR.
Conclusions: As part of its efforts to stimulate HIT
adoption, DHHS is tracking the progress of
implementing HITECH programs, how they interact,
and how they will contribute to providers becoming
meaningful users of the technology.
Implications for Policy, Delivery or Practice: The
HITECH Act is intended to help achieve the potential
of HIT to curb health-care costs by eliminating
duplication, decreasing medical errors, increasing
care coordination, and using cutting edge science to
inform provider decisionmaking. Understanding the
programs and policies being implemented is critical to
evaluating their effects on HIT adoption and changes
in health-care delivery over the next four years.
Funding Source(s): Office of the National
Coordinator
Wither or Bloom? Moving from Successful Pilots
on Reducing Avoidable Rehospitalizations to
National Transformation
Chair: Anne-Marie Audet, M.D., M.Sc., S.M.
Sunday, June 27 * 11:00 a.m.-12:30 p.m.
Panelists: John Chang, Zynx Health; Luke Hansen,
Northwestern University Feinberg School of
Medicine; Douglas Levy, Harvard Medical School
Panel Overview: The US healthcare system is
poised to undergo significant transformation in the
next decade. Momentum is growing towards a
number of national priorities: creating accountable
care networks, strengthening primary care through
the medical home, building the national health
information technology infrastructure. Given the
magnitude of the problem, avoidable
rehospitalizations (avr) have also emerged as a
priority of national scope. In 2009, the Obama
Administration, MedPAC, and Congress identified
avrs as a significant source poor quality and of costly
waste.
A growing number of provider-level,
community, regional, state and national efforts are
now specifically focused on reducing avrs. The
evidence base re. effective interventions is
improving. The challenge is no longer so much what
to do, but getting the will and organizing to act. It is a
question of execution, diffusion and scalability.
The roundtable will engage the audience in
a rigorous conversation about how to design a
national strategy to achieve rapid and sustainable
system transformation. The framework proposed will
be the following: based on the body of evidence
about the impact of quality improvement models,
collaboratives, campaigns, a comprehensive set of
change levers (payment, recognition, transparency,
professionalism) will have to be applied together to
achieve any progress, and those levers will need to
be applied at each level of the health care system –
local, regional, state and national. For example,
payment strategies are necessary but financial
incentives sufficient for effective and durable change
might cause unintended responses. Leadership at
the national, state and regional levels is equally
important, and require new forms of accountability
between groups that have functioned independently.
Theories and models of spread will be needed to
achieve diffusion of innovation at a rapid pace.
Each of the 5 panelists will launch the
discussion with a short presentation drawing from her
knowledge and experience, using evidence from
scientific studies, current initiatives and their own
current work. The roundtable will begin by setting
the stage for the topic as exposed above, providing
the framework for a national multi-level and multilever strategy to enable system transformation. Next,
two panelists will provide the state-level and
community-level perspectives, as to how system
redesign can be most effectively achieved at those
levels. The last 2 panelists will then discuss essential
change levers: one will discuss those used by a large
private payer, and the last discussion will focus on
the theoretical and pragmatic models of spread.
State perspective: the panelist will discuss
state roles to accelerate and ensure sustainable
success in system redesign to reduce avrs. The
arguments proposed are as follow: state-led efforts to
drive healthcare system transformation are very
promising. Although signals from the federal
government can contribute to the broad agenda
setting, leadership and implementation have a key
state-based locus of influence and activities.
Opportunities to drive change at the state level
through public and private sector initiatives include:
mobilizing quality improvement efforts, coordinating
and aligning initiatives within and across settings,
collecting and analyzing performance data at a
community/state level, addressing systemic barriers
to effective care delivery (e.g. payment policies,
regulations, practice norms, supply driven utilization).
Drawing upon her experience providing technical
assistance to state efforts to reduce avrs in the
STAAR Initiative (State Action to Avoid
Rehospitalizations, a 5 year initiative involving 3
states, MA, MI and WA), the panelist will discuss
areas of active knowledge development including:
structures of state based efforts leading change: is
there one “right way”? How do issues (specifically
reducing avrs) get on the agenda, and why? How
does working on reducing readmissions fit in with
state based reform agendas, and does supporting
process improvement at the front lines inform the
work of public and private sector leaders?
Community Perspective: The panelist will
explore levers for improvement based on the concept
that 'all healthcare is local.' She will discuss her
experience in working with 14 geographically defined
communities, to support improvement efforts aimed
at reducing avrs. Clinical, social and economic
models will inform the discussion around innovative,
actionable and scalable community-based
improvement and payment reform approaches. The
presentation will include an overview of lessons
learned from a case study of a best practice
community, and how to replicate those lessons in
other communities.
Payer Perspective: the panelist will discuss
the levers being used by a large private payer to
foster care redesign in a setting that includes a robust
Medicare Care Management program. Both
challenges and evidence of impact will be presented.
In this case, an evidence-based model, the
Transitional Care Program was adopted and
deployed broadly, in incremental steps. The impact
has been significant – a relatively well-managed
population, and a significant (20%) reduction in avrs.
Further plans for nationwide deployment of the model
throughout the Medicare Advantage population will
be presented, as will issues as to how best to use
other levers such as financial incentives, and
promising payment reform pilots.
The last panelist will tackle models of spread.
In order to bring effective health care and public
health interventions to those who require them,
nations require durable systems for disseminating
sound practice. Such systems help define and
prioritize problems, refine appropriate interventions,
create aligned aims and incentives for change, and
support active implementation through networked
learning. With many ongoing efforts to reduce avrs at
local, state and national levels, the opportunity exists
to use this experience to reflect more deeply on how
to build such a network. The panelist will discuss his
work advising national-level improvement projects in
eight countries (United States, England, Canada,
Japan, Denmark and Ghana), and his perspective
about how creating national systems of coordinated
action, incentives and national learning is possible
through mindful design. Some of the common
elements of a powerful system for dissemination will
be discussed, including: engaged, aligned leadership;
simple, shared aims; thoughtfully-timed incentives;
shared self-consciousness (a common image of
work); safe spaces for trial and error; capacity for
rapid discovery and redistribution of good ideas;
systems of rapid recognition (for individuals and
organizations; devolution of control from central
structures to the front lines of practice.
The momentum toward a national, largescale, all-payer and all provider system aimed at
reducing avrs, if well orchestrated could lead to the
fundamental redesign of how care is delivered in the
US, thus establishing the infrastructure for high
performance and impact. This roundtable discussion
is timely and will foster rich debates about a
challenge facing many if not most health care leaders
in this country and abroad. The framework proposed
is one that could be repurposed to solve other
problems in health care and health (beyond avrs).
Health Information Technology Policy and
Evaluation from the City and State Perspective
Chair: Rainu Kaushal, M.D., M.P.H.
Sunday, June 27 * 11:00 a.m.-12:30 p.m.
Panelists: Rachel Block, New York State
Department of Health; Sarah Shih, New York City
Department of Health and Mental Hygiene
Panel Overview: Through the American Recovery
and Reinvestment Act (ARRA), the United States is
making an unprecedented investment in health
information technology (HIT) and health information
exchange (HIE). New York state has been making
similar investments since 2005, making the state
currently one of the most mature in terms of health
information exchange. New York's $250 million
investment in HIT through the HEAL NY capital
grants program is about eight times that of the next
leading state's. In addition, New York City is in the
midst of a $60 million public-private initiative to
deploy community-level interoperable electronic
health records. This provides New York with a unique
perspective on HIT and HIE policies at the state and
city level, as well as evaluation approaches at both
levels. In this roundtable discussion, three panelists
will present their experiences in developing policy
about HIT and HIE, and evaluating it, from the local
and state-wide perspectives.
State-Wide Policy: HEAL NY was established
in 2004 to invest an anticipated $1 billion to
reconfigure New York’s health care delivery system
to improve patient care and increase efficiency. A
major element of the plan is the development of an
interoperable standards-based network to advance
EHRs and other HIT applications. This includes the
SHIN-NY as the health information exchange
infrastructure through which EHRs and other HIT
applications interconnect. New York also formed a
public-private partnership entity – the New York
eHealth Collaborative – to facilitate a statewide
collaboration and governance process for its health
information infrastructure. In addition, statewide
policy guidance has been developed surrounding
information policies, standards, privacy and security,
and protocols and technical approaches. Grants have
been awarded to multiple regional health information
exchange organizations (RHIOS) as well as
community HIT adoption collaborations (CHITAs) to
promote interoperable EHRs and provide
implementation and adoption services.
State-Wide Evaluation: A formal academic
collaborative between four universities has been
designated by New York State as the official
evaluation entity for the HEAL NY program. The
collaborative brings together researchers in health
services, informatics, public health, biostatistics,
industrial engineering, and clinical medicine to
conduct rigorous and standardized evaluations of all
of the HEAL NY information technology projects, at
both the local and state-wide level using qualitative
and quantitative methods from all of these disciplines.
The group takes a community- based participatory
research approach, in which community stakeholders
participate in developing the research plan to help
ensure that it reflects the community's priorities, while
academic investigators provide methodological
expertise and national context. Throughout the
research, community stakeholders are also involved
in collecting data, reviewing community-relevant
interim reports, and providing feedback on the
progress of the research plan. This involvement is
designed to help ensure that these community
stakeholders feel a benefit to themselves and to the
success of their own projects.
City-Wide Policy and Evaluation: In 2005, the
New York City Department of Health and Mental
Hygiene (DOHMH) created the Primary Care
Information Project (PCIP) to improve the delivery of
health care in the ambulatory care setting through the
adoption of HIT. Since its inception, PCIP has
recruited 2,501 providers to join the program and
implemented prevention-oriented HIT systems with
over 1,750 providers. The vision of the program is to
reduce gaps in primary care and thus lower the
overall number of avoidable deaths from heart
attacks, stroke, and other conditions where there is
strong evidence for treatment or preventive services.
Three principles guide the core operational mission of
PCIP: enable practices to easily access patient
information at the point of care (implementing HIT
and HIE); integrate information to inform decisions,
tasks, and routines (workflow redesign to focus on
preventive care); and engage payers so that payment
for tasks and services will sustain a focus on
prevention and help patients stay healthy. The city’s
initial investment in PCIP was intended to reach 20%
of the providers serving primarily Medicaid or
uninsured patients, with the hope that creating an
early group of EHR users would help demonstrate
the benefits and accelerate widespread HIT adoption
throughout the city. Much of the initial efforts were
further bolstered by substantial support through the
statewide funding and programs on HIT and HIE.
The conversion of practices from paper to
fully electronic information systems requires
substantial support. Support is provided at various
stages of the adoption process as health care
providers and their staff need to be re-oriented in
their documentation and retrieval of patient
information. The city provides technical support
before and during adoption, as well as training
activities for providers on EHR use and on quality
improvement to transform practices to provide health
care from a patient population perspective, rather
than focusing only on the patient visit. PCIP has
developed a workforce to support these practices
through the adoption and use of HIT and will become
a regional extension center for the New York City
area to implement and help an additional 2,500
priority providers to meet meaningful use
requirements with their EHRs. In addition, PCIP
continues to innovate existing HIT and HIE with a
public health focus in order to maximize the potential
of electronic information to improve the overall health
of New York City.
Policy Implications: As the nation expands its
HIT and HIE infrastructure, health information policy
and evaluation are at the forefront of national
concerns. Lessons learned at the state and local
levels can provide valuable insight nationally. As New
York State and New York City are relatively
advanced in building and evaluating health
information infrastructures, their perspectives and
policies may assist other states and regions that are
making similar transitions to more fully interoperable
health information environments.
What is the Relationship Between Health Care
Cost and Quality?
Chair: Ateev Mehrotra, M.D., M.P.H.
Sunday, June 27 * 11:00 a.m.-12:30 p.m.
Panel Overview: Policymakers are searching for
ways to improve the cost and quality – or “value” – of
care. Area-level studies that have found a weak or
negative relationship between quality and cost have
captured the attention of policymakers seeking ways
to increase health system performance. However, the
relationship between cost and quality is poorly
understood, particularly at the provider level, where
most policy interventions are targeted and medical
decisions are made. Few studies have examined the
relationship between the cost and quality of care by
individual providers, and these studies have
employed different methods and arrived at somewhat
conflicting results.
This panel presents an overview of recent
studies comparing health care cost and quality at the
physician, hospital, and area levels. The panel will
explore (1) what is known about the association
between cost and quality at each of these three
levels; (2) what might explain discrepant findings; and
(3) the implications of these studies for the ongoing
debate on whether cutting costs will negatively
impact quality. Understanding these issues is critical
to the design of policies such as pay-forperformance, selective and tiered networks, and
bundled payment that target both cost and quality.
• Measuring Efficiency: The Association of
Hospital Costs and Quality of Care
Ashish Jha, M.D.; John Orav; Allen Dobson; Robert
Book; Arnold Epstein
Presented by: Ashish Jha, M.D., Associate
Professor, Harvard School of Public Health, 677
Huntington Avenue, Boston, MA 02115; Phone:
(617) 432-5551; Email: ajha@hsph.harvard.edu
Research Objective: Providers with lower costs may
be more efficient and, therefore, provide better care
than those with higher costs. However, the
relationship between risk-adjusted costs (often
described as efficiency) and quality is not well
understood. We examined the relationship between
hospitals' risk-adjusted costs and their structural
characteristics, nursing levels, quality of care, and
outcomes.
Study Design: A relative cost index was calculated
for each hospital as the ratio of its actual average
cost per case for Medicare patients, divided by its
predicted average cost per case for Medicare
patients. For each hospital, we calculated a summary
quality score for each of three conditions using
publicly reported Hospital Quality Alliance measures.
We examined the relationship between risk-adjusted
hospital costs and three sets of hospital
characteristics: nurse-to-census ratio (calculated by
dividing the number of nurses on staff by the number
of patient days in thousands), ownership (for-profit
versus not-for-profit), and percentage of patients who
had Medicare insurance. We examined the
relationship between risk-adjusted hospital costs and
risk-adjusted mortality rates. We used a combination
of chi-square tests and t-tests, as appropriate, to
compare various hospital characteristics with their
quartile of risk-adjusted costs. We used correlation
coefficients to examine the relationship between the
hospital cost index and performance on the quality
summary scores as well as a hospital’s nurse-tocensus ratio.
Population Studied: Medicare beneficiaries
hospitalized for congestive heart failure, acute
myocardial infarction, or pneumonia among a
national sample of U.S. hospitals.
Principal Findings: U.S. hospitals with low riskadjusted costs were more likely to be for-profit, treat
more Medicare patients, and employ fewer nurses
than hospitals designated as being high costs. Low
cost hospitals, on average, provided modestly lower
quality of care for acute myocardial infarction and
congestive heart failure but had comparable rates of
risk-adjusted mortality.
Conclusions: We found no evidence that low-cost
providers provide better care. Instead, they had
slightly worse performance on process-based quality
indicators for AMI and CHF and comparable riskadjusted mortality rates.
Implications for Policy, Delivery or Practice: Many
have advocated calculating risk-adjusted costs as an
indicator of “efficiency.” Implicitly, this assumes that
all hospitals produce the same output in terms of
quality of care. Better management should lead to
both lower costs and higher quality of care. Our
results do not, in aggregate, support this hypothesis.
We found that, on average, hospitals with lower costs
had marginally lower quality of care, although the
magnitude of this association was small. As payers
increasingly reward greater “efficiency” or lower
costs, they need to exercise caution to ensure that
they are not inadvertently encouraging worse care.
Funding Source(s): CWF
• Outcomes for Elderly Patients With Heart Failure
Looking Forward, Looking Back: Assessing
Variations in Hospital Resource Use
Michael Ong, M.D., Ph.D.; Carol Mangione M.D.,
M.S.P.H.; Patrick Romano, M.D., M.P.H.; Qiong
Zhou, M.A.; Andrew Auerbach, M.D., M.P.H.; Alein
Chun, Ph.D., M.S.P.H.
Presented by: Michael Ong, M.D., Ph.D., Assistant
Professor in Residence, Department of Medicine,
UCLA, 911 Broxton Avenue, 1st Floor, Los Angeles,
CA 90024; Phone: (310) 794-0154; Email:
MOng@mednet.ucla.edu
Research Objective: Recent studies have found
substantial variation in hospital resource use by
expired Medicare beneficiaries with chronic illnesses.
By analyzing only expired patients, these studies
cannot identify differences across hospitals in health
outcomes like mortality. This study examines the
association between mortality and resource use at
the hospital level, when all Medicare beneficiaries
hospitalized for heart failure are examined.
Study Design: Multivariate risk-adjustment models
for total hospital days, total hospital direct costs, and
mortality within 180-days after initial admission
("Looking Forward") or within 180-days before death
("Looking Back").
Population Studied: A total of 3999 individuals
hospitalized with a principal diagnosis of heart failure
at 6 California teaching hospitals between January 1,
2001, and June 30, 2005 ("Looking Forward") and a
subset of 1639 individuals who died during the study
period ("Look
Principal Findings: "Looking Forward" risk-adjusted
hospital means ranged from 17.0% to 26.0% for
mortality, 7.8 to 14.9 days for total hospital days, and
0.66 to 1.30 times the mean value for indexed total
direct costs. Spearman rank correlation coefficients
were –0.68 between mortality and hospital days, and
–0.93 between mortality and indexed total direct
costs. "Looking Back" risk-adjusted hospital means
ranged from 9.1 to 21.7 days for total hospital days
and 0.91 to 1.79 times the mean value for indexed
total direct costs. Variation in resource use site ranks
between expired and all individuals were attributable
to insignificant differences.
Conclusions: California teaching hospitals that used
more resources caring for patients hospitalized for
heart failure had lower mortality rates.
Implications for Policy, Delivery or Practice:
Contrary to public discussion of variation, it is likely
that not all variation is inefficient or wasteful.
However, much more work is needed to truly
distinguish inefficient from beneficial resource use.
Focusing only on expired individuals may overlook
mortality variation as well as associations between
greater resource use and lower mortality. Reporting
values without identifying significant differences may
result in incorrect assumption of true differences.
• The Association Between Cost and Quality of
Care Provided by Individual Physicians
Peter Hussey, Ph.D.; Ateev Mehrotra, M.D., M.P.H.;
John Adams, Ph.D.; Julie Lai; Elizabeth McGlynn,
Ph.D.
Presented by: Peter Hussey, Ph.D., Policy
Researcher, , RAND, 1200 S Hayes Street w7w,
Arlington, VA 22202; Phone: (703) 413-1100 ext.
5460; Email: hussey@rand.org
Research Objective: The relationship between
physician quality and cost has important implications
for the design of policy interventions and for
physician strategies to improve performance. Policy
initiatives typically treat cost and quality as
independent domains of performance with no
relationship. Yet the underlying relationship is
unclear. Area-level and hospital studies have found
no relationship or an inconsistent relationship
between quality and cost. However, to our
knowledge, no studies have compared the cost and
quality of care at the level of the individual physician.
The purpose of this study was to examine the
association between cost and quality among
individual physicians.
Study Design: Consistent with the approach taken
by health plans and Medicare, we created individual
cost profiles for each physician. We first used
commercial software to construct episodes of care
which were assigned to the physician with the highest
proportion of professional costs in the episode. We
created a summary cost profile for each physician by
summing the costs of assigned episodes and dividing
by the sum of average costs of case-mix matched
episodes for physicians in the same specialty. The
RAND claims-based Quality Assessment Tools were
used to evaluate quality performance. Performance
scores were created by dividing all instances in which
recommended care was delivered by the number of
times patients were eligible for such care. We used
“shrinkage” estimates of physician cost and quality
scores to adjust for the amount of information in each
estimate. We calculated the correlations between
physician cost and quality scores, with separate
analyses for groups of physician specialties and
types of care (acute, chronic, preventive).
Population Studied: All Massachussetts physicians
who cared for one of the 1.1 million adults enrolled in
four commercial health plans in Massachusetts.
Principal Findings: There was no significant
association between cost and quality scores overall
(Pearson correlation coefficient = -0.01, p=0.28) or
for specialty groups. There were significant but small
positive correlations between cost and quality for all
three types of care, when analyzed separately. The
correlation was stronger for preventive care
(coefficient=0.15, p<0.001) than for acute care
(coefficient=0.04, p=0.001) and chronic care
(coefficient=0.04, p<0.001).
Conclusions: Overall, we found no association
between physician cost and quality. In other words,
physicians who deliver high-quality care do not
necessarily use more health care resources.
However, for preventive care services, there is a
positive association between cost and quality. Our
findings largely confirm the results of previous studies
at the regional and hospital levels.
Implications for Policy, Delivery or Practice:
These findings suggest that policy interventions could
potentially be designed that reward low-cost care
without adversely impacting quality, and vice versa.
However, external programs could be designed to
account for the higher cost associated with highquality preventive care. For example, costs
associated with preventive care could be excluded
from a physician’s cost profile.
Funding Source(s): CWF
• Medicare Spending, the Physician Workforce,
and Beneficiaries' Quality of Care
Katherine Baicker, Ph.D.; Amitabh Chandra, Ph.D.
Presented by: Katherine Baicker, Ph.D., Professor
of Health Economics, Department of Health Policy
and Management, Harvard School of Public Health,
677 Huntington Avenue Kresge, 4th Floor, Boston,
MA 02115; Phone: (617) 432-5209; Email:
kbaicker@hsph.harvard.edu
Research Objective: The quality of care received by
Medicare beneficiaries varies across areas. We first
determined whether quality differences can be
explained by differences in Medicare spending. That
is, are states where there is more spending per
Medicare beneficiary also more likely to provide
effective care? We next examined whether highspending states provide more care along other
dimensions, such as multiple specialist consultations,
hospitalizations, and use of intensive care units
(ICUs) in the last six months of life. Finally, we
explored potential mechanisms through which
intensive care might crowd out high-quality care. This
session of the panel will discuss these findings, which
were published in 2004, in the context of other arealevel and provider-level studies of the relationship
between cost and quality.
Study Design: Quality was measured using twentyfour quality measures developed by the Medicare
Quality Improvement Organization. We calculated
Medicare reimbursement per beneficiary at the state
level using Medicare claims data, adjusted for
inflation, state price levels, and demographics. We
explored the determinants of state spending and
quality using generalized least squares regressions
weighted by the size of the Medicare population in
each state. We analyzed the relationship between
spending and end-of-life care, such as the fraction of
patients admitted to the ICU and the number of days
spent in the hospital. We regressed spending per
Medicare beneficiary and overall quality rank on the
number of specialists, general practitioners, and
registered nurses per capita, controlling for the total
number of physicians per capita, to explore the effect
of changing the composition of the medical
workforce.
Population Studied: Fee-for-service Medicare
beneficiaries in 50 states.
Principal Findings: We found a significant negative
correlation between state spending and quality; a
state spending $1,000 more per beneficiary dropped
almost ten positions in overall quality ranking (p <
.001). Medicare beneficiaries in states that spent
$1,000 more per beneficiary spent an average of 1.3
more days in the hospital (p < .01) and were 3.9
percent more likely to be admitted to an ICU (p <
.005). Increasing the number of general practitioners
in a state by 1 per 10,000 population (while
decreasing the number of specialists to hold constant
the total number of physicians) is associated with a
rise in that state’s quality rank of more than 10 places
(p < .0005) as well as a reduction in overall spending
of $684 per beneficiary (p < .0005). Conversely,
states where more physicians are specialists have
lower-quality care and higher cost per beneficiary.
Conclusions: We find that states with higher
Medicare spending have lower-quality care. This
negative relationship may be driven by the use of
intensive, costly care that crowds out the use of more
effective care. One mechanism for this trade-off may
be the mix of the provider workforce: States with
more general practitioners use more effective care
and have lower spending, while those with more
specialists have higher costs and lower quality.
Implications for Policy, Delivery or Practice:
Improving the quality of beneficiaries' care could be
accomplished with more effective use of existing
dollars.
Funding Source(s): NIA
OECD’s Health Care Quality Indicator Project:
Conceptual, Methodological and Policy
Challenges in International Health System
Comparison
Chair: Niek Klazinga, Ph.D.
Sunday, June 27 * 11:00 a.m.-12:30 p.m.
Panelists: Saskia Droesler, Niederrhein University
of Applied Sciences; Gaetan Lafortune,
Organization for Economic Co-Operation and
Development; Jan Mainz, Aarhus University;
Edward Sondik, National Center for Health Statistics
Panel Overview: The round-table will discuss the
widespread contemporary interest in health care
quality in 30 OECD member-states (along with other
non-member collaborators) and progress and
challenges in international health system
performance measurement. It will describe the role
and functions of the OECD Health Care Quality
Indicators (HCQI) Project and examine the
conceptual, methodological and policy challenges
associated with measuring, collecting, reporting,
comparing and using health care quality data
internationally, citing examples from the HCQI’s
ongoing research programs in primary care, mental
health, patient safety and patient experiences.The
panel will highlight the progress made over the past 7
years in developing and reporting internationally
comparable indicators of quality of care, and discuss
the lessons learned and future plans of the HCQI
project.
The panel is composed of a group of
international multidisciplinary experts involved in the
coordination and leadership of the HCQI project and
its ongoing research programs in the quality of
primary care, mental health care, patient safety and
patient experiences.
Policy makers are increasingly interested in
measuring, evaluating and internationally comparing
the quality of care in their respective health systems
for three main reasons: promoting accountability,
strategy development and mutual learning (Veillard et
al, 2009). They are interested in knowing how their
national quality of care compares to other
constituencies, explaining differences and deviations,
and potentially deriving policy lessons from the
experiences of other countries. However,
policymakers have been hampered by the lack of
comparable, meaningful and timely cross-national
data, and have stated the need for such information
to guide policies and social action to improve health
system performance.
In response, the HCQI project was
developed, initially building on work by the
Commonwealth Fund, the Nordic Council of Ministers
and several other countries. Over 7 years, it has
expanded to include more than 30 countries, and
actively works with a multitude of international
organizations – reconciling and synthesizing diverse
strands of work done across a multitude of countries,
institutions, professions and disciplines (Mattke et al,
2006). The crux of the approach is to complement
and coordinate efforts of national and other
international bodies, to avoid duplication and
streamline initiatives. The key goal is to develop and
implement a set of quality indicators at the
international level that could produce benchmarks,
offering policymakers and other stakeholders a toolkit
to stimulate cross-national learning.
HCQI work is currently divided into two
streams: regular data collection of readily available
care process and outcome indicators (chronic
conditions, mental disorders, cancer and
communicable disease), and developmental work in
four major priority indicator areas (primary care,
mental health, patient safety and patient
experiences), while simultaneously improving
international information systems and indicator
comparability. Currently, approximately 40 health
care quality indicators are considered suitable for
cross-national data collection and have been
reported in working papers and the bi-annual OECD
publication Health at a Glance in 2007 and 2009
(HCQI website, 2010). While methodological work
remains to improve the comparability of indicators,
the developmental work has yielded valuable insights
on the challenges in conceptualizing and constructing
indicators, collecting and interpreting data, and in
designing national performance reporting systems.
On a conceptual level, work in the new
priority areas, especially primary care, patient safety
and mental health, has highlighted the changing
nature of population health and the increasing
importance of capturing comorbidities, health
inequalities and coordination of care (temporally and
spatially) in corresponding indicators that focus on
patients rather than diseases, and are adjusted for
differences in patient risk profiles. These issues give
rise to the difficult question of whether more
appropriate measures can be collected.
On an operational and methodological level,
a multitude of challenges exist, mainly of a political
and technical nature concerning the lack of
availability of data. Politically, some priority areas and
measures are more desirable than others. In addition,
there exists a tension between maintaining a
temporally stable indicator set vs continuously asking
policymakers in over 30 countries to drop or add
indicators as their importance and validity change
(Veillard et al, 2009).
There is also the compromise that must be made
between ensuring rigour and feasibility, considering
the diversity of technical competences, resources
and different approaches, cognitive understandings
and languages used when conducting the same
study (eg. patient experience questionnaires via
email, phone, or mail). Other underlying, but major
causes impeding data availability include the slow
adoption of interoperable electronic health records,
the lack of use of unique patient identifiers, and
differences in definitions, data sources, coding
systems, privacy legislation and data collection
standards.
For example, the work on mental health
showed the importance of being able to track people
between different institutions within the health system
and to differentiate between health and social care.
The work on patient safety illustrated the importance
of recording and distinguishing between pre-existing
conditions and those acquired during hospital stay
(and thus the importance of developing 'present on
admission' flags) (Drösler et al, 2009).
A new area of work by the HCQI project
involves the challenge of helping policymakers make
sense of cross-national variations in quality of care,
and to promote further analysis of different
experiences by looking into causal mechanisms,
taking into account contextual factors, and presenting
data in policymaker-friendly ways (eg. concise
graphics). OECD’s HCQI project recently performed
initial analyses on cancer care to explore whether
differences in outcomes can be explained by the
respective national organization and financing of
health care. Analytical work on cardiovascular
diseases and diabetes is planned. The main difficulty
relates to deciphering multifactor causal attribution
mechanisms impacting health outcomes.
Nevertheless, such work is a critical precondition
underlying the appropriate use of quality indicators in
national decision making. This is especially
important, as governments are increasingly basing
macro governance decisions through inferences
made on HCQI data, many of which are linked to
their national performance reporting initiatives.
Advances in HCQI data have been made over the
past 7 years, including the improvement of data
quality standards, the use of confidence intervals,
unifying definitions and standardizing age and sex
adjustment procedures. The exciting insights gained
from new areas of indicator work warrant innovative
approaches to tackle the conceptual, methodological
and policy challenges highlighted above, to harness
the immense potential for cross-national learning and
improving quality of care internationally. The round
table will not only inform the participants of Academy
Health of the progress made in the four focus areas,
but should also result in conclusions that will be used
as academic input for a ministerial conference and
the related Forum on Quality of Care at the OECD
(October 7-8, 2010).
Consumer Sentiment Toward Health Reform
Chair: Lynn Blewett, Ph.D.
Sunday, June 27 * 4:15 p.m.-5:45 p.m.
Panelists: Thomas Grannemann, Centers for
Medicare & Medicaid Services; Carol Irvin,
Mathematica Policy Research, Inc.; Sharon Long,
Urban Institute; Elizabeth Lukanen, University of
Minnesota; Alan Weil, National Academy for State
Health Policy
Panel Overview: The health reform debate of 2009
offered an unprecedented opportunity to monitor
consumer opinion on a highly politicized topic. This
roundtable will present an overview of four different
polls/tracking surveys that were conducted during the
course of the 2008 election and the health reform
debate. These surveys are important because they
offer both historical evidence of public sentiment and
have monitored changes in sentiment over the year.
The roundtable will include an overview of
the polls and tracking surveys conducted from
November 2008 through spring 2009, including
intermittent and repeated surveys. This covers postelection opinions as media coverage transformed
from election issues to the transfer to power and
priority legislative issues under the Obama
administration. The overview will include survey
content relating to health reform opinions and
personal health-related experiences, timeline of
environmental influences such as policy events and
media activity, and methodological considerations.
The panelists will overview research
suggesting that reporting of public opinion plays an
important role in shaping legislation. Results have
shown that the public forms an overall view leading it
either to support or to oppose enactment, but this
view can change substantially over time. Multiple
factors may contribute to the public's judgment,
including the popularity of major policy elements of
the bill, its perceived effect on the country, and its
potential effect on their own future health care. The
public surveys presented here will be balanced by an
opinion leader’s survey, with discussion on the
leaders’ support for reform despite disparate
agreement on specific components of the bill.
One panelist will discuss a consumer
sentiment index developed in early 2009 to assess
recent barriers to care and concerns for future access
to care. This index is based on a monthly survey of
U.S. consumers and is designed to track opinions
over time, as well as longitudinal changes among a
subsample. Results to date show that the recent
barriers tend to remain consistent, but future
concerns often fluctuate significantly. The survey also
includes questions relating to health reform
legislation, showing that consumer support for reform
does not necessarily correspond with how they feel it
will impact them personally.
A second panelist will discuss a monthly poll
that addresses health and health legislation issues
during and post-election. This poll has been
conducted regularly since spring of 2007 (more than
20 surveys have been conducted to date with over
30,000 respondents) to examine the public’s
experiences in the health care system, their ranking
of health as a policy priority, and their views on health
care reform options. The monthly tracking allowed an
in-depth exploration of public’s views beyond
measuring just an overall reaction to debate. The
polls examined which components of the policy
discussion most resonated and which caused the
most apprehension and opposition amongst the
public. Furthermore, the project allowed for looking
closely at how different segments within the public
reacted to various aspects of the reform discussion –
including the elderly, those with lower incomes, the
uninsured, those with different political party
identifications, and those with chronic conditions.
A third panelist will discuss general
population polls conducted over the course of health
reform debate and how public opinion on health
reform has played out relative to other policy issues.
These polls offer insight on public response to
specific components of the legislation as well as
media coverage of health reform and other events.
The polls provide timely insight on public reaction to
media coverage, placing the topic of health reform in
context with other news and legislative events.
Furthermore, the polls have queried specific
elements of reform to shed insight on public opinion
on controversial matters such as the public option,
abortion benefits, quality, and taxation, as well as
public sentiment about the legislative process.
The final panelist will discuss a survey of health care
opinion leaders. This panel of high-level experts
across multiple sectors was surveyed in summer of
2009 for their views on a number of key health reform
issues. The survey addressed pertinent reform
considerations such as the public plan option,
provider payments, insurance exchanges, cost
saving strategies, benefits standards, and enrollment
issues. Results found that most opinion leaders
support the main elements of federal reform and
support the need to enact comprehensive changes,
but their views vary concerning the details of health
reform. By the time of the research meeting a survey
update will be completed to incorporate opinions on
impressions of the final bill, potential challenges in
implementation, and priorities for the future.
Prescribing Efficiently and Safely: Quality of Care
for Prescription Drugs
Chair: Walid Gellad, M.D., M.P.H.
Sunday, June 27 * 4:15 p.m.–5:45 p.m.
Panel Overview: Medications are an essential and
growing part of modern medicine, and prescribers
have great discretion in their ability to choose one
medication over another to treat a given condition.
The efficiency and safety of prescribing are key
aspects of quality of care, and this panel will present
evidence from five studies that examine the efficiency
and safety of outpatient prescribing in the US. The
first panelist will present evidence on the physician
prescribing patterns for psychiatric medications,
showing the heavy concentration in the antipsychotic
market, with many physicians prescribing only a few
of the many different medications available to them.
The second panelist will continue to explore
prescribing patterns and efficiency by describing the
variation, over geography and over time, in the use of
Angiotensin Receptor Blockers in the VA system. The
third panelist will present evidence on the potential
savings associated with greater use of low-cost $4
generic programs, with a discussion about the
implications of broad availability of these low-cost
generics on physician prescribing. The fourth panelist
will focus on the issue of safety in prescribing by
examining the impact of Medicare Part D on the use
of high-risk medications among older adults. Finally,
the fifth panelist will tie efficiency, safety, and quality
of prescribing together by presenting evidence from
over 5 million patients on the epidemiology of
prescriptions abandoned at pharmacies by patients.
The panelists will discuss how their findings can and
should influence quality of care measurement and
reporting for prescription drugs.
• Use of Angiotensin Receptor Blockers in the VA,
2000-2009 – Why So Much Variation?
Walid Gellad, M.D., M.P.H.; John Lowe M.B.A.; C.
Bernie Good, M.D., M.P.H.; Julie Donohue, Ph.D.
Presented by: Walid Gellad, M.D., M.P.H.,
Assistant Professor of Medicine, , VA
Pittsburgh/University of Pittsburgh, 7180 Highland
Drive (151C-H), Pittsburgh, PA 15206; Phone: (412
)954-5267; Email: walid.gellad@va.gov
Research Objective: ACE inhibitors (ACE-I) and
Angiotensin Receptor Blockers (ARB) are important
medication classes with similar indications for use.
Although there are no significant differences in
efficacy between the two classes, ARBs are
substantially more expensive. Regional variation in
healthcare use has become a primary indicator of
inefficiency in the healthcare system, yet little is
known about variation in medication use. We used
national data on prescribing of ACE-Is and ARBs in
the VA, where drug price and drug coverage are
consistent, and focused on prescribing patterns to
assess 1) variation in use of ARBs among VA
Medical Centers (VAMC) in 2009, and 2) the change
in use of ARBs over time from 2000 to 2009.
Study Design: We aggregated national VA data on
outpatient ACE-I and ARB use for fiscal years 20002009 at the VAMC-level. We calculated the
proportion of patients who use ARBs among those
who require renin-angiotensin inhibitors, by dividing
the number of patients on ARBs by the number of
patients on either ACE-I or ARB at each VAMC. We
then assessed the 10-year growth rate in the
proportion of patients on ARBs ((2009 proportion –
2000 proportion)/2000 proportion). To calculate the
potential savings for VAMCs if they were to use fewer
ARBs, we determined how many fewer ARB
prescriptions a high-use VAMC would fill if it used
ARBs at the same rate as an average facility.
Population Studied: We studied 132 VAMCs. There
were 1.7 million patients on these medications with
15.7 million prescriptions in 2009 alone.
Principal Findings: For VAMC patients taking either
an ACE-I or ARB in 2000, the median proportion
using ARBs was 6.8%, with a range from 0.2% to
15.7%. The median rate of growth in this proportion
over 10 years was 194% (IQR 104% to 285%) but
also showed sizeable variation. Four VAMCs had
less than 5% growth over the 10 years, while seven
VAMCs had over 1000% growth, with 6 of those 7
VAMCs located in the same two states. In 2009, the
median proportion of patients taking an ACE-I or ARB
who used ARBs was 17.2% (IQR 13.4% to 21.1%),
with a range from 6.4% to 33.6%. Almost 80% of
VAMCs in the bottom half of use are located in the
South. If the highest-use VAMC in 2009 (with a
proportion of 33.6%) had the same proportion of ARB
use as the median facility, it alone would save
$205,292 yearly. If that VAMC filled ARBs at the
same rate as the least-using facility, it would save
$344,625, or 1.3% of its total yearly drug costs.
Conclusions: There is substantial variation across
VAMCs in the proportion of patients using ARBs, with
a steady increase over the past decade. Although
some increase over time in the use of ARBs over
ACE-I is to be expected due to side effects, it is
unlikely that medical indications alone explain this
variation and this increase over time.
Implications for Policy, Delivery or Practice: Costeffective, high-value, and efficient prescribing should
be a target of quality improvement programs, even in
systems with robust formulary management, such as
the VA.
Funding Source(s): VA
• Physician Prescribing Patterns for Psychiatric
Medications
Haiden Huskamp, Ph.D.; Haiden Huskamp Ph.D.;
Marcela Horvitz-Lennon, M.D., M.P.H.; Ernst Berndt,
Ph.D.
Presented by: Haiden Huskamp, Ph.D.,
Department of Health Care Policy, Harvard Medical
School, 180 Longwood Avenue, Boston, MA 02115;
Phone: (617) 432-0838; Email:
huskamp@hcp.med.harvard.edu
Research Objective: Psychiatric medications are
known to have highly heterogeneous treatment
response. Large-scale effectiveness trials indicate
that several medication trials are often required
before an adequate agent and dose are identified for
a particular patient. Studies suggest that, in general,
physician preferences for medications used for a
particular indication are quite stable and resistant to
change. This has implications for the ability of new
agents to gain market share and for physicians’
willingness to try new agents for their patients who
are not responsive to initial treatment choice. Little is
known, however, about whether physicians who
prescribe psychiatric medications use the full range
of available options for a given indication and
whether this varies across specialty. The objective of
this study was to examine concentration of physician
prescribing (i.e., how narrow vs. broad a physician is
with respect to prescribing) within a category of
psychiatric medications and how prescribing patterns
differ by specialty.
Study Design: We used monthly physician-level
data from IMS Health on the number of filled
prescriptions for a national random sample of 25,538
physicians from one of the ten specialties with the
highest prescribing rates for antipsychotic
medications over the period 1996 through 2008. We
linked these data with information on physician
characteristics from the AMA Masterfile and focused
on physicians who had prescribed at least one
antipsychotic medication. We examine concentration
of prescribing overall and by physician
characteristics, including specialty.
Principal Findings: The four most commonlyprescribed medications (Seroquel, Risperdal, Abilify,
and Zyprexa) comprised approximately two-thirds of
the market in 2008. The market was even more
concentrated at the physician-level. The top four
drugs made up 77% of prescriptions written by
general practitioners, 78% of those written by
psychiatrists, 92% written by pediatricians and 80%
by other physicians. Only 4 of 20 medications in the
class were prescribed at least once by a majority of
physicians in the sample with the number and
selection of drugs differing by specialty. For example,
the median number of different antipsychotic
medications prescribed at least once was 9 for
psychiatrists, 5 for general practitioners, 4 for
neurologists, and 2 for pediatricians. The median
proportion of physicians prescribing a given drug
varies from 7% for GPs, 21% for psychiatry, 1% for
pediatrics, and 5% for other specialties.
Conclusions: The antipsychotic market is heavily
concentrated, with only a handful of drugs accounting
for the majority of prescriptions filled in the class. The
market is even more highly concentrated at the
physician level, particularly among non-psychiatrists.
Psychiatrists typically used a much broader set of
medications, while many pediatricians and
neurologists prescribed only a couple of different
medications.
Implications for Policy, Delivery or Practice: Our
findings have important implications for quality
improvement initiatives and efforts to improve
compliance with treatment guidelines that call for
multiple medication trials for treatment refractory
mental disorders and point to potential difficulties in
altering physician preferences for medications.
Funding Source(s): none, The Robert Wood
Johnson Foundation Investigator Awards in Health
Policy Research, NIMH, and NIH National Center for
Research Resources
• Potential Savings from Broad Use of $4 Generic
Drugs: 2007 Medical Expenditure Panel Survey
Yuting Zhang, Ph.D.; Lei Zhou B.S.; Walid Gellad,
M.D., M.P.H..
Presented by: Yuting Zhang, Ph.D., Assistant
Professor of Health Economics, Health Policy and
Management, University of Pittsburgh Graduate
School of Public Health, 130 DeSoto Street,
Pittsburgh, PA 15261; Phone: (412) 383-5340;
Email: ytzhang@pitt.edu
Research Objective: Generic drugs are
bioequivalent to brand-name drugs but cost
substantially less. Several US retailers now offer
heavily-discounted generic drugs at $4 for a 30-day
supply. No data exist on how the program is used or
potential national savings from broad use of these
highly-discounted generics. Our study fills this gap.
Study Design: The 2007 Medical Expenditure Panel
Survey (MEPS) is a nationally representative sample
of 30,964 community-dwelling US adults, which
includes all prescribed medications used by
respondents. We identified a list of generic
formulations commonly available at $4 generic-drug
programs and identified respondents in the MEPS
who used these drugs. We compared characteristics
between those who paid $4 in 2007 for their generic
drugs vs those who could potentially have saved by
switching to $4 programs. For the latter, we
calculated the potential total annual savings as well
as annual savings by payer if they had switched to
the $4 programs. We also reported savings by top 5
medications purchased.
Population Studied: We identified 7,133 adults older
than 18 years of age who used generic formulations
available through the $4 programs. We then
categorized the individuals into three sub-cohorts
depending on whether they paid greater than, less
than, or equal to $4 for th
Principal Findings: Among 7,133 adults who used
generic formulations available through the $4
programs, only 5.9% paid $4 for their generics, and
66.5% could potentially have saved by filling these
prescriptions in a $4 generic program, corresponding
to 50,292,349 US individuals. Those who paid less
than $4 had other subsidies such as VA or
Medicare/Medicaid. Compared to those who
appeared to be using $4 programs in 2007, those
who could potentially have saved by switching to $4
programs were more likely to be male (42.7% vs
32.5%, p<.05), middle- or high- income (75% vs 70%,
p<.05), have zero chronic condition (51.4% vs 44.3%,
p<.05), and were less likely to have Medicare and
supplementary private coverage (18.5% vs 22.2%,
p<0.05). If patients had filled their generic
prescriptions through the $4 programs, the total
annual savings per-person would be $66.22
(s.e.=$2.43) in 2007, of which $38.50 (s.e.=1.57)
would be savings by patients, $16.46 (s.e.=1.33) by
private health plans, and $10.22 (s.e.=1.07) by
Medicare. This translates into $3 billion in total
annual savings in the US: $1.9 billion by patients,
$0.8 billion by private insurance, and $0.5 billion by
Medicare. The 5 medications with the highest total
annual per-person savings include metformin
1000mg ($81.98), levothyroxine 75mcg ($73.35),
lisinopril 20mg ($57.64), metoprolol 50mg ($51.74),
lisinopril 10mg ($41.89).
Conclusions: Total annual savings of $3 billion was
possible in the US in 2007 if patients had used $4
generic programs. This is the lower bound of
potential savings because it does not capture savings
if patients switch from brand-name drugs to
equivalent $4 generics.
Implications for Policy, Delivery or Practice: Lowcost generics could potentially save patients and
payers billions of dollars and lead to more costeffective prescribing and a more efficient healthcare
system.
Funding Source(s): The RAND University of
Pittsburgh Health Institute (RUPHI) and the NIH
Clinical and Translational Science Institute (CTSI)
• Medicare Part D’s Impact on Use of High Risk
Medications among Older Adults
Julie Donohue, Ph.D.; Zachary Marcum Pharm.D.;
Yuting Zhang, Ph.D.; Aiju Men, M.S.; Walid Gellad,
M.D., M.P.H.; Joseph Hanlon, Pharm.D., M.S.
Presented by: Julie Donohue, Ph.D., Assistant
Professor, Health Policy and Management, University
of Pittsburgh Graduate School of Public Health, 130
DeSoto Street, Pittsburgh, PA 15261; Phone: (412)
624-4562; Email: jdonohue@pitt.edu
Research Objective: The National Committee on
Quality Assurance recently developed measures of
“high risk medications in the elderly” as part of
Healthcare Effectiveness Data and Information Set
(HEDIS) to improve the appropriateness of
medication use among older adults. Recent
expansions in drug coverage under Medicare Part D
may have important effects on use of these drugs,
because lower out-of-pocket costs may increase
prescription fill rates for high risk drugs.
Study Design: We obtained pharmacy claims and
enrollment data from a large Medicare-Advantage
insurer two years before and after Part D’s
implementation. We used a pre-post-with-acomparison-group study design to examine changes
in use of the HEDIS high risk medications (excluding
benzodiazepines from the list since they were not
covered by Part D) in beneficiaries with varying levels
of drug coverage pre-Part D. Three groups (one with
no coverage and two with quarterly caps of either
$150 or $350 depending on county of residence)
were automatically enrolled in the insurer’s Part D
plans in 2006. A fourth group of enrollees had
generous retiree drug coverage throughout the study
period and serves as a comparison group. We used
generalized estimating equations to estimate the
likelihood of using a high risk medication before and
after Part D adjusting for demographic and health
status differences.
Population Studied: 34,679 elderly beneficiaries
continuously enrolled in the plan in 2004-2007.
Principal Findings: The comparison group with
stable retiree coverage reduced their use of high risk
drugs slightly from 20.4% in 2004 to 18.1% in 2007.
In 2004, before Part D, 15.2% of the group with no
coverage used high risk medications whereas in
2007 (after Part D) 17.0% of the no-coverage group
filled prescriptions for high risk drugs. After adjusting
for trends in the comparison group, those who
experienced improved coverage increased slightly
their use of high risk drugs [Adjusted Ratios of the
Odds Ratios post- vs. pre-Part D relative to the
comparison group were 1.33 (95% CI 1.21-1.47) for
the No coverage group; 1.10 (95% CI 1.00-1.22) for
the $150 cap group; and 1.08 (95% CI 1.02-1.14) for
the $350 cap group].
Conclusions: One unintended consequence of
expanded drug coverage to Medicare beneficiaries
may be a slight increase in use of high risk
medications among the elderly. Fortunately, the
relative increase in use of high risk drugs among the
group who transitioned from no coverage to Part D
was slightly smaller than what other studies have
shown for other drug classes.
Implications for Policy, Delivery or Practice: Use
of these high risk drugs is sensitive to out-of-pocket
costs and health plans might consider increasing
cost-sharing for these medications to discourage their
use.
Funding Source(s): NIH National Center for
Research Resources
• The Epidemiology of Prescriptions Abandoned
at the Pharmacy
William Shrank, M.D., M.S.H.S.; Niteesh Choudhry
M.D., PhD; Michael Fischer, M.D., M.P.H.; Jerry
Avorn, M.D.; Sebastian Schneeweiss, M.D., Sc.D.;
Joshua Liberman, Ph.D.
Presented by: William Shrank, M.D., M.S.H.S.,
Assistant Professor, Division of
Pharmacoepidemiology and Pharmacoeconomics,
Brigham and Women's Hospital, Harvard Medical
School, 1620 Tremont Street, Suite 3030, Boston,
MA 02120; Phone: (617) 278-0930; Email:
wshrank@partners.org
Research Objective: Important gaps remain in our
understanding of the causes of non-adherence to
essential chronic medications. No previous studies
have systematically examined rates and correlates of
prescriptions abandoned at the pharmacy. Some
abandoned prescriptions may never be picked up,
representing a missed opportunity for therapy, while
other prescriptions abandoned may be purchased
later at the same pharmacy or at another pharmacy,
indicating a delay in treatment and a challenge to
pharmacy efficiency. A better understanding of these
prescriptions may offer a fertile opportunity to
intervene and improve appropriate medication use.
Study Design: All prescriptions filled and either
purchased by a patient or returned to stock (RTS - or
abandoned), at CVS retail pharmacies were identified
during a 3 month period, from 7/1/08 – 9/30/08 (the
identification period). The CVS consumers who were
covered by Caremark, a PBM, were then identified
and datasets merged. PBM claims from the 6 months
prior to the identification period were used to identify
first prescriptions in a class. PBM claims from a three
month follow up period were used to assess whether
patients who abandoned prescriptions at the
pharmacy subsequently filled those prescriptions at
the same or another pharmacy. We identified
prescriptions filled in the identification period as either
filled or RTS (abandoned), or RTS with a fill in the
same medication class in the subsequent 30 days.
We included only the first prescription in a drug class
(the Index prescription) during the identification
period in our outcome assessment. We described
rates of abandonment by drug class. We used
generalized estimating equations to evaluate patient,
insurance, neighborhood and prescription-level
characteristics correlated with medication
abandonment.
Population Studied: In total, we evaluated
10,349,139 Index prescriptions filled by 5,249,380
individual patients who used CVS retail pharmacies
and who received pharmacy benefits from Caremark.
Principal Findings: Overall, 3.27% of all Index
prescriptions filled were returned to stock; 1.77%
were abandoned and 1.50% were filled at any
pharmacy in the subsequent 30 days. Opiates were
least likely to be RTS prescriptions (1.85%). Higher
rates of abandonment were seen in proton pump
inhibitors (4.43%) and insulin (5.09%). In multivariate
analyses, prescriptions with copayments of $40.01 –
50.00 had 3.49 times greater odds of being
abandoned, and prescriptions costing over $50.01
had 4.93 times greater odds of being abandoned
than prescriptions with copayments of $10 or less. (p
< 0.001) Patients living in the highest income quintile
zip codes had 32% lower odds of abandonment than
those living in the lowest quintile. (p < 0.001) Young
adults age 18-34 were most likely to abandon, and
new users of medications had over 2.8 times greater
odds of abandonment than prevalent users. (p <
0.0001 for both) Electronic prescriptions had 72%
greater odds of being abandoned than non-electronic
prescriptions. (p < 0.0001)
Conclusions: Prescription abandonment represents
a discreet and potentially actionable locus on the
path to appropriately adhering to medication therapy
and a number of significant patient and prescription
characteristics are strongly correlated with
abandonment.
Implications for Policy, Delivery or Practice:
Physicians, insurers and pharmacies should consider
the correlates to abandonment and may develop
interventions to improve appropriate medication use.
The use of electronic prescribing may have
significant unintended consequences in terms of
pharmacy efficiency and costs, and alternative
system improvements are needed as more and more
physicians prescribe electronically.
Funding Source(s): CVS Caremark, and National
Heart Lung and Blood Institute
Saving Dr. Ryan: Is There a Future for Primary
Care Physicians in the U.S.?
Chair: John McKinlay, Ph.D.
Monday, June 28 * 9:45 a.m.-11:15 a.m.
Panel Overview: That primary health care is in a
critical state in the U.S. is now beyond dispute. Some
30-50 per cent of Primary Care Physicians (PCPs)
report discontent with their work and regret their
career choice. Only 5 per cent of medical students
plan to become PCPs. Such concerns generate
proposals for payment reform, increased physician
training, restructuring the medical curriculum, building
medical homes, etc. These proposals are an
understandable and promising response at a
particular level of analysis. However, at a more
fundamental level, political and economic processes
are undermining the tenability of primary care in the
U.S.: namely, the changing role of the state, medical
specialization, the epidemiologic transition, rise of
other health workers and retail clinics, corporatization
of doctoring, declining social status and public trust,
and structural changes at the level of the clientprovider encounter. Whether there will be a future for
primary care depends on policies and actions
designed to address these more fundamental social,
political and economic processes.
• Is the Primary Health Care Crisis in America
Solvable ?
David Mechanic, Ph.D.
Presented by: David Mechanic, Ph.D., Director and
Rene Dubos University Professor, Institute for Health,
Health Care Policy and Aging Research, Rutgers
University, 30 College Avenue, New Brunswick, NJ
08901; Phone: (732) 932-8415; Email:
dmechanic@ifh.rutgers.edu
Research Objective: Most agree that we face a
growing shortage of primary care physicians and
increasing difficulties in insuring timely access to
basic health care services. While primary health care
--with its focus on first-contact assessment , a holistic
approach to health , linkage with a range of more
specialized services, and responsibility for
coordination and continuity – is central to a well
functioning service, clinicians face many
disincentives for such careers. Barriers include the
relatively unfavorable reimbursement , the need to
maintain a pace of work to meet income targets
inconsistent with the time needed to provide the
personal care valued by both patient and clinician ,
and the lower prestige accorded to primary care
functions during medical school and residency
training and relative to other medical activities.
Primary care physicians commonly adapt in ways
that fail to provide the needed comprehensiveness of
care and the potential for quality .
Principal Findings: Primary care is a function that
can be provided in a range of ways and by clinicians
with varying levels of training and responsibilities ,
use of teams , and varying technologies . Large
group settings offer a broader context for organizing
the needed facilities , technologies and personnel but
most primary care clinicians practice alone or in very
small groups that lack the needed capacity and
business models for good primary care required in
constrained economic environments. Enhanced
capitation models adjusted for patient risks and with
quality incentives offer opportunities for efficiencies
but most small practices do not manage capitation
risk well. Stresses affecting work pace can be
alleviated by fairer reimbursement relative to
subspecialties but the politics of reimbursement make
large redistributions impossible.
Conclusions: As international experience
demonstrates, there are ways of elevating the
position of primary care within health systems but this
requires more stringent regulatory and
reimbursement modifications than is likely to be
acceptable in the American political context and with
the economic interests involved.
Implications for Policy, Delivery or Practice: In all
likelihood we will struggle toward a mixed set of
solutions in iterative ways depending on greater use
of nurse practitioners , physician assistants and other
clinicians, importing more clinicians from abroad ,
somewhat enhancing primary care payment ,
providing incentives for larger aggregated practices
that provide more potential for approximating medical
home and accountable care organization models ,
continuing to grow the community health center
arena , and depending increasingly on retail clinics
and related concepts. Given the diversity of contexts ,
the tough economic and politics involved , and the
need for multiple solutions it will be difficult to
approximate the ideal patient oriented accountable
care models characteristic of many aspirations.
Hopefully we can muddle through even if not in a fully
satisfactory way. A major challenge will be to do so in
ways that are equitable and maintain an acceptable
level of care.
• Primary Care Physicians and the Medical Home:
Neither Ready, Willing, or Able
Timothy Hoff, Ph.D.
Presented by: Timothy Hoff, Ph.D., Associate
Professor of Health Policy and Management,
University at Albany School of Public Health, 1
University Place, Rensselaer, NY 12144; Phone:
(518) 402-6512; Email: THoff@uamail.albany.edu
Research Objective: Primary care medicine in the
United States is undergoing profound change. Fewer
young primary care physicians (PCPs), changing
PCP career expectations, a business model built
around high-volume ambulatory care, and a shift in
primary care work have thrust the field into crisis. At
the same time, a new model for primary care, the
patient-centered medical home (PCMH), is offered as
a means to reinvigorate the work of PCPs and
provide more cost-effective, higher quality care. This
study compares the changes now occurring in
primary care with the necessary requirements for
effective medical home implementation. The intent is
two-fold: (a) to clarify the prospects for fulfilling the
medical home ideal through a realistic assessment of
primary care medicine’s present and future
capabilities, and (b) to raise key issues about the
future alignment between primary care doctoring and
medical home implementation that merit extended
policy development.
Study Design: A qualitative approach was employed
involving semi-structured interviews with 88 PCPs
practicing within a variety of distinct work settings.
The qualitative approach was chosen given the
exploratory nature of the study with respect to the
lack of existing research comparing PCP capabilities
and expectations with medical home requirements.
The tools of comparative case analysis and
theoretical sampling were employed to help identify
general patterns of agreement in the data and major
themes related to the research objective.
Population Studied: Eighty-eight primary care
physicians stratified on the basis of primary care
specialty, age, career stage, gender, race and
ethnicity, type of employment status, employment
setting, and geographic location. These sampling
strata were selected purposively
Principal Findings: The results reveal a general lack
of alignment between current and future PCP
capabilities, values, and expectations and many of
the requirements for effective medical home
implementation. This lack of alignment derives from
how PCPs have adapted strategically to the
necessities of performing high-volume, office-based
ambulatory care; emerging values and career
expectations among younger PCPs that stress
lifestyle and standardized clinical approaches; and
the absolute manner in which PCPs have given up
complex work such as hospital and procedural
medicine to other specialties.
Conclusions: The results raise serious questions in
relation to how ready, willing, and able PCPs as a
professional group are to fulfill the roles expected of
them in the patient-centered medical home (PCMH)
model of care such as team leaders, care
consultants, case managers, and complex care
clinicians.
Implications for Policy, Delivery or Practice: If
these roles cannot be fulfilled adequately by an
appropriate number of well-equipped, motivated
PCPs, doubts should be raised about the viability of
the PCMH in its current form. It may suggest future
implementation of the PCMH in a less ambitious form
to achieve success.
their time, and specify policy changes that would be
necessary to make this possible.
• A Martian View of Primary Care
Lawrence Casalino, M.D., Ph.D.
• From the Patient’s Perspective: their
Continuously Changing Relationship with
Primary Care Physicians
Lisa Marceau, M.P.H.; John McKinlay Ph.D.
Presented by: Lawrence Casalino, M.D., Ph.D.,
Livingston Farrand Associate Professor of Public
Health, Division of Outcomes and Effectiveness
Research, Weill Cornell Medical College, 402 E. 67th
Street, New York, NY 10065; Phone: (646) 9628044; Email: lac2021@med.cornell.edu
Research Objective: A Martian arriving on earth,
observing primary care physicians (PCPs) at work,
would likely be convinced that he or she had
uncovered further evidence of human irrationality.
These physicians have spent at least seven years
training. Their time should be valuable. Is this really
the best way that it can be used? As piece workers
running from patient to patient as fast as they can?
Always with a little clock in their heads exquisitely
conscious of the seconds ticking by when a patient
tries to say something? Doing things that less highly
trained people could be doing? And what about
patients? Isn’t there a better way to give them what
they need? A benevolent Martian might say: “Wait a
minute. Let’s wipe the slate clean. Let’s forget about
the way that physicians have traditionally practiced,
and try to imagine ways that would work better for
physicians, their staff, and their patients. How can
PCPs’ time best be used?”
Principal Findings: In theory, proposals to redesign
primary care practice – notably the Chronic Care
Model (CCM) and the Patient-Centered Medical
Home (PCMH) – attempt to start from a clean slate.
They rely on the use of information technology and
on the use of non-physician staff to enable practices
to use systematic processes proactively care to their
population of patients. The proposals emphasize
giving patients easier access to care through the use
of the Internet and of telephone and e-mail
communication with patients.
Conclusions: Taken to their logical conclusion,
these proposals imply that PCPs should spend their
time quite differently than they do at present. There is
some evidence to suggest that, if PCPs have face-toface visits only when necessary, they would have
only 8-10 such visits a day, or fewer, compared to the
20-25 that are currently the norm. Yet, strikingly,
peer-reviewed articles about the CCM and the PCMH
virtually never specifically address the issue of how
PCPs would spend their time. Physicians fear that
PCMH/CCM responsibilities will simply be added to
the full day of office visits that they already do;
indeed, this does appear to be what has happened in
many pilot projects to date.
Implications for Policy, Delivery or Practice: I will
discuss reasons for this fundamental omission,
propose ways that PCPs could most usefully spend
Presented by: Lisa Marceau, M.P.H., V.P., Media
and Communications, New England Research
Institutes, 9 Galen Street, Watertown, MA 02472;
Phone: (617) 972-3011; Email:
Lmarceau@neriscience.com
Research Objective: Over several decades we have
witnessed transformational changes to the
organization and financing of primary health care in
the U.S. This paper: a) identifies some of these
system-level changes; b) describes their impact on
the Doctor-Patient relationship; and c) how they
affect the work and status of PCPs.
Study Design: A comprehensive review of published
literature on socio-cultural and macroeconomic
influences on the D-P relationship and the changing
status of PCPs.
Principal Findings: Most PCPs are now salaried
employees of large organizations (and are required to
follow organizational prerequisites); Increasing
specialization is marginalizing PCPs (medical
specialties are accessed directly or PCPs are
reduced to “gate-keeper” status); Private health
insurers dictate what PCPs are permitted to do
(preauthorization of procedures, test-ordering and
prescriptions is required); Clinical guidelines have
become a practice imperative (pay-for-performance is
based on adherence to prescribed norms);
Malpractice threats are now commonplace (causing
PCPs to practice defensive medicine); Patients surf
the internet for health information, self-diagnose and
develop expectations regarding appropriate treatment
(patients often present with a diagnosis and
treatment plan); Direct-to consumer advertising
activates patients (they increasingly follow Pharma
advice and request specific medications); Negative
publicity concerning physician errors, private
investments in medical companies and insurance
company malfeasance is eroding patient trust
(patients question who their PCP is actually serving);
Changes in employment and unemployment often
require a change in health insurance and PCP and
physicians often change their employers (making
continuity of care increasingly difficult to sustain);
Health care is increasingly viewed as just another
commodity (patients desire convenience, shop
around for the “best” physician and expect
satisfaction) The popular media no longer portrays
physicians as culture heroes (physicians no longer
enjoy high levels of social esteem).
Conclusions: Many different sociopolitical and
macroeconomic factors are altering the structure and
content of the D-P relationship. The terms now
employed to describe it reflect the magnitude of the
change-the physician has become “a provider”, the
patient is now “a client”, and the relationship is “an
encounter”! The power balance in the D-P encounter
appears to have shifted.
Implications for Policy, Delivery or Practice:
During the recent health care reform debate in the
U.S. considerable discussion focused on the
preservation, even the sanctity, of the D-P
relationship. No interest group, public or private,
should be allowed to intrude on the D-P relationship.
However, the extent to which this “relationship” has
changed , and whether it can even exist given
structural changes to the health care system, has
received lamentably little attention.
Funding Source(s): NIH
Impact of Delivery System on Care for Cancer
Patients: A Comparison of a Large Integrated
System (Veterans Health Administration) and
Fee-for-Service Medicare
Chair: Mary Beth Landrum, Ph.D.
Monday, June 28 * 3:00 p.m.-4:30 p.m.
Panel Overview: The Veterans Health
Administration (VHA) is the largest integrated health
care system in the United States. The system is
primary-care focused, reports on a wide range of
quality measures, utilizes an integrated electronic
medical record, and finances care with global
payments. The VHA also cares for a
socioeconomically disadvantaged population with
high levels of disease burden. Prior studies have
demonstrated that care in the VHA is of equal or
better quality than the private sector for preventive
and chronic care. Nevertheless, concerns remain
about the quality of specialized services delivered to
patients with diseases requiring complex care
management, such as cancer. In this panel, we will
present results from a recent national evaluation of
the quality and outcomes of care delivered to
veterans with cancer. In this evaluation, we
compared older male veterans with colorectal, lung,
prostate and hematological cancers diagnosed or
treated in the VHA with similar men who were
enrolled in fee-for-service Medicare. We will present
five related papers from this evaluation. In the first
paper, we demonstrate the reliability of VHA data to
capture cancer therapies. We then report on the use
of guideline recommended care, primary therapy for
prostate cancer, end-of-life and survival following
diagnosis in the remaining four papers. This panel
will present important results on the quality and
outcomes of cancer care in the VHA and will also
shed light on how health delivery systems can be
reformed to deliver high quality and effective care.
• Veterans Health Administration Cancer Registry
and Administrative Data Are Highly Valid
Measures of Chemotherapy and Radiation
Therapy Use
Elizabeth Lamont, M.D., M.S.; Mary Beth Landrum,
Ph.D.; Nancy Keating, M.D., M.P.H.; Samuel
Bozeman, M.P.H.; Barbara McNeil, M.D., Ph.D.
Presented by: Elizabeth Lamont, M.D., M.S.,
Associate Professor of Medicine and Health Care
Policy, Department of Health Care Policy, Harvard
Medical School, 180 Longwood Avenue, Boston, MA
02115; Phone: (617) 432-4465; Email:
lamont@hcp.med.harvard.edu
Research Objective: To determine the accuracy
with which VA Central Cancer Registry (VACCR) and
administrative data measured the Veterans Health
Administration (VHA) cancer patients' utilization of
chemotherapy and radiation therapy (RT).
Study Design: In this external validation study of 295
VHA colorectal cancer patients, we compared
VACCR and administrative data regarding receipt of
chemotherapy and RT to gold-standard medical
record data. We calculated sensitivity and specificity.
Principal Findings: The combination of VHA registry
and administrative data for measuring chemotherapy
was highly accurate, with a sensitivity of 0.99 (95%
CI: 0.96-1.00) and a specificity of 0.92 (95% CI: 0.860.96). For administrative data alone, the sensitivity
was 0.98 (95% CI: 0.94-0.99) and the specificity was
0.94 (95% CI: 0.86-0.97). For VACCR data alone, the
sensitivity was 0.89 (95% CI: 0.83-0.93) and the
specificity was 0.94 (95% CI: 0.88-0.97). For RT, the
combination of VACCR and administrative data had a
sensitivity of 1.00 (95% CI: 0.96-1.00) and a
specificity of 0.88 (95% CI: 0.80-0.94). For
administrative data alone, the sensitivity was 0.92
(95% CI: 0.84-0.96) and the specificity was 0.88
(95% CI: 0.80-0.94). For VACCR data alone, the
sensitivity was 0.87 (95% CI: 0.78-0.93) and the
specificity was 0.94 (95% CI: 0.87-0.98).
Conclusions: VACCR and administrative data are
each valid sources of information regarding
chemotherapy and RT utilization, but the combination
of the two data sources yields the highest sensitivity
without compromising specificity.
Implications for Policy, Delivery or Practice: VHA
data may provide useful information regarding receipt
of chemotherapy and/or RT for studying patterns of
care and outcomes for veterans with cancer.
Funding Source(s): VA
• A National Study of the Quality of Cancer Care
for Older Cancer Patients in the Veterans Health
Administration versus Fee-for-Service Medicare
Nancy Keating, M.D., M.P.H.; Mary Beth Landrum
Ph.D.; Elizabeth Lamont, M.D., M.S.; Samuel
Bozeman, M.P.H.; Steven Krasnow, M.D.; Barbara
McNeil, M.D., Ph.D.
Presented by: Nancy Keating, M.D., M.P.H.,
Associate Professor of Medicine and Health Care
Policy, Department of Health Care Policy, Harvard
Medical School, 180 Longwood Avenue, Boston, MA
02115; Phone: (617) 432-3093; Email:
keating@hcp.med.harvard.edu
Research Objective: We compared the quality of
care delivered to older veterans with cancer in the
VHA with that delivered to patients with cancer in the
private sector enrolled in fee-for-service (FFS)
Medicare using process measures of recommended
care.
Study Design: We identified guidelinerecommended care for stage-specific cohorts of men
aged 66 years and older diagnosed with lung,
colorectal, prostate, and hematologic cancers during
2001-2004 in the VHA or in areas covered by
Surveillance, Epidemiology, and End Result (SEER)
registries. Eligible cohorts ranged in size from 1,758
to 24,741 men in the VHA and 4,640 to 75,312 men
in FFS Medicare. For each measure, we used
propensity score methods to match men in the VHA
with similar men in the FFS Medicare cohorts.
Patients were matched on age, race/ethnicity, marital
status, region, comorbidity, area-level indicators of
socioeconomic status, and stage (where indicated),
with exact match on quarter of diagnosis. We used
McNemar’s test to compare differences in the VHA
with the private sector cohorts within matched
cohorts.
Principal Findings: Before matching, men in the
VHA were younger, more often black or Hispanic vs
white, unmarried, living in the South, and living in
areas of lower socioeconomic status (all P<.001);
these differences were no longer present after
matching. Of 11 measures, adjusted rates were
similar in the VHA to FFS Medicare for 7, lower for 2,
and higher for 2 (Table). Table. Quality Measure (%
in VHA, % in FFS, P-value) Diagnosis with stage IV
colon cancer (VHA: 18.0%, FFS: 17.8%, P=.83)
Adjuvant chemotherapy for stage III colon (VHA:
65.1%, FFS: 63.8%, P=.66) Adjuvant chemotherapy
for stage II/III rectal (VHA: 58.7%, FFS: 53.3%,
P=.31) Curative surgery for stage I/II non-small cell
lung (VHA: 59.3%, FFS: 65.4%, P<.001) Mediastinal
evaluation before curative surgery for stage I/II nonsmall cell lung (VHA: 86.3%, FFS: 85.3%, P=.45)
Chemotherapy and radiation therapy for limited stage
small cell lung (VHA: 48.6%, FFS: 49.5%, P=.77)
Androgen ablation for metastatic prostate (VHA:
75.8%, FFS: 75.8%, P=1.0) 3D-CRT or IMRT if
localized prostate cancer treated with radiation (VHA:
62.4%, FFS: 86.3%, P<.001) CHOP for diffuse large
B-cell lymphoma (VHA: 70.8%, FFS: 57.7%, P<.001)
CHOP-R for diffuse large B-cell lymphoma (VHA:
87.8%, FFS: 88.9%, P=.75) Bisphosphonates for
myeloma (VHA: 62.0%, FFS: 47.9%, P<.001)
Conclusions: Older men with cancer diagnosed or
treated in the VHA received care that was generally
comparable to care delivered to older men enrolled in
FFS Medicare.
Implications for Policy, Delivery or Practice: More
research is needed to understand the reasons for
underuse of effective therapies in older men and to
determine the right rates of treatment. Nevertheless,
our results provide encouraging support for the
effectiveness of health care delivery, including
specialized cancer care, for men cared for in the VHA
and suggest that the VHA system might serve as a
model for care delivery as health care reform is
implemented, particularly with the need to deliver
care of high quality and high value.
Funding Source(s): VA
• Variations in Primary Prostate Cancer Treatment
Approaches in the Veterans Health
Administration Versus the Private Sector
Vinod Nambudiri; Mary Beth Landrum Ph.D.;
Elizabeth Lamont, M.D., M.S.; Samuel Bozeman,
M.P.H.; Barbara McNeil, M.D., Ph.D.; Nancy Keating,
M.D., M.P.H.
Presented by: Vinod Nambudiri, Student, Harvard
Medical School, Boston, MA 02115; Email:
vnambudiri@gmail.com
Research Objective: The first-line management of
loco-regional prostate cancer may include
prostatectomy, radiation therapy, or active
surveillance. Appropriate treatment selection requires
an assessment of tumor characteristics, patient
preferences, risk-to-benefit analysis of therapeutic
options, and physician judgment. Integrated health
care systems such as the Veterans Health
Administration (VHA) deliver care across large
geographic areas and multiple clinical environments
with differing medical resources. We examined
primary therapy of loco-regional prostate cancer for
men within the VHA system compared with
individuals treated in the private sector under fee-forservice Medicare plans. We also assessed factors
associated with treatment variations within the VHA.
Study Design: We identified individuals with prostate
cancer from 2001 – 2004 in the VHA or in areas
covered by the Surveillance, Epidemiology, and End
Result (SEER) registries. Among men over 65
diagnosed with loco-regional cancers, we used
propensity score methods to match 19,210 veterans
with 65,776 Medicare beneficiaries in one of the
SEER regions. Patients were matched on age,
race/ethnicity, marital status, region, comorbidity,
area-level indicators of socioeconomic status, cancer
history, and grade with exact match on quarter of
diagnosis to yield a final sample of 16,883 matched
pairs for analysis. We also surveyed 138 VHA
Medical Centers to understand factors associated
with choice of treatments among 39,547 veterans of
all ages.
Principal Findings: Compared with patients in feefor-service Medicare, VHA patients were younger and
more likely to be minorities, unmarried, living in areas
of lower socioeconomic indicators, and more likely to
have vascular disease and diabetes; these
differences were no longer present after matching.
Adjusted rates of radiation therapy (40.1% vs. 52.2%)
and radical prostatectomy (12.1% vs. 15.7%) were
lower in the VHA population and rates of active
surveillance were significantly higher (47.9% vs.
32.1%) in the VHA population compared to the
private sector population (p < 0.001). Among VHA
patients, those who were older (age > 70), of black
ethnicity, had a prior history of cancer, or had high
comorbidity scores were more likely to undergo
active surveillance. Rates of primary radiation
therapy increased over time from 2001 to 2004 in the
VHA. Significant variations in rates of primary therapy
were seen across VHA facilities, with rates of surgery
ranging from 5% to 66% and rates of radiation
therapy ranging from 18% to 89%. Facility
characteristics explained very little of this variation.
Conclusions: Primary prostate cancer therapy for
older men is less aggressive in the VHA than in the
private sector. Difference in treatment rates by race
persisted even in the VHA. Treatment rates varied
substantially by facilities, with very little of variation
explained by facility characteristics.
Implications for Policy, Delivery or Practice: With
the absence of data demonstrating benefits of
aggressive therapies for most older men with locoregional prostate cancer, observed differences may
reflect more appropriate selection of therapies in the
VHA, a system where care is coordinated and there
are no financial incentives for more intensive care.
Further research is underway to examine the
contribution of local practice patterns and additional
facility factors to explain the large variations across
VHA facilities.
Funding Source(s): VA
• Aggressiveness of End-of-Life Care for Older
Cancer Patients in the Veterans Health
Administration Versus Fee-for-Service Medicare
Nancy Keating, M.D., M.S.; Mary Beth Landrum
Ph.D.; Elizabeth Lamont, M.D., M.S.; Craig Earle,
M.D., M.S.; Barbara McNeil, M.D., Ph.D.
Presented by: Nancy Keating, M.D., M.S.,
Associate Professor of Medicine and Health Care
Policy, Department of Health Care Policy, Harvard
Medical School, 180 Longwood Avenue, Boston, MA
02115; Phone: (617) 432-3093; Email:
keating@hcp.med.harvard.edu
Research Objective: Studies suggest that treatment
of older cancer patients at the end of life has become
increasingly aggressive over time, despite the
absence of evidence that aggressive care at the end
of life is associated with better outcomes. Integrated
health care delivery systems may be better suited to
limit overly aggressive care than non-integrated
systems. We compared aggressiveness of care at
the end of life for older individuals with metastatic
cancer cared for in the Veterans Health
Administration (VHA) with that for older individuals
cared for in the private sector under fee-for-service
Medicare arrangements.
Study Design: We used propensity score methods
to match 2713 men in the VHA who were diagnosed
with stage IV lung or colorectal cancer in 2001-2002
and died by the end of 2005 with 2713 similar men
living in areas covered by Surveillance,
Epidemiology, and End Result (SEER) registries
enrolled in fee-for-service Medicare. Patients were
matched on age, race/ethnicity, marital status, region,
cancer type, year of death, comorbidity, and arealevel indicators of socioeconomic status. We
assessed receipt of chemotherapy within 14 days of
death, intensive care unit (ICU) admissions within 30
days of death, and more than 1 emergency room visit
within 30 days of death.
Principal Findings: Before matching, men in the VA
system were younger, more likely to be black or
Hispanic versus white, unmarried, living in the South,
and living in areas of lower socioeconomic status;
these differences were no longer present after
matching. Among matched cohorts, men treated in
the VHA were less likely than men treated in the
private sector to receive chemotherapy within 14
days of death (4.3% vs. 7.6%, P<.001) or to be
admitted to an ICU within 30 days of death (11.6 vs.
20.0, P<.001), and were similarly less likely to have
more than one emergency room visit within 30 days
of death (12.6 vs. 13.1, P=.65).
Conclusions: Older men with metastatic lung or
colorectal cancer who are treated in the VHA were
less likely to have aggressive chemotherapy and
intensive care unit stays at the end of life than similar
men treated in the private sector. Additional studies
are needed to assess whether men who undergo less
aggressive care at the end of life also experience
better outcomes.
Implications for Policy, Delivery or Practice: The
lower rates of aggressive care at the end of life in the
VHA may result from the absence of financial
incentives for providing care in the VHA or because
the VHA’s integrated delivery system is structured
better to understand wishes of patients and/or to limit
what may be potentially futile medical care.
Funding Source(s): VA
• A National Study of Survival in Older Cancer
Patients in the Veterans Health Administration
Versus Fee-for-Service Medicare
Mary Beth Landrum, Ph.D.; Nancy Keating M.D.,
M.P.H.; Elizabeth Lamont, M.D., M.S.; Samuel
Bozeman, M.P.H.; Steven Krasnow, M.D.; Barbara
McNeil, M.D., Ph.D.
Presented by: Mary Beth Landrum, Ph.D.,
Associate Professor of Health Polciy, Department of
Health Care Policy, Harvard Medical School, 180
Longwood Avenue, Boston, MA 02115; Phone: (617)
432-2460; Email: landrum@hcp.med.harvard.edu
Research Objective: To compare survival following
lung or colorectal cancer diagnosis in older veterans
diagnosed or treated in the Veterans Health
Administration (VHA) with that of cancer patients
enrolled in fee-for-service (FFS) Medicare.
Study Design: We identified patients diagnosed with
colon, rectal, small cell lung, and non-small cell lung
cancers during 2001-2004 in the VHA or in areas
covered by Surveillance, Epidemiology, and End
Result (SEER) registries. For each cohort, we used
propensity score methods to match men aged >65 in
the VHA with similar men in the FFS Medicare
cohorts. Patients were matched on age,
race/ethnicity, marital status, region, comorbidity and
area-level indicators of socioeconomic status, with
exact match on quarter of diagnosis. In secondary
models we matched on stage at diagnosis and
receipt of treatments to examine the role of these
factors in explaining survival differences. Severity of
comorbid disease was assessed through medical
record abstraction in a subset of VHA patients. We
examined the robustness of results to unmeasured
confounders through sensitivity analyses.
Principal Findings: Before matching, men in the
VHA were more likely to be younger, black or
Hispanic vs. white, unmarried, living in the South, and
living in areas of lower socioeconomic status; these
differences were no longer present after matching.
Patients diagnosed with colon cancer in the VHA had
lower all cause and colon cancer mortality following
diagnosis compared with matched FFS Medicare
patients, a difference partly explained by earlier stage
at diagnosis. Patients with small cell lung cancer had
similar survival in the two settings. VHA patients with
rectal cancer and non small cell lung cancer had
lower survival compared with matched FFS Medicare
patients. These survival differences were partly
explained by differences in receipt of surgery.
Examination of severity of comorbid disease using
medical record data and sensitivity analyses
demonstrated that lower survival rates in these two
cohorts could also be explained by differences in
unmeasured patient characteristics including
socioeconomic status, performance status and
severity of comorbidity.
Conclusions: In two of the four disease cohorts,
older men with cancer diagnosed or treated in the
VHA had survival that was better or comparable to
that in older men enrolled in FFS Medicare. In two
cohorts there was evidence of lower survival in the
VHA. These differences are likely explained by
unobserved confounders, including greater severity
of comorbid disease and lower socioeconomic status.
However, they may also reflect cautiousness in the
VHA in surgical resection of lung and rectal cancers
among older patients with comorbid illness, for whom
uncertainty about the risks and benefits exist.
Implications for Policy, Delivery or Practice: Our
results provide encouraging support for the
effectiveness of health care delivery, including
specialized cancer care, for men in the VHA,
particularly for cancers where therapies have been
shown to be effective and well tolerated in elderly
patients. However, less aggressive care in the face of
clinical uncertainty in the VHA may contribute to
worse outcomes for some cancers. Improved data on
the effectiveness of cancer therapies in elderly
patients are needed to further improve outcomes of
cancer patients in both delivery systems.
Funding Source(s): VA
The German Social Health Insurance: Recent
Reforms and New Challenges
Chair: Sebastian Bauhoff, M.P.A.
Monday, June 28 * 3:00 p.m.–4:30 p.m.
Panel Overview: This panel aims to provide insights
into recent developments and current challenges of
the German social health insurance (SHI). The SHI
covers 90 percent of the German population with a
comprehensive benefits package at a uniform
contribution rate and largely free choice of providers.
Concerns over cost-control and equity have led to a
series of fundamental reforms over the past decade,
including a reorganization of the SHI financing model,
changes to physician and hospital reimbursements
and new forms of contracting. The panelists will
discuss these recent reforms, and key implications
and challenges for the operations and economics of
the system.
The first presentation introduces the recent
reforms from the perspective of a large sickness fund
and offers insights into newly created opportunities
and challenges, with a comparative view towards
health reforms in the US.
The second presentation evaluates the
welfare and distributional impacts of the new
financing arrangements in Germany’s health care
system and of alternative policies which would lead to
a flat health premium and partially replace the current
financing tied to wage income. The modeling
framework integrates abundant empirical data on
heterogeneous households and allows an evaluation
of the efficiency-equity tradeoff of health care
reforms.
The third presentation is concerned with riskselection as potential adverse effect of competition in
the SHI. The risk adjustment to sickness funds omits
geography, an important and easily observable
predictor of an individual’s expected costs. The paper
discusses results from an audit study to assess
whether sickness funds select using address
information of fictitious applicants.
• German Health Reforms - On Their Way
Towards Managed Competition?
Norbert Klusen
Presented by: Dr. Norbert Klusen, Prof,. CEO,
Techniker Krankenkasse, Bramfelder Strasse 140,
Hamburg, 22305, Germany; Phone:
+011494069091291
Research Objective: Recent reforms in Germany
have fundamentally altered the operation and
structure of the health care system. The goal of this
presentation is to outline several major reforms from
the perspective of a large sickness fund, provide the
context for the following two presentations and offer a
comparative perspective on health care reforms in
the United States.
Study Design: The presentation draws on the
experience of a large sickness funds and reflections
by its CEO. It aims to provide insights from the
frontlines of policy-making and implementation of the
reforms. Focusing on the main elements of reform
throughout the last few years, major challenges in the
German Health Care System will be shown and
current reform options will be reflected.
Principal Findings: The reforms have transformed
the social health insurance in important ways and
provide new opportunities and challenges for all
actors. From the perspective of sickness funds,
reforms have to a small extent led to more
competition between insurers and providers and
allowed more options to organize health care
delivery. The new financing arrangements have in a
first step abolished the financial autonomy of
sickness funds, while price competition is expected to
slowly return with supplemental fees levied by the
sickness funds. This might develop into new
financing mechanisms such as employer
contributions that are fixed and employee
contributions that are not related to income, unlike in
the current system.
Conclusions: The German reforms offer new
possibilities for improved care delivery but are not
sufficiently far-reaching in allowing health plans to
manage care effectively and efficiently. As health
care reforms prove to be widely dependent on
political lines, regulatory initiatives promoting
managed competition are often paralleled by
contradictory measures. Thus, while the last coalition
government has limited financial autonomy and price
competition among insurers, managed competition is
likely to play an increasing role under the current
administration.
Implications for Policy, Delivery or Practice:
Designing and implementing large-scale health
reforms puts stress on the system and creates new
challenges that must be addressed in incremental
approaches. Germany proves to be an example for
continually ongoing health care reforms slowly
adapting to current challenges.
• The German Small Health Premium:
Employment and Welfare Results from a
Computable General Equilibrium Model
Stefan Felder
Presented by: Stefan Felder, Dr., Chair of Health
Economics, Economics and Business Administration,
Duisburg-Essen University, Schuetzenbahn 70,
Essen, 0 45117, Germany; Email: stefan.felder@unidue.de
Research Objective: Germany combines payroll
contributions and tax revenues to finance social
health insurance. In order to reduce the distortionary
effects of payroll and general taxes, the new coalition
government is likely to introduce in 2010 a small or
medium flat premium that is independent of wage
income. Large premiums would involve adverse
distributional effects which in turn require tax money
to subsidize low income households. The paper
analyzes the equity-efficiency trade-off of reforming
social health insurance in Germany.
Study Design: The framework is a computable
general equilibrium model calibrated on currently
observed inputs and outputs of firms, income and
expenditure of households, social security and the
German government. It is highly disaggregated on
the household side in order to assess the
consequences of health care financing for labor
supply and the distribution of income. The paper
follows a counterfactual approach aimed at
comparing potential policy reforms with the status
quo.
Population Studied: Germany
Principal Findings: A more premium-orientated
financing of German health care has positive overall
welfare effects, mainly due to increased labor supply
of households of all skill types. Pensioners and
unemployed households would not benefit from such
a health care reform, despite tax-financed
compensating transfers to these low-income
households. Distributional effects can also be
mitigated by a change in the current tax scheme.
Conclusions: Substituting health premiums for
payroll contributions eases the distortion in the labor
market, which in turn increases labor supply and
overall welfare. As the distributional effects of such a
reform are substantial, compensating transfers for
low income households or a change in the tax
scheme are required.
Implications for Policy, Delivery or Practice: The
German government should reform its payroll
financed health care system and introduce a
substantial health premium. This policy needs
accompanying measures in order to mitigate the
distributional effects and to gain public support.
Funding Source(s): Duisburg-Essen University, RWI
Essen
• Quantifying Cream-Skimming in the German
Social Health Insurance: Results from an Audit
Study
Sebastian Bauhoff, M.P.A.
Presented by: Sebastian Bauhoff, M.P.A., Ph.D.
Candidate in Health Policy (Economics), Department
of Health Care Policy, Harvard University, 180
Longwood Avenue, Boston, MA 02115; Email:
bauhoff@post.harvard.edu
Research Objective: Competition among health
plans creates a trade-off between efficiency and riskselection. To mitigate this trade-off, payments to
plans can be risk-adjusted using indicators that are
predictive of expected costs. Predictors that are not
included in the adjustment can be used by plans to
identify and select low-risk individuals. This analysis
aims to establish empirically whether sickness funds
in the German social health insurance engage in
direct risk-selection based on an individual’s location,
an important and easily observed predictor of costs
that is not accounted for in the risk-adjustment
system.
Study Design: This paper aims to identify plan-side
selection (cream-skimming) separately from
potentially concurrent demand-side selection
(adverse selection). In a double-blind experiment I
present health plans with fictitious applicants who
have randomly assigned characteristics and differ in
their geographic locations and hence expected costs.
I measure response time and volume for letters,
emails, and phone calls, as well as resource costs
that health plans expend in contacting the
prospective members.
Population Studied: Sickness funds in the German
social health insurance.
Principal Findings: The results suggest that
insurers do not cream-skim based on the information
contained in applicants’ addresses. There is little
variation response times for letters, emails or phone
calls across different applicant profiles, although
some indication that follow-ups and resource costs
differ by the applicants’ locations.
Conclusions: In spite of financial incentives to
leverage address information to select low-risk
members, German sickness funds do not appear to
engage in significant efforts to exploit this
information.
Implications for Policy, Delivery or Practice:
Unlike in the US Medicare system and other
European countries, the German risk-adjustment
does not account for geographic variations in
expected costs. The absence of this adjustment
factor does not appear to lead to large-scale
selection by funds at this moment, but may become
relevant as competition intensifies and the funds’
financing constraints become more binding.
Funding Source(s): Harvard Institute of Quantitative
Social Sciences
Getting to Outcomes: An Approach to
Measurement in Health IT
Chair: Michael Plotzke, Ph.D.
Monday, June 28 * 4:45 p.m.–6:15 p.m.
Panel Overview: The call for Health IT adoption and
use in the U.S. has grown louder in the past decade.
Most recently, The American Recovery and
Reinvestment Act of 2009 authorized $20 billion in
funding to help develop a robust Health IT
infrastructure. This funding will generate incentive
payments to physicians and hospitals that will begin
in 2011. In order to evaluate the impact of the
incentive payments, researchers and policymakers
first need to develop methods to measure Health IT
adoption, use, and impacts, as well as establish
baseline measures of each.
Adoption, use, and health outcomes are
closely related and a thorough understanding of each
needs to occur to measure HIT. These areas of HIT
have not been adequately studied and this panel
presents a systematic approach to produce a
continuum of Health IT measures starting at adoption
and use and culminating in outcome assessment. We
provide four examples that examine four key
indicators of Health IT progress: (1) Consumer
access to their medication information online, (2)
Adoption of evidence-based decision support
technologies in hospitals, (3) Adoption, use and
outcomes of clinical decision support in ambulatory
settings and (4) Reduction in medication errors due
to adoption of electronic prescribing systems in U.S.
hospitals. The panel will conclude with a discussion
of the future of Health IT outcome measurement in
light of the new incentives for meaningful use of
health records.
• Measuring Consumer Access to their
Medication Information Online
Presented by: Sarah Shoemaker, Ph.D., Pharm.D.
Pharmacy Health Services & Policy Researcher, Abt
Associates, Inc., 55 Wheeler Street Cambridge, MA
02138; Phone: (617) 349-2472; Email:
sarah_shoemaker@abtassoc.com
Research Objective: While there have been
advances in the availability of personal health records
(PHRs) both linked to care providers and through
independent platforms, the extent to which U.S.
adults access and use these health IT platforms is
unknown. To measure the impact of PHRs on
outcomes of interest in health care, we must first
assess the extent to which patients have access to
these platforms, whether various functionalities are
offered on the platforms, and the degree to which
consumers use these functionalities. Doing so
requires not only a clarification of the constructs to be
measured, but also an understanding of consumers’
perceptions of these technologies. The purpose of
this study was to develop and field a survey to obtain
a national estimate of the number of U.S. adults who
have access to their medication information online. In
this presentation, we describe the process used to
develop and pre-test the survey, and the conceptual
issues that had to be addressed to finalize the survey
instrument.
Study Design: We completed a construct analysis to
develop a 10-minute, random-digit-dial (RDD)
telephone survey of the U.S. adult population, offered
in English and Spanish. Survey questions addressed
the availability, use, source, and functionalities of
PHRs; the availability and use of medication therapy
information in PHRs; and respondent sociodemographics. We conducted two rounds of cognitive
testing of the survey instrument in English and
Spanish.
Population Studied: Cognitive testing was
conducted with 16 participants representing different
genders, races, ethnicities, ages, and education
levels. Participants included 12 English-speakers and
4 Spanish-speakers, ranging between age 26 and 75
(mean 44). Most (9) had
Principal Findings: Several constructs of interest
were problematic for respondents. There was no one
accepted term to refer to online records that might
include medication information. Women defined their
personal health information as including family
members’ information. Respondents of different
ethnicities retrieved information from varying timeframes to answer questions about the “past year”.
Some appropriate response options were missing
from the original instrument. Finally, respondents
were alarmed by some answer options in questions
about who maintains their health record online. We
accommodated respondent preferences by
explaining key concepts, offering multiple words to
cover the same concept, clarifying time-frames and
persons of interest, and removing or rewording
alarming answer options.
Conclusions: Results demonstrate the importance
of thoughtfully assessing respondents’ understanding
and interpretation of health information technologies
in consumer surveys on Health IT.
Implications for Policy, Delivery or Practice: While
it is critical to understand the outcomes of health
information technologies like PHRs, one must first
understand and measure the extent to which
consumers have access to and use these
technologies. Careful construct clarification and
cognitive testing with consumers are essential to
obtain valid and reliable estimates.
• Measuring Adoption by Hospitals of EvidenceBased Decision Support Technologies
Presented by: Michael Plotzke, M.A., Ph.D.,
Associate, Abt Associates, Inc., 55 Wheeler Street,
Cambridge, MA 02138; Phone: (314) 387-8988;
Email: michael_plotzke@abtassoc.com
Research Objective: To estimate the number and
proportion of U.S. hospitals that have adopted
Clinical Decision Support (CDS) technologies.
Study Design: We use the 2007 American Hospital
Association (AHA) Annual Survey to compute
estimates. This survey provides an abundance of
information on hospitals including health information
technology (HIT) adoption. The 2007 survey consists
of a main set of questions that are asked annually
and an Electronic Health Record (EHR) Adoption
Supplement not previously fielded.
Population Studied: Population Studied: Hospitals
responding to the AHA Annual Survey and EHR
Adoption supplement which met the following criteria:
i) located in the 50 states or the District of Columbia,
ii) classified as public, not-for-profit, or for-profit
hospitals.
Principal Findings: The EHR Adoption Supplement
asks six questions regarding hospitals’ adoption of
six different CDS technologies. For each question the
AHA provides six options for describing the degree of
implementation. We define adoption as having “Fully
implemented in all units” or “Fully implemented in at
least one unit” at least one of the six different types of
CDS technologies asked about on the EHR Adoption
Supplement. The six different types of CDS include: i)
Clinical Guidelines, ii) Clinical Reminders, iii) Drug
Allergy Alerts, iv) Drug-Drug Interaction Alerts, v)
Drug-Lab Interaction Alerts, and vi) Drug Dosing
Support. Using non-response weights to account for
the hospitals that did not respond to the EHR
Adoption Supplement, we estimate that 3,054 out of
the 4,701 (65.0%) hospitals in our study population
have adopted CDS.
Conclusions: Overall, we have found that a large
proportion of hospitals have adopted some type of
CDS technology. In addition to finding high adoption
rates of CDS in general, the adoption rates seem to
be highest for those CDS technologies used to
correct courses of action (Drug-Lab Interaction Alerts,
Drug-Drug Interaction Alerts, Drug Allergy Alerts)
rather than inform courses of action (Clinical
Guidelines, Clinical Reminders, Drug Dosing
Support).
Implications for Policy, Delivery or Practice: The
results in this report suggest a number of promising
lines of future research. This research finds lower
adoption rates of CDS technologies used to inform
courses of action compared to CDS technologies
used to correct courses of action. Literature reviews
and qualitative interviews of physicians and Chief
Information Officers at hospitals may lead to a better
understanding of why this occurs and the value of the
different types of technologies. This research also
shows there are some types of hospitals that have
higher adoption rates. For example, using weighted
estimates, only 1,175 out of 2,262 (52.0%) small
hospitals have adopted CDS versus 377 out of 447
(84.3%) of large hospitals. Additionally, members of
hospital systems have higher adoption rates than
non-members; for-profit and not-for-profit hospitals
have higher adoption rates than public hospitals;
hospitals in urban locations have higher adoption
rates than rural locations; and major teaching
hospitals have higher adoption rates than nonteaching hospitals. Future research should
investigate the reasons that some types of hospitals
have lower rates of CDS adoption, whether they
would benefit from adopting CDS, and how to
stimulate adoption.
• Measuring Adoption, Use and Outcomes of
Clinical Decision Support in Ambulatory Settings
Presented by: Melanie Wasserman, Associate
Domestic Health Abt Associates, Inc. 55 Wheeler
Street, Cambridge, MA 02138; Phone: (617) 5202714; Email: melanie_wasserman@abtassoc.com
Research Objective: Research suggests that
without proper implementation of CDS, Health IT is
unlikely to produce major improvements in the quality
and cost of care (Berner, 2009). Measuring the
adoption and use of CDS is an important step in
assessing the effect of Health IT on health care
quality, safety, efficiency and cost. The purpose of
this AHRQ-funded study was to report the adoption
and use of 3 key clinical decision support (CDS)
technologies in ambulatory settings: (1) guidelinebased interventions and/or screening tests; (2)
warnings of drug interactions or contraindications;
and (3) highlighting of out-of-range lab results. In this
presentation, we describe the current state of CDS
adoption/ use and outline next steps to enhance and
evaluate the impact of CDS adoption on health and
health care outcomes.
Study Design: We conducted a descriptive data
analysis, adjusting univariate and bivariate crosstabulations for non-response weights. We used Chisquare tests adjusted for sampling structure and nonresponse to assess the association between CDS
adoption and physician and practice characteristics.
Population Studied: We used the 2008 National
Survey of Health Record Keeping among Physicians
and Group Practices in the United States, funded by
ONC. The survey was sent to 5,000 physicians
drawn from the 2007 Physician AMA Masterfile. A
total of 2,758 physicians responded.
Principal Findings: We estimate that 68.6% of
physicians practicing in ambulatory settings have any
one of three types of CDS available to them, of whom
94.4% using at least one type of CDS system at least
some of the time; 57.4% of physicians have available
a computerized system that highlights out-of-range
lab results, of whom 95.8% use this feature at least
some of the time; 28.8 % of physicians have
available a computerized system that provides
warnings of drug interactions or contraindications, of
whom 91.9% use this feature at least some of the
time; and 23.1% of physicians have available a
computerized system for reminders for guidelinebased interventions or screening tests, of whom
85.3% use this feature at least some of the time.
Adoption and use of CDS technologies is significantly
correlated with larger practice size, presence of
multiple specialties within the practice, and location of
the practice within a hospital/medical center.
Conclusions: Generally speaking, CDS use is high
once the technology is made available to physicians.
Adoption is higher for higher for out-of-range lab
result highlighting and drug interaction alerts relative
to reminders for guideline-based interventions and/or
screening tests.
Implications for Policy, Delivery or Practice:
Results suggest a number of promising lines of future
research to enhance and evaluate the outcomes of
CDS adoption. Research is needed on the reasons
why adoption is higher for out-of-range lab result
highlighting and drug interaction alerts relative to
reminders for guideline-based interventions and/or
screening tests, since the latter are more likely to
realize public health benefits. An important next step
in evaluating health and health care outcomes of
interest is to use a meta-analytic approach to
estimate the average effect of CDS on selected
outcomes.
• Reduction in Medication Errors due to Adoption
of Electronic Prescribing Systems in U.S.
Hospitals
Presented by: David Radley, M.P.H., Associate,
Domestic Health, Abt Associates, Inc., 55 Wheeler
Street, Cambridge, MA 02138; Phone: (617) 5202651; Email: david_radley@abtassoc.com
Research Objective: Medication errors in hospitals
are common, expensive and sometimes harmful to
patients. Computerized provider order entry (CPOE)
allows healthcare providers to order medication
electronically, and has been shown to mitigate some
of the risks associated with medication ordering
processes. Estimates of CPOE’s effect on medication
errors vary and there are no nationally representative
estimates of attributable error reduction. The
objective of this study was to derive a nationally
representative estimate of medication error reduction
attributable to CPOE.
Study Design: Data were derived from several
sources for this study. First, a systematic literature
review was conducted to determine the effect of
CPOE on the likelihood that a prescription drug order
results in error. Data were pooled from ten qualifying
peer-reviewed studies using random-effects metaanalytic techniques to derive a summary effect
estimate of the percent reduction in medication order
frequency to result from the use of CPOE. Second,
hospital survey data from the American Hospital
Association Annual Survey (2007), the Electronic
Health Record Adoption Database (a supplement to
the AHA Survey funded by the ONC: 2008), and the
American Society of Health-System Pharmacists
Annual Survey (2006) to estimate current levels of
CPOE adoption and the total number of prescription
drug orders exposed to CPOE across all US
hospitals. These data elements were combined using
a series of arithmetic functions to estimate the
percent and absolute reduction in medication errors
attributable to CPOE.
Population Studied: All general medical and
surgical acute-care hospitals in the United States
(N=4,701).
Principal Findings: Approximately 34% of all acutecare hospitals in the Untied States have adopted
CPOE systems capable of processing prescription
drug orders, and about 26% of all in-hospital
prescription drug orders are processed by a CPOE
system. Processing a prescription drug order through
a CPOE system decreases the likelihood of that
order resulting in an error by approximately 34%.
Given this effect size, and the degree of CPOE
adoption, we estimate an 8% (95%CI: 7-9%)
reduction in medication errors nation wide due to
CPOE in 2008. This equates to approximately 13.6
million (95% CI: 13.5-13.7 million) fewer medication
errors than would have been expected in 2007 had
CPOE not been used to process any medication
orders. Greater adoption and use of CPOE could
have averted as many as 65 million fewer medication
errors in 2008.
Conclusions: CPOE systems are effective at
preventing medication errors. However, the adoption
and use of this technology in US hospitals remains
modest and there is still a great deal of potential for
this technology to further reduce medication errors.
Implications for Policy, Delivery or Practice:
Efforts should be made to ensure that expanded use
of electronic medical records in hospitals integrate
CPOE technology. Additional research should focus
on estimating (a) the effect of CPOE on harmful
medication errors in hospitals, (b) the administrative
and health care related costs of medication errors,
and (c) the effect of CPOE on harmful medication
errors in ambulatory settings.
Moving Research into the Real World:
Strengthening Real-World Evidence for Decision
Making
Chair: Kathryn Phillips, Ph.D.
Monday, June 28 * 4:45 p.m.–6:15 p.m.
Panel Overview: A key challenge in healthcare is
moving towards evidence-based practice. Yet, to do
so, we must have practice-based evidence. This
Panel and Roundtable examines real-world
approaches to strengthening practice-based
evidence for decision making. We will include both
(1) a panel of empirical analyses of actual practices
and decision making and (2) a panel of experts on
evidence development outside of the academic Ivory
Tower.
We address three questions: 1.) How do
payers use evidence to make coverage and policy
decisions? A study of evidence frameworks; 2.) How
can researchers use health plan data to build the
evidence base?; 3.) What are next steps and
implications for health reform, comparative
effectiveness research, and health policies?
We focus on private payers because of their
key role in healthcare policies and our unique
collaborative research. Our work is based on
extensive analyses of private plan data as well as
interviews and meetings with our Center’s
Reimbursement Board, which includes senior
executives from leading health plans and other
relevant stakeholders and thought leaders including
pharmacy benefit managers, Medicare and
government experts, and biotech industry executives.
We draw from two sets of interviews and four
meetings between 2007–2010 with senior executives
at six of the seven largest US plans and at leading
regional plans as well as other organizations. The
national plans represent more than 125 million
enrolled lives in the US – approximately one-half of
total commercial plan enrollment.
We focus on emerging technologies, which
are often a key challenge to healthcare because of
their cost and complexity. In order to make our
findings concrete, we present several case studies
and empirical analyses of personalized medicine health care that targets medical interventions to
patients based on their genetics. There are high
hopes that personalized medicine can improve
quality and reduce costs, yet evidence on their realworld benefits is lacking. The issues in translating
personalized medicine into practice portend
challenges that will be faced with other emerging
technologies.
We focus our discussion on two critical gaps
for building the evidence base: lack of an evidence
base that would enable payers and policymakers to
make evidence-based decisions and lack of forums
bringing together the multiple stakeholders needed to
formulate, recommend, and implement relevant
guidelines and policies.
Key findings to be presented and discussed
include: “Variety is the spice of life”. Payers use a
variety of frameworks for decision making, all of
which are somewhat different; “One size does not fit
all”. It is probably infeasible and possibly
inappropriate to have one framework that is applied
to all decisions; “When you’ve seen one payer,
you’ve seen one payer.” Health payer coverage and
policy decisions vary, particularly when the clinical
evidence is unclear and when other health care
system factors need to be considered; “The sum is
better than the parts.” It is challenging to use health
plan data to build the evidence base, but by working
collaborative with plans and combining claims and
medical record data, it can be done; “Evidence and
value are key – but what you see depends on where
you sit.” Appropriate decisions require evidence of
clinical utility, effectiveness, and value added, yet
stakeholders often use different definitions and
metrics.
Two empirical studies will be presented,
followed by a panel discussion. The abstracts report
on a structured review of the frameworks that private
payers use for evaluating technologies and a study
done collaboratively with a national health plan on the
use of targeted tests and treatments for breast
cancer.
• One Size Does Not Fit All: Payers Use of
Evidence Frameworks to Make Coverage and
Policy Decisions
Stephanie Van Bebber, M.S.; Julia Trosman Ph.D.,
M.B.A.; Kathryn Phillips, Ph.D.
Presented by: Stephanie Van Bebber, M.S.,
Executive Director, Clinical Pharmacy, The
TRANSPERS Center at the University of California,
San Francisco, 3333 California Street Suite 420, San
Francisco, CA 94118; Phone: (415) 404-6353;
Email: vanbebbers@pharmacy.ucsf.edu
Research Objective: Payers, via coverage,
reimbursement, and utilization policy, play a key role
in translating emerging technologies to practice. We
examine whether and how payers are using existing
evidence frameworks and evaluations in policy
decisions.
Study Design: This is a mixed methods study using
literature review, interviews and a Roundtable
meeting. Literature review was used to identify,
review and compare existing evaluation frameworks
available to guide payer decisions. Focused
interviews were used to identify whether and how
these frameworks were used in real world policy
decisions made by individual health plans. A
Roundtable meeting was used to discuss the
similarities and differences across payers in whether
and how formal evaluations informed policy. We
included both frameworks used widely for technology
assessment and those specific to personalized
medicine and genomic technologies.
Population Studied: We found that payers regularly
use seven evidence evaluation frameworks for policy
decisions, developed by: Blue Cross Blue Shield
Technology Evaluation Center (BCBS TEC); ECRI
Institute, Evaluation of Genomic Applications in
Practice and Prevention (EGAP
Principal Findings: Existing evaluation frameworks
vary in: main purpose, primary questions of interest,
range of evidence included, availability, and capacity.
All frameworks were used by at least one payer to
inform policy decisions with one framework (BCBS
TEC) used by all but one interviewed payer. All
payers reported using multiple frameworks, with one
payer utilizing all frameworks. The three most
important features to payers were the expertise of
reviewers, rigor of evaluation and support for
comparative effectiveness. Almost all payers (n=16)
reported a lack of evidence on healthcare system
factors, more than half (n=10) noted a lack of breadth
in evaluations and almost half (n=8) reported a lack
of timeliness. Across payers the range of evidence
used to inform decisions was believed to result in
policy variation. In particular, when clinical evidence
is uncertain but policy decisions are needed, payers
reported using evidence on other health care system
factors - such as guidelines from professional
organizations, FDA decisions, and economic
analyses - to help guide decisions.
Implications for Policy, Delivery or Practice: We
found that payers use a variety of evaluation
frameworks for policy decisions, which has
implications for technology assessment, health
reform, and comparative effectiveness research
(CER). Our results suggest that there is no one
“ideal” framework that suits all needs. Furthermore,
our results suggest that when the clinical evidence is
uncertain – as will often be the case, even with CER
efforts – payers consider a wide range of evidence
including health care system factors. By recognizing
the inherent multi-factorial nature of plan policy
decisions and by conducting systematic evaluations
of these factors, CER and other evaluation
approaches can be improved and unwarranted
variability may decrease.
Funding Source(s): NCI The study was supported
by the National Cancer Institute (P01CA13081801A1) and Blue Shield of California Foundation.
• How can Researchers Use Health Plan Data to
Build the Evidence Base? A Study of Targeted
Tests and Treatment for Breast Cancer using
Health Plan Data
Jennifer Haas, M.D., M.S.P.H.; Su-Ying Liang Ph.D.;
Kathryn Phillips, Ph.D.; Michael Hassett, M.D.,
M.P.H.; Carol Keohane, B.S.N., R.N.; Elena Elkin,
Ph.D., Joanne Armstrong, M.D., M.P.H.; Michele
Toscano M.S.
Presented by: Jennifer Haas, M.D., M.S.P.H.,
Associate Professor, Division of General Medicine
and Primary Care, Brigham and Women's Hospital,
1620 Tremont Street, Boston, MA 02120; Phone:
(617) 525-6652; Email: jhaas@partners.org
Research Objective: Private health plans have a
wealth of data, but it is often hard to use for research
purposes because of limited access to datasets and
inability to use claims data alone because of lack of
clinical details and lack of coding specificity. Our
objective is to describe a study that overcomes these
challenges in using health plan data. We collaborated
with a national health plan to conduct a study of
targeted tests and treatments for breast cancer care
(HER2 testing to guide Herceptin therapy and gene
expression profiling (GEP) to provide information on
risk of recurrence and response to chemotherapy).
Despite the growing importance of targeted tests and
treatments for cancer, evidence about use in practice
is extremely limited.
Study Design: Cross-sectional medical record
review of cases identified using claims from a large,
national health plan.
Population Studied: Women age 35 – 65 years
diagnosed in 2006-2007 with invasive, localized
breast cancer (n = 775).
Principal Findings: We compiled a unique dataset,
linking claims, medical record review, and area-level
household income data, to study real-world practice
of targeted tests and treatments. Claims-directed
medical record abstraction is an efficient way of
obtaining detailed data from a broad cross section of
insured women to examine the use of targeted tests
and treatments. Claims data suggested a significantly
lower usage rate of HER2 tests compared to record
review (97% vs. 77%), and slightly higher rates of
trastuzumab, GEP and adjuvant chemotherapy use,
although these differences may be related to limited
specificity of coding for HER2 tests. Despite almost
universal testing for HER2 status (97%), many
insured women (42%) who are HER2-positive may
not receive trastuzumab, perhaps suggesting
underuse. Potential overuse of this expensive
treatment, by women without a positive HER2 test,
was less common (4%). In contrast to the near
universal adoption of HER2 testing, we found more
modest use of GEP (25% among clinically eligible
patients), perhaps because of the lack of guidelines
recommending universal use, newness of the test,
and the less straightforward treatment implications.
Racial and socioeconomic disparities in the use of
targeted tests and treatments for breast cancer are
also apparent, e.g., GEP use was less common
among non-White women and women with a lower
household income.
Conclusions: It is possible to use claims to identify
cases for medical record review. This technique
allows for sufficient clinical detail to improve the
evidence base around the use of targeted tests and
treatments. This study provides some of the first “real
world” evidence of how targeted tests and treatments
are being used in clinical practice for women with
early stage breast cancer in the US.
Implications for Policy, Delivery or Practice: It is
critical to use health plan data to further the evidence
base in order to support technology assessment and
comparative effectiveness research (CER). This
study demonstrates that the health plan data can be
rich and useful for studying the emerging
technologies and provides an example of how to
address the challenges in obtaining data for research
purposes, developing collaborative efforts with health
plans, and addressing methodological issues in
linking claims and medical record data. We conclude
with discussion of ongoing research using data from
other health plans and integrated delivery systems
and next steps for research and policy development.
Funding Source(s): This study was supported by
the Aetna Foundation and the National Cancer
Institute (P01CA130818-01A1). Claims data for
Aetna enrollees were used to identify women
potentially eligible for this study. Drs. Haas, Phillips,
Liang and Ms Keohane received funding from a
research grant from the Aetna Foundation for this
research. Dr. Armstrong and Ms. Toscano are
employees of Aetna and own Aetna stock. Drs.
Hassett and Elkin have no potential conflicts of
interest. The Aetna Foundation did not have any role
in the data collection, analysis and interpretation of
the findings, and was not involved in manuscript
review or approval. Medical records were reviewed
by trained data abstractors contracted through a third
party vendor (i.e., not the health plan), who released
a de-identified analytic dataset to the study
investigators.
Patient-Centered Medical Home Evaluators'
Collaborative: Reporting on Proposed Core
Measure Recommendations
Chair: Meredith Rosenthal, Ph.D.
Tuesday, June 29 * 8:00 a.m.–9:30 a.m.
Panelists: Asaf Bitton, Brigham and Women's
Hospital and Harvard Medical School; Benjamin
Crabtree, Robert Wood Johnson Medical School;
Elbert Huang, University of Chicago; Sarah Hudson
Scholle, National Committee for Quality Assurance
Panel Overview: Patient-centered medical home
(PCMH) pilot projects have been undertaken
throughout the U.S., with support from a broad array
of stakeholders including employers, health plans,
practicing physicians, policy makers, and
professional societies. Proponents of the PCMH
agree on the need to reinvigorate the primary care
workforce and many share aspirations that the PCMH
model will improve the quality of health care, patient
experience and efficiency. Such aspirations are
linked in part to findings from related literatures on
the value of primary care and the chronic care model.
Questions remain, however, about whether and how
the PCMH, as currently configured, will accomplish
these ambitious goals.
In light of the large number of PCMH pilots
underway and in the planning stages, substantial
benefit could result from establishing a core set of
measures to be tracked across PCMH pilot
evaluations. The PCMH Evaluators Collaborative, a
group formed in 2008 under the auspices of the
Commonwealth Fund, charged five workgroups to
outline the key measure domains that PCMH pilot
evaluations should assess regarding cost/efficiency,
clinical quality, patient experience, professional
satisfaction, and implementation of the intervention.
The proposed panel will comprise reports on three of
these domains (cost/efficiency, clinical quality, and
patient experience), linked together by a discussion
of common measurement, research design, and
other challenges facing the evaluators. Each panelist
will report on the work of one of these groups and
offer a set of core evaluation measures for that
domain.
Cost/Efficiency The desire to improve the
efficiency of care and reduce total costs are the most
compelling reasons that payers and policy makers
have thrown their support behind these efforts. Based
on an evidence-informed logic model, we sought to
identify a core set of efficiency- and cost-related
measures that PCMH evaluators should track.
Through changes in incentives and efforts to
transform practice structures and processes, the
PCMH can be expected to alter patterns of patient
care in ways that will be measurable in billed health
services utilization and cost data. Logical connections
can be established between the PCMH and primary
care visits, specialist visits, screening and diagnostic
tests, prescription drugs, emergency department
visits (all and ambulatory-care sensitive), ambulatorycare sensitive hospital admissions, and all-cause
readmissions. Changes in utilization may be positive
or negative and for some categories the expected
sign of the change is ambiguous.
Total health care costs should also be
tracked using two approaches: cost per case
(episode) and risk-adjusted cost per member per
month. Cost per case, calculated using standard
episode grouper software has the advantage of
accounting for case mix differences. Costs per
member per month have the advantage of simplicity
and the ability to detect changes in the number of
episodes as well as cost per episode, but requires
risk adjustment.
Clinical Quality: Logical links can be
established between the PCMH and improved quality
measures in the following three core domains:
primary care, patient centeredness, and new models
of practice. Improved primary care can be traced to
first contact, longitudinal, integrated, and
comprehensive treatment. In turn, these sub-domains
are associated with improvements in preventive care
(HEDIS measures for tobacco counseling, Chlamydia
screening, pap smears, mammography, and
colorectal cancer screening in relevant demographic
groups), chronic disease care (HEDIS process and
outcomes measures for diabetes, asthma, and
coronary artery disease), and measures of patient
activation and engagement (Patient Assessment of
Care for Chronic Conditions survey[PACIC]). Patient
centeredness encompasses whole person
orientation, better patient-provider communication,
and enhanced access. These changes should
increase a variety of patient experience measures
evaluated through CG-CAHPS and PACIC survey
tools, and may reduce some overuse measures in
areas such as radiology for low back pain and
antibiotic prescription for viral infections. New models
of practice involve structural improvements in teambased care, improved care coordination, clinical
information systems, and payment reform.
Transformative changes in this area may be linked
with higher e-prescribing rates, reduced adverse drug
events, increased medication reconciliation, better
chronic disease outcomes (HEDIS measures), and
potentially decreased emergency room utilization.
This recommended set of measures will necessitate
data extraction from billing claims, medical records,
and patient surveys, but should contain sufficiently
frequent occurrences to ensure feasible use in
upcoming PCMH evaluations.
Patient Experience: An important quality
outcome to assess in medical home evaluations is
the experience of patients. To be patient-centered, a
practice must obtain feedback from its patients.
Important issues remain however about survey
design, sampling strategies, and a fair scoring
approach that will lead to valid and meaningful
benchmarks for patient experience in the medical
home. Key issues include: the extent to which
existing instruments and methods capture the
concepts underlying the patient-centered medical
home; what additional constructs need to be
developed; how and when surveys should be
conducted; and what hypotheses evaluators should
test with regard to the impact of the PCMH on patient
experience. A panel of technical experts on patient
experience surveys along with NCQA’s new
Physician Practice Connections Advisory Panel will
produce consensus-based recommendations on 1) a
core set of survey items for evaluating medical
homes, as well as content areas for new survey item
development, and 2) procedures for sampling and
data collection to allow fair comparison across
practices.
From Research to Decision-Making: Lessons in
Quality and Usefulness of Observational
Research
Chair: Nancy Dreyer, Ph.D., M.P.H.
Tuesday, June 29 * 8:00 a.m.-9:30 a.m.
Panelists: Sarah Garner, National Institute for
Health and Clinical Excellence; Robert Mechanic,
Brandeis University; Fadia Shaya, University of
Maryland School of Pharmacy
Panel Overview: Comparative effectiveness
research (CER) can be used to inform coveragepolicy and formulary decisions, support treatment
decisions in clinical practice, and provide evidence
for best care. Although randomized controlled trials
are considered the highest level of evidence, there is
also a recognized need for more information -- on
broader populations and special applications -- and
for non-experimental data to understand actual use
and effectiveness. Observational studies are useful
when evidence gaps exist, but it is important to be
able to distinguish those studies that are of sufficient
or appropriate quality. Can observational studies be
used to guide evidence-based decision-making? In
what capacity? And how can we evaluate studies and
determine their quality? This panel will discuss and
share experiences of using observational research,
as well as some recent initiatives to foster highquality research supporting evidence-based decision
making.
The Moderator and Panelists will represent
several stakeholder perspectives, including those that
conduct observational studies and comparative
effectiveness research, as well as decision-makers
considering evidence from such studies. The
Moderator, affiliated with an organization that has
extensive experience designing and managing
registries, will introduce the panelists, and guide the
discussion throughout the program.
The first panelist is affiliated with an
independent organization that develops national
clinical guidelines for recommended practices and
provides appraisals for health care interventions to
inform national payment decisions in the United
Kingdom. The first panelist will provide a brief
overview of the growing role of observational
research and the decision-making opportunities for
such studies in the UK, including the role of registries
for interventional procedures or novel treatments with
little evidence. The challenges of using observational
studies in decision-making will also be explored.
The second panelist, from a U.S.-based
organization conducting health technology
assessment for a variety of stakeholders, will present
initiatives establishing good practices and describe
characteristics of high-quality studies, with references
to pertinent method tools, such as the Agency for
Healthcare Research and Quality (AHRQ) Registry
Handbook and the Good Research for Comparative
Effectiveness (GRACE) initiative. The AHRQ Registry
Handbook serves as a guide to the design and
implementation of patient registries, the analysis and
interpretation of data, and evaluation of registry
quality. The GRACE quality initiative, designed by a
small group of academic and industry collaborators,
includes the development of good practice principles
for observational comparative effectiveness research
and is a guide to identifying high quality studies.
The third panelist will add the payer and
provider perspectives from the United States. With
considerable experience in generating evidence for
drug coverage, the third panelist will present cases,
demonstrating the use of observational and realworld studies to guide formulary decisions. The
presentation will include selected case examples that
highlight the translation of comparative effectiveness
research into decision-making and a discussion of
the strengths and limitations of such real-world
studies for this purpose.
A concluding panel discussion led by the
moderator will explore what types of good-practice
guidelines would help meet the methodological and
acceptance challenges faced when using
observational research to support decision-making.
The audience will be encouraged to participate in
discussing additional key elements to distinguish
quality and improve the GRACE principles, and how
broad consensus of the usefulness of observational
studies could be achieved.
National Progress Towards Eliminating
Healthcare-Associated Infections
Chair: Peter Pronovost, M.D., Ph.D.
Tuesday, June 29 * 8:00 a.m.–9:30 a.m.
Panelists: William Munier, Agency for Healthcare
Research and Quality; Chesley Richards, Centers
for Disease Control and Prevention; Don Wright,
Centers for Disease Control and Prevention; Lauren
Harris-Kojetin, National Center for Health Statistics;
Jill Marsteller, Johns Hopkins University
Panel Overview: Healthcare-associated infections or
HAIs exact a significant toll on human life. They are
among the leading causes of preventable death in
the United States, accounting for an estimated 1.7
million infections and 99,000 associated deaths in
2002. In hospitals, they are a significant cause of
morbidity and mortality. In addition to the substantial
human suffering caused by HAIs, the financial burden
attributable to the infections is staggering. It is
estimated that HAIs cause 28 billion dollars to 33
billion dollars in excess healthcare costs each year.
The purpose of the roundtable is to: 1.
Provide a broad context on HAIs, highlighting
variations in the extent of the evidence base on HAIs
and interventions across health care settings; 2. Give
an update on the U.S. DHHS’ Action Plan to Prevent
Healthcare-Associated Infections; 3. Discuss the key
strategies behind the Federal prevention effort; 4.
Explore implications of the initiative on patient safety
and healthcare quality; and 5. Share two illustrative
examples of how the current state of knowledge
about HAIs varies in long-term care settings and
acute care settings.
Prevention and reduction of HAIs are a top
priority for the U.S. DHHS. The DHHS Steering
Committee for the Prevention of HAIs was
established in July 2008. The Steering Committee
was charged with developing a comprehensive
strategy to prevent and reduce HAIs and issuing a
plan which establishes national goals for HAI
prevention and outlines key actions for achieving
identified short- and long-term objectives.
In January 2009, DHHS released the Action
Plan to Prevent Healthcare-Associated Infections,
and in June 2009 released an update that
incorporates public comment. The Action Plan
represents the efforts of a broad partnership across
DHHS, including the Office of Public Health and
Science/Office of Healthcare Quality, CDC, the
Centers for Medicare and Medicaid Services or CMS,
AHRQ, and non-DHHS Federal partners including the
Department of Veterans Affairs.
With the development of the Action Plan,
DHHS outlined a multi-pronged, collaborative, public
health approach for reducing HAIs. The Action Plan
prioritizes CDC’s infection prevention
recommendations and prioritizes a research agenda.
It outlines projects for integrating data collection
across DHHS systems, progressing towards systems
interoperability, accelerating the transition to
electronic health record use, and reducing the data
collection burden on hospitals. The document
suggests policy options for connecting payment
incentives or disincentives to quality of care,
enhancing regulatory oversight of hospitals, and
encouraging the public reporting of infection rates. It
also delineates a national messaging and outreach
plan to engage consumers, providers, and academia.
Drs. Munier, Richards, and Wright will provide an
update on CDC, AHRQ, and CMS investments to
fund state-based organizations to implement proven
HAI prevention strategies.
Within this broader context of the Federal
perspective on HAIs, the round table will continue
with two research presentations intended to illustrate
how the current evidence base on HAIs varies by
health care setting.
Most research to estimate HAI prevalence
has focused on hospitals. The scant research that
exists on infections in long-term care or LTC focuses
on nursing homes and is not national in scope. Dr.
Harris-Kojetin will present findings on the prevalence
of and factors associated with infections among
nursing home, home health care, and hospice care
populations using nationally representative data.
The current state of knowledge on HAIs is
most advanced in hospital settings, and intensive
care units or ICUs in particular. Whereas the
evidence base in LTC has developed only as far as
beginning to identify the extent of the problem, cutting
edge research in ICUs is examining the effectiveness
of interventions to reduce the prevalence of HAIs.
Central-line associated bloodstream infections in
ICUs are common and costly, though largely
preventable. Using an observational design, a
previous study showed that an evidence-based
intervention significantly reduced these infections and
improved unit safety culture. Dr. Marsteller will
present findings from a randomized controlled trial to
test the effectiveness of this intervention and to
determine the generalizability of the intervention
effects.
• Prevalence of Infections in U.S. Long-Term Care
Populations
Lauren Harris-Kojetin, Ph.D.; Lisa Dwyer M.P.H.;
Joyce Frazier, R.H.I.A.; Roberto Valverde, M.P.H.;
Alan Simon, M.D., M.P.H.
Presented by: Lauren Harris-Kojetin, Ph.D., Chief,
Long-Term Care Statistics Branch, Division of Health
Care Statistics, National Center for Health Statistics,
3311 Toledo Road, Room 3431, Hyattsville, MD
20782; Phone: (301) 458-4369; Email: fti3@cdc.gov
Research Objective: The 2009 American Recovery
and Reinvestment Act provided 50 million dollars to
fight health care-associated infections or HAIs. Most
research to estimate HAI prevalence focuses on
hospitals. The scant research that exists on infections
in long-term care or LTC focuses on nursing homes
and is not national in scope. We estimate the
prevalence of and factors associated with infections
among nursing home, home health care, and hospice
care populations using nationally representative data.
Study Design: Data are from the National Center for
Health Statistics’ 2007 National Home and Hospice
Care Survey and 2004 National Nursing Home
Survey. ICD-9 codes identified infections at the time
of interview for current nursing home residents and
current home health care patients or at the time of
discharge for hospice care discharges. Unadjusted
bivariate analyses were performed. Patient/resident
characteristics analyzed include sex, age, race,
length of care, assistance in activities of daily living or
ADLs, number of medications, number of comorbidities, recent hospitalization or emergent care
use, indwelling catheter use, oxygen therapy use,
and where care was received for home health care
and hospice care only. Provider characteristics
analyzed include metropolitan statistical area status,
bed size for nursing home only, and presence of
infection control staff for nursing home only. Chi
square tests were calculated using SAS callable
SUDAAN with an alpha of .05.
Population Studied: We examined those with and
without infections among national samples of home
health care patients, hospice care discharges, and
nursing home residents.
Principal Findings: About 10 percent of U.S. longterm care recipients had at least one infection: 9
percent of home health care patients, 10 percent of
nursing home residents, and 8 percent of hospice
care discharges. Among all infections, urinary tract
infections and pneumonia were the two most
common types across LTC populations. Skin
infections constituted the third most common type
among nursing home and home health care
populations whereas septicemia was the third most
common type among the hospice population. Among
home health care patients, those more likely to have
any infection received care for fewer than 90 days,
took more than nine medications, had four or more
co-morbidities, had an indwelling catheter, or
received oxygen therapy. Among nursing home
residents, infection prevalence was higher among
those who were in the facility for fewer than 90 days,
took more than nine medications, had five or more
co-morbidities, had an indwelling catheter, were
white, had four to five ADLs, were hospitalized in the
previous 90 days, or were in a facility with infection
control staff. Among hospice care discharges,
infection prevalence was higher among those with
four or more co-morbidities, had an indwelling
catheter or received oxygen therapy, were older than
84 years of age, or did not live in a private residence.
Conclusions: Among all three LTC populations
infections are common and having more comorbidities or using an indwelling catheter is
associated with higher infection prevalence.
Implications for Policy, Delivery or Practice:
Findings could provide a benchmark for LTC infection
surveillance and control programs and help identify
what proportion of infections may be prevented.
Further research could develop evidence-based
interventions to lower infection prevalence among
LTC populations.
Funding Source(s): CDC
All-Payer Claims Databases and Health Policy
Research
Chair: Craig Schneider, Ph.D.
Tuesday, June 29 * 8:00 a.m.– 9:30 a.m.
Panelists: Sean Kolmer, Oregon Health Authority;
Denise Love, National Association of Health Data
Organizations; Patrick Miller, University of New
Hampshire; Alan Prysunka, Maine Health Data
Organization
Panel Overview: The number of states that have
implemented or are developing all-payer claims
databases (APCDs) has grown substantially in recent
years, and is expected to grow further as states
realize the value of APCDs and federal health
information technology grants and healthcare reform
legislation impact states. APCDs have the potential to
reduce costs, improve quality, enhance transparency,
and increase researchers’ and policy makers’
understanding of the healthcare system.
This roundtable discussion will begin with a
status report on states’ progress to implement
APCDs, and then will provide examples of the cost,
quality, and other data analysis that may be
generated from an APCD. The session will continue
with a reactor panel that will discuss how this data
may benefit health services researchers, state policy
makers, health plans, employer coalitions,
consumers, and provider organizations.
The sources of claims databases are
insurance carriers, third-party administrators,
pharmacy benefit managers, dental claims carriers,
state Medicaid agencies, and Medicare. The APCDs
transform these sources to include eligibility,
provider, and claims, and are being used to report
cost, utilization, quality information, and preventive
services.
Based solely on Medicare data, The
Dartmouth Institute for Health Policy and Clinical
Practice has done groundbreaking work on studying
geographic variation in costs and quality. It would be
extremely valuable to have such research conducted
on the under-65 population as well, and APCDs can
make these analyses possible. Ideally, states would
be able to establish databases that include the full
range of private plans, Medicare, and Medicaid data,
which would cover virtually the entire population in a
state, and then would make the database available to
health services researchers and other interested
parties. The issue of the uninsured remains to be
addressed, as does the data from TRICARE.
Examples of analytics based on these
databases can show policy makers, researchers,
employers, consumers, and insurers the following
types of information: 1) the cost of treating patients
for a particular condition by hospital, 2) price
differentials for a procedure by insurer and hospital,
3) payment rate benchmarking comparing Medicaid
to private plans, 4) disease prevalence of Medicaid
patients compared to commercial patients, 5)
prevalence of conditions over time, 6) costs for
different treatment options for a condition, 7) patient
migration between healthcare service areas, and 8)
relative price index by hospital.
There have been a series of national
meetings to address the topic of APCDs. The
Massachusetts Health Data Consortium (MHDC), the
National Association of Health Data Organizations
(NAHDO), the Regional All Payer Healthcare
Information Council (RAPHIC), and the New
Hampshire Institute for Health Policy and Practice at
the University of New Hampshire (NHIHPP)
partnered to hold the first National All-Payer Claims
Database Conference. The meeting was held in
Beverly, MA on April 17-18, 2008 and attracted 125
people representing 26 states.
The Beverly meeting was succeeded by
national meetings preceding the annual NAHDO
conferences in October 2008 in San Antonio and
October 2009 in Alexandria, VA. The October 2009
meeting was jointly sponsored by The
Commonwealth Fund and AcademyHealth’s State
Coverage Initiatives Program. MHDC hosted a
seminar on the topic on December 1, 2009 in Boston.
While these meetings have been successful, we
believe the time is appropriate to engage an
important health services research audience in the
conversation about the role of APCDs in healthcare
reform, cost control, and quality improvement efforts.
Issues to Be Addressed During the Roundtable
Discussion:
APCDs vs. other claims databases: APCDs
are essential because other data sources have
serious limitations. Medicare data offers a complete
picture of care, but with a limited population (the
elderly and disabled). Similarly, Medicaid data is
complete, but only covers a limited population (lowincome and under-served). Hospital inpatient
discharge data includes all populations, including the
uninsured, but is only a segment of healthcare
services. APCDs cross all age groups and all settings
of care (although the uninsured are not represented).
Public reporting and transparency: Most
states that have established APCDs have also
created websites for the purpose of publicly reporting
quality data and, in some cases, pricing information.
Such transparency can be a critical tool in the efforts
to improve quality by shining a light on provider and
health plan outcomes, and reduce costs by
encouraging informed decision-making by patients.
The challenges of expanding APCDs to other
states: The national movement is growing rapidly. As
recently as early 2005 there were only two states
(Maine and Maryland) with APCDs, but as of January
1, 2010 there are seven, with three other states
developing programs and another ten seriously
interested in creating APCDs. However, states must
consider the governance, stakeholder interests,
funding, data collection and release rules, and public
reporting decisions that need to be made.
Data collection: The private sector data is
collected from individual health plans and pharmacy
benefit managers. However, the submission process
is burdensome for the plans/PBMs, and states may
have different data submission requirements. How
can states collaborate to minimize the burden on the
plans while meeting the states’ needs, and what is
the potential for leverage health information
exchanges to link to APCD data?
Data release: There are numerous
organizations that would be interested in obtaining
all-payer claims datasets. How can data release rules
be crafted to make the data as widely available as
possible while also protecting the privacy of enrollees
and the security of the data? Some states have
created models for new states to consider.
Medicare and Medicaid data: The Centers for
Medicare & Medicaid Services has been cautious
about providing Medicare and Medicaid data to the
states. NAHDO and RAPHIC have proposed
legislative language to Congress to make data
available to states with the appropriate oversight to
ensure the security of CMS data.
Analytic uses: States are undertaking the
challenges of establishing APCDs because the
databases are so valuable for healthcare reform,
payment reform, quality improvement, public health,
comparative effectiveness, and other purposes. What
specific uses does the reactor panel suggest, and for
what purposes might the audience members wish to
use this data?
Medicare Part D: Five Years and Still Evolving
Chair: Jack Hoadley, Ph.D.
Tuesday, June 29 * 9:45 a.m.-11:15 a.m.
Panel Overview: Medicare’s Part D drug benefit is in
its fifth year, providing coverage to about 27 million
beneficiaries. The program has been valuable to
many beneficiaries, yet some program gaps and
issues with its design remain. Through health reform
legislation, Congress is making modifications,
including changes to the benefit’s infamous coverage
gap where enrollees with high expenses are left
without coverage during part of the year. This panel
will present research findings from the program’s first
five years in the context of actual and potential policy
changes in the program. The first panelist will draw
upon the cumulative findings of five years’ research
on program offerings to explore trends in plan
availability, enrollment, and premiums. The second
panelist will discuss whether Part D has changed the
operations of long-term care pharmacies and nursing
homes and the implications of those changes for
nursing home residents. The third panelist will report
on analysis of formularies offered by plans from 2006
through 2010 and report whether formulary offerings
vary significantly over time and across different types
of plans, such as Medicare Advantage versus
standalone, benchmark plans for low-income
beneficiaries versus non-benchmark plans, or plans
offered by national versus local sponsors. The final
panelist will discuss different incentives faced by plan
sponsors offering Medicare Advantage drugs plans
versus standalone plans and present findings on
whether these incentives lead to differences in plan
formularies. In the session, each panelist will be
asked to discuss findings in light of enacted or
proposed policy changes to Part D.
• Five-Year Trends in Medicare Part D Program
Offerings
Juliette Cubanski, Ph.D., M.P.P., M.P.H.; Tricia
Neuman Sc.D.; Jack Hoadley, Ph.D.; Elizabeth
Hargrave, M.P.Aff; Laura Summer, M.P.H.
Presented by: Juliette Cubanski, Ph.D., M.P.P.,
M.P.H., Associate Director, Medicare Policy Project,
Kaiser Family Foundation, 1330 G Street, NW,
Washington, DC 20005; Phone: (202) 347-5270;
Email: jcubanski@kff.org
Research Objective: Since 2006, Medicare Part D
has helped cover the cost of outpatient prescription
drugs for Medicare beneficiaries through private
plans available on a regional basis, with beneficiaries
in each state facing dozens of drug plan choices
each year. This research examines the current
landscape of Part D stand-alone prescription drug
plan (PDP) offerings, differences between basic and
enhanced plans, and the trends in plan availability,
availability of low-income subsidy benchmark plans,
enrollment, and premiums between 2006 and 2010.
Study Design: The project analysis uses plan-level
characteristics and enrollment to study yearly plan
offerings.
Population Studied: Data from CMS on
characteristics of drug plans offered each year since
2006 and annual plan enrollment.
Principal Findings: In 2010, a total of 1,576 PDPs
are offered nationwide, down from 1,689 PDPs in
2009 and a peak of 1,875 plans in 2007, but still
higher than the 1,429 PDPs in 2006. Conversely the
availability of benchmark plans, or PDPs available for
no monthly premium to low-income subsidy (LIS)
enrollees, has decreased significantly over time from
a high of 640 benchmark plans in 2007 to 307 in
2010. Despite the availability of numerous plan
options each year, enrollment has been concentrated
in only a few plans and there has been minimal
voluntary switching from one year to the next.
Monthly premiums have increased dramatically, up
50 percent between 2006 and 2010, weighted by
enrollment, and there is significant variation in plan
premiums both within and across PDP regions.
Enhanced plans are typically more expensive than
basic plans, in accordance with their greater actuarial
value and more generous coverage. But many also
charge higher cost-sharing amounts for prescriptions
than basic plans, and the added value of enhanced
coverage compared to basic coverage is not always
apparent.
Conclusions: Despite early conjecture that the Part
D plan marketplace would consolidate as enrollment
gravitated to the few most popular plans, Part D
enrollees have faced a wide array of Part D plan
choices in each year since 2006. Rather than the
multitude of plan choices resulting in greater price
competition, enrollees have also faced steep drug
plan premium increases over time, including for the
most popular plans. Annual changes in the PDP
marketplace present challenges for low-income
beneficiaries who may face monthly premiums unless
they change plans, despite qualifying for zeropremium coverage. An inability to distinguish clearly
between plan options, including plans with basic and
enhanced benefit designs, can make it more difficult
for consumers to choose coverage that best meets
their needs.
Implications for Policy, Delivery or Practice:
Findings from this research support taking additional
steps to improve consumers’ ability to distinguish
between Part D plan offerings and to choose based
on a more complete understanding of the differences
between plans. Recent CMS regulations indicate that
the agency intends to limit the wide array of plan
options by restricting the number and type of
offerings that plan sponsors are allowed to market,
which could have the effect of making the Part D plan
marketplace more transparent and competitive.
Funding Source(s): Kaiser Family Foundation
• Medicare Part D and the Nursing Home Setting
Haiden Huskamp, Ph.D.; Tara Sussman Oakman
Ph.D.; David Stevenson, Ph.D.
Presented by: Haiden Huskamp, Ph.D., Associate
Professor Health Care Policy, Health Care Policy,
Harvard Medical School, 180 Longwood Avenue,
Boston, MA 02115; Phone: (617) 432-0838; Email:
huskamp@hcp.med.harvard.edu
Research Objective: To explore how Medicare Part
D has changed the operations of long-term care
pharmacies (LTCPs) and nursing homes (NHs) and
the implications of those changes for nursing home
residents.
Study Design: We reviewed existing sources of
information and conducted two rounds of semistructured interviews of 51 key stakeholders in
2006/2007 and 2009/2010.
Population Studied: Key stakeholders across
various perspectives, including nursing homes, longterm care pharmacies, prescription drug plans,
patient advocates, nursing home physicians, and
consultant pharmacists.
Principal Findings: Part D represents a substantial
departure from how prescription drugs were
previously financed and administered in NHs, and NH
providers and LTCPs have struggled in adapting to
some of these changes. A number of stakeholders
reported that Part D’s focus on choice and
competition has proved challenging to residents,
family members, and NHs. Since NH residents and
their families may not be well prepared to make
appropriate decisions about which drug plan will best
meet their medication needs, there is an ongoing
tension between providing freedom of choice to
beneficiaries and allowing NH providers to assist
families in plan selection, something that is currently
restricted by regulation. A related issue is that dual
eligibles, who are randomly assigned to plans, can
face potential disruptions if their assigned plans lose
benchmark status from year to year. NHs and LTCPs
perceive meaningful variation across plans in breadth
of formulary coverage and policies governing
coverage approvals, noting coverage problems with
selected medication classes including erythropoietin
drugs, some pain medications, and proton pump
inhibitors. Stakeholders noted that NHs are required
by law to provide all medications included in a
resident’s care plan, and dispensed medications not
covered by the resident’s drug plan must be paid for
by either the NH or LTCP. Although NHs and LTCPs
have established better systems over time for dealing
with non-covered drugs, including approaches for
shifting patients to covered medications, the
assumption of costs for non-covered drugs has
added tension to the NH/LTCP relationship, and both
types of stakeholders report financial losses from
non-covered medications. NH and LTCP
stakeholders reported shifts in drug utilization within
classes, but no stakeholders interviewed stated that
Part D had a sizeable impact on resident outcomes
or quality of care.
Conclusions: The overall fit between Part D and the
NH pharmacy sector is a matter of contention among
stakeholders we interviewed. Although many issues
that occurred during the initial transition to Part D
appear to have been addressed to some extent, NH
and LTCP stakeholders identify remaining issues with
the benefit, including concerns about access to
selected high-cost medications, restrictions on
providing assistance to residents in selecting a plan,
and costs associated with non-covered medications.
Implications for Policy, Delivery or Practice:
Although stakeholders do not perceive a large effect
of Part D on resident outcomes, analysis of Medicare
claims and data on resident functioning and
outcomes is needed in order to determine the effect
on quality of nursing home care received by
institutionalized Medicare beneficiaries.
Funding Source(s): Medicare Payment Advisory
Commission
• Medicare Part D Formularies, 2006-2010
Elizabeth Hargrave, M.P.Aff.; Jack Hoadley Ph.D.;
Laura Summer, M.P.H.; Katie Merrell, B.A.
Presented by: Elizabeth Hargrave, M.P.Aff., Senior
Research Scientist, Health Care, NORC at the
University of Chicago, 4350 East-West Highway,
Bethesda, MD 20814; Phone: (301) 634-9327;
Email: Hargrave-Elizabeth@NORC.org
Research Objective: To explore how Medicare Part
D plans have used formularies to manage utilization
during the first 5 years of the program.
Study Design: We analyzed formulary variations
using a dataset we built at the chemical entity level
from the formularies used by drug plans from 2006 to
2010.
Population Studied: CMS formulary data for
standalone prescription drug plans (PDPs) and
Medicare Advantage drug plans (MA-PDs) for each
plan year since 2006.
Principal Findings: The overall share of drugs listed
on Part D formularies has remained stable over the
first five years of the program, at an average of about
88 percent of chemical entities for which there is
coverage information. However, there is variation
among plans: some cover as few as 37 percent of
drugs while some large plans cover 100 percent of
drugs. On average, MA-PDs tend to cover slightly
more drugs than PDPs. Among PDPs, plans
qualifying for automatic enrollment of low-income
subsidy beneficiaries tend to cover fewer drugs than
non-LIS plans. While there have not been dramatic
changes in the share of drugs that plans cover, there
have been other changes in plan formularies that
likely affect utilization. For example, plans’ use of
prior authorization and step therapy has increased
since the start of the program. On average, PDPs
now require prior authorization for 15 percent of the
drugs they list on formulary, up from 8 percent in
2007. PDPs have step therapy requirements for an
average of 4 percent of covered drugs, up from 1
percent in 2007. In addition, plans are moving toward
increasingly complex tiering arrangements aimed at
discouraging the use of high-cost drugs. Part D plans
now almost universally charge coinsurance for at
least one tier on which they can place high-cost
drugs: either a specialty tier with coinsurance of 25 to
33 percent or a non-preferred tier with coinsurance
ranging up to 75 percent. There has also been a
trend over time to more differentiation between
preferred and non-preferred brands and preferred
and non-preferred generics.
Conclusions: There is an inherent tension in Part D
between the need to encourage beneficiaries to use
low-cost alternatives, and the need to ensure that
beneficiaries have access to the drugs they need.
Current law aims to protect beneficiaries by focusing
on whether or not a drug is listed on a plan’s
formulary; plans are required to cover a certain
number of drugs in each drug class. But even among
drugs listed as being on formulary, there can be
dramatic differences in the price and hassle faced by
beneficiaries seeking to fill a prescription. These
complex issues may make it increasingly difficult for
beneficiaries to determine which plan offers the best
coverage for their situation.
Implications for Policy, Delivery or Practice: The
increased use of restrictions such as prior
authorization and very high coinsurance deserve
ongoing scrutiny to ensure that Medicare
beneficiaries continue to have access to the drugs
they need, while plans have the tools they need to
steer beneficiaries to lower-cost drugs when the
substitution is appropriate.
Funding Source(s): Medicare Payment Advisory
Commission
• Differences in Incentives Between Standalone
Medicare Drug Coverage Versus Medicare
Advantage Plans
Kosali Simon, Ph.D.; Kurt Lavetti B.A.
Presented by: Kosali Simon, Ph.D., Associate
Professor, Department of Policy Analysis and
Management, Cornell University, MVR Hall, Ithaca,
NY 14850; Phone: (607) 255-7103; Email:
kis@cornell.edu
Research Objective: We test whether standalone
prescription drug plans (PDPs) have systematically
different formulary designs than Medicare Advantage
drug plans (MAPDs). Theory predicts that PDPs have
an incentive to minimize the cost of providing drugs
to customers, while MAPDs have incentives to
minimize the total cost of insuring the patient. This
implies MAPDs have a stronger incentive during
open enrollment periods for low formulary generosity
for drugs whose use signals that the patient also has
high non-drug costs. These drugs are called set S,
for testing the Selection hypothesis. Potential
enrollees with higher costs might be discouraged
from enrolling, and current enrollees might be
encouraged to disenroll. After open enrollment,
MAPDs have stronger incentives to increase
formulary generosity for drugs whose use reduces
hospital costs so as to optimize medical
management. These drugs are called set M, for
testing the Medical management hypothesis. The
incentives are clear in theory, but regulations attempt
to prevent risk selection through reimbursement
adjustments and subsidies or taxes on the losses and
profits that sponsors can earn. Thus, the net effect is
unclear and is an empirical question.
Study Design: We will examine whether MAPD
formularies are less generous than PDP formularies
during open enrollment for set S drugs whose use
signals that a patient also has high non-drug costs.
We construct set S by empirically observing
correlations between people’s use of certain drugs
and their medical costs from the Medicare Current
Beneficiary Survey, and then obtaining the input of
clinical experts on whether these empirically
observed correlations seem realistic. We also test
whether MAPD formularies are more generous than
PDP formularies after open enrollment for set M
drugs whose use can lower non-drug costs. We
construct set M using lists identified in prior literature.
We also compare the MAPD formularies to the
Australian National Formulary. Both have medical
management incentives, but only MAPD plans have
the added selection incentive.
Population Studied: Part D plan formularies for
2007
Principal Findings: Preliminary results show a
mixed picture based on 2007 formulary data, using
prior authorization and quantity limits as the
measures of generosity. There are some small signs
that MA plans may be engaging in selection. That is,
when comparing the MA plans' generosity towards
drugs associated with conditions that are expensive
in terms of non-drug services, they appear to be
slightly more restrictive in the open enrollment period
than afterwards. This is consistent with wanting to
engage in selection in the open enrollment period. In
our preliminary tests of the medical management
hypothesis, we also find mixed evidence depending
on the class of drugs selected.
Conclusions: Preliminary findings do not indicate
strong evidence that MAPD formularies are being
designed to enroll low-cost patients selectively.
Implications for Policy, Delivery or Practice:
Knowing whether MAPD plan drug coverage is
designed in a more efficient manner than standalone
plans in terms of reducing total health care costs is
important as regulators continue to improve the
design of Medicare Part D.
Impact of Early Intervention Programs for People
with Severe Mental Illness and Other Behavioral
Health Conditions on Health, Employment, and
Progression to Disability: Evidence from the
Demonstration to Maintain Independence and
Employment
Chair: Henry Ireys, Ph.D.
Tuesday, June 29 * 9:45 a.m.-11:15 a.m.
Panel Overview: In November 1999, Congress
passed the Ticket to Work and Work Incentives
Improvement Act, which had the primary goal of
making health insurance more available and
affordable to working individuals with potentially
disabling mental or physical health impairments. The
legislation established a series of initiatives, including
the Demonstration to Maintain Independence and
Employment (DMIE). By authorizing this
demonstration, Congress signaled its interest in
examining whether comprehensive medical care and
employment assistance could delay or prevent the
loss of employment due to a potentially disabling
mental or physical impairment. This panel will present
findings from the federal evaluation and two state
evaluations of DMIE programs targeted at individuals
with behavioral health conditions. The first paper
provides an overview of the DMIE programs and their
randomized control evaluation design. The second
paper presents findings from the federal evaluation
on the impact of intervention services on earnings
and application for disability benefits. The third paper,
based on the Texas DMIE, examines whether
participants with mental health conditions receiving a
coordinated set of health and employment supports
exhibit improved medication adherence and
persistence. The fourth paper, based on the
Minnesota DMIE, examines how access to and use
of medical, behavioral health, and employment
support services for individuals with serious mental
illness influences the progression of potentially
disabling conditions. If effective, this program can
offer a way to help workers with a wide range of
mental and physical impairments remain employed
for a longer time, increase their earnings, and rely
less on federal disability benefits.
• Impact of Early Intervention Programs for
Persons with Mental Health Conditions: Evidence
from the National DMIE Evaluation
Gilbert Gimm, Ph.D.; Henry Ireys Ph.D.; Boyd
Gilman, Ph.D.; Noelle Denny-Brown, M.P.A.; Sarah
Croake, M.P.P.
Presented by: Boyd Gilman, Ph.D., Senior
Researcher, Health, Mathematica Policy Research,
955 Massachusetts Avenue, Suite 801, Cambridge,
MA 02139; Phone: (617) 301-8974; Email:
bgilman@mathematica-mpr.com
Research Objective: Using random assignment, this
study examined whether a program of enhanced
medical care and employment support can improve
the mental health status, employment, and disability
outcomes of working adults with behavioral health
conditions.
Study Design: Two participating states (Minnesota
and Texas) included target populations with mental
illness or a behavioral health condition co-occurring
with a physical condition. Using federal administrative
data from the Social Security Administration (SSA),
we analyzed the impact of program interventions on
earnings and disability. Specifically, we integrated
data from baseline (Round 1) and follow-up (Round
2) surveys provided by state DMIE programs with the
SSA Master Earnings File, Ticket Research File, and
831 File. State data include a uniform set of variables
on the demographic, health, and employment
characteristics of participants derived from participant
surveys and state administrative files. We compared
the unadjusted mean outcomes between the
treatment and control groups at the time of the oneyear follow-up survey. We also used multivariate
analysis to estimate regression-adjusted impacts on
the likelihood of applying for federal disability benefits
and earnings after controlling for baseline participant
characteristics.
Population Studied: The study sample included
3,370 participants in Minnesota (N = 1,785) and
Texas (N = 1,585) having valid personal identifiers.
The Minnesota DMIE targeted persons with severe
mental illness and other mental conditions.
Principal Findings: There was a significant increase
in the mental health status (measured by the SF12
composite score) in the Minnesota treatment group
relative to the control group (39.4% versus 37.8%) at
the time of the Round 2 follow-up survey. There were
no other observed differences in health status one
year after DMIE enrollment. In addition, a lower
proportion of treatment group members applied for
disability benefits after DMIE enrollment in Minnesota
(6.7% versus 8.0%) and in Texas (11.8% versus
13.2%). Evidence of early intervention services on
earnings is forthcoming.
Conclusions: An early intervention program of
medical care and employment supports that is
focused on working adults with mental health
conditions was shown to improve the mental health
status of participants and reduce the likelihood of
applying for federal disability benefits.
Implications for Policy, Delivery or Practice: Early
intervention programs can influence the mental
health trajectory of participants with mental health
conditions and reduce dependence on SSA disability
benefits. These findings suggest that disability can be
prevented or delayed with a well-designed program
that includes both health and employment supports
for individuals.
Funding Source(s): CMS
• Health Insurance Access, Employment
Supports, and the Disability Trajectory: Lessons
from Minnesota’s Demonstration to Maintain
Independence and Employment
Karen Linkins, Ph.D.; Jennifer Brya M.P.P.;
MaryAlice Mowry, M.S.W.; Joshua McFeeters,
M.P.P.; Allison Oelschlager, B.A.; Maik Schutze,
M.H.S.
Presented by: Karen Linkins, Ph.D., Managing
Director, The Lewin Group, 14723 E. Peak View
Road, Scottsdale, AZ 85262; Phone: (480) 4717516; Email: karen.linkins@lewin.com
Research Objective: The goals of the Minnesota
demonstration were to (1) create a comprehensive
and coordinated set of health, behavioral health, and
employment support services for employed
individuals with serious mental illness; and (2)
determine how access to and utilization of these
services and supports influences the progression of
potentially disabling conditions. The ultimate goal of
the demonstration was to prevent or delay persons
with serious mental illness from becoming disabled
and no longer being able to work.
Study Design: Study participants were identified
through analyses of the MMIS data using an
algorithm targeting mental health and pharmacy
services. Participants were stratified by age,
functional status, geography, and income, and
randomly assigned to an intervention group (N =
1,285) or a control group (N = 298). Individuals
assigned to the intervention group had access to an
expanded Medicaid benefit set including medical,
behavioral health, and pharmacy services;
employment supports; and a personal navigator.
Individuals assigned to the control group received
“usual care.” Data sources included MMIS, other
administrative data, and navigator encounter data to
capture utilization of medical, mental health,
employment support, and other public services, as
well as annual earnings. Participants completed an
annual survey at baseline and at 12- and 24-month
intervals. Analyses examined differences between
the intervention and control groups on outcomes
related to health status, functioning, earnings,
personal finances, and applications to disability.
Population Studied: Eligibility criteria included (1)
working at least 40 hours per month; (2) diagnosis of
mental illness as determined by a clinical assessment
conducted during the application process; and (3)
ineligible to participate in other Minnesota-sponsored
public h
Principal Findings: There were statistically
significant differences between the intervention and
control groups on several outcomes. Compared with
the control group, the intervention group showed
increased health care utilization of dental, mental
health, outpatient, and pharmacy services; improved
mental health status (measured by SF-12 MCS) and
functional status (measured by ADL/IADLs); and
improved employment stability (measured by job
turnover). Additionally, two years post enrollment,
significantly more control group participants reported
increased medical debt than intervention group
participants (48% versus 17%). Significantly fewer
intervention group participants applied for SSDI than
intervention group participants (4% versus 14%).
Multivariate analyses show that certain covariates,
such as age, diagnosis, and frequency of navigator
contact, influence the likelihood of applying for SSDI.
Conclusions: The findings suggest that providing a
comprehensive health insurance benefit with personcentered navigation and employment support
services to individuals at risk of becoming disabled
slows down their disability trajectory by stabilizing
their health and employment.
Implications for Policy, Delivery or Practice: The
study provides important insights for state and federal
Medicaid policy regarding the intersection of medical,
mental health, and employment services that
influence independence and stability for a population
at risk of becoming disabled.
Funding Source(s): CMS
• Impact of Enhanced Health Benefits on Use of
Medications among Low-Income, Uninsured
Working Adults with Behavioral Health
Conditions
Thomas Bohman, Ph.D.; Lynn Wallisch Ph.D.; Dena
Stoner, B.A.; Britta Ostermeyer, M.D.; Brian Reed,
M.D.; Richard Spence, Ph.D.
Presented by: Thomas Bohman, Ph.D., Research
Scientist, Addiction Research Institute, University of
Texas at Austin, 1717 West 6th Street, Suite 335,
Austin, TX 78703; Email:
bohman@austin.utexas.edu
Research Objective: This study tests whether early
intervention through a coordinated health benefits
package, including outpatient case management,
predicts improved medication use 18 months after
enrollment in the Texas Demonstration to Maintain
Independence and Employment (DMIE). The Texas
DMIE evaluation examines whether participants with
a potentially disabling behavioral health condition
with or without a co-occurring physical health
condition receiving a coordinated set of health and
employment supports can avoid dependence on
federal disability benefits.
Study Design: Patients from the Harris County
Hospital District (HCHD), a large public health system
providing indigent care in the Houston metroplex,
were recruited and randomized into an intervention
group (N = 904) or a control group (N = 712). The
DMIE intervention included individualized case
management services focusing on health navigation
and employment support, expedited appointments,
free medications, elimination of copayments for
medical visits, and vocational counseling.
Administrative data regarding participants’
prescriptions filled through the HCHD pharmacy 12
months prior to enrollment and 12 months after
enrollment were utilized to measure drug adherence
and peristence. Drug adherence was measured using
the proportion of days covered during the 365-day
pre- and post-enrollment observation periods.
Medication persistence was measured as the
duration of time from initiation to discontinuation in
therapy based on a 35-day permissible gap (that is,
days without supply) between medication refills.
Findings were based on analysis of covariance for
persistence and survival analysis for persistence.
Eleven drug classes related to chronic disease
conditions were examined for adherence and
persistence. Covariates included morbidity, age,
race/ethnicity, gender, occupation, serious mental
illness, and recruitment method.
Population Studied: DMIE participants were
between the ages of 21 and 60, working a minimum
of 40 hours per month, diagnosed with serious
mental illness or a less severe mental or substance
misuse condition plus a potentially disabling physical
health condition, and not alre
Principal Findings: After adjusting for preenrollment adherence, the intervention group showed
between 10% and 20% higher adherence compared
with the control group for the following medications:
angiotensin converting enzyme (ACE) I inhibitors,
beta adrenergic agonists, biguanides, HMG-CoA
reductase inhibitors, insulins, sulfonylureas, and
thiazide diuretics. Adjusting for the pre-enrollment
number of days without a break, the intervention
group also showed statistically significantly higher
persistence for biguanides (hazard ratio = 0.59) and
insulins (hazard ratio = 0.59) compared with the
control group. Participants with serious mental illness
were more likely to experience interruptions in use of
biguanides (hazard ratio = 2.34) and beta adrenergic
agonists (hazard ratio = 1.75).
Conclusions: Among patients with behavioral health
diagnoses (including serious mental illness)
accompanied by a co-occurring chronic physical
condition, the intervention group showed greater
medication use as measured by adherence and
persistence.
Implications for Policy, Delivery or Practice:
Coordinated health benefits, including personcentered outpatient case management services, can
help individuals with behavioral health conditions
manage their chronic conditions through improved
medication utilization. Health providers should
consider providing increased support for medication
utilization for patients with behavioral health
conditions.
Funding Source(s): CMS
• Overview and Lessons on the Design and
Implementation of Early Intervention Programs
for Individuals with Potentially Disabling Mental
Health Conditions
Boyd Gilman, Ph.D.; Henry Ireys Ph.D.; Gilbert
Gimm, Ph.D.; Noelle Denny-Brown, M.P.A.; Sarah
Croake, M.P.P.
Presented by: Henry Ireys, Ph.D., Senior Fellow,
Mathematica Policy Research, Inc., 600 Maryland
Avenue, Suite 550, Washington, DC 20024-2512;
Phone: (202) 554-7536; Email:
hireys@mathematica-mpr.com
Research Objective: This presentation provides an
overview of the goals of the Demonstration to
Maintain Independence and Employment (DMIE),
describes the DMIE programs of participating states,
outlines the state and federal evaluation design, and
identifies lessons on design and implementation of
early intervention programs for individuals with
disabling mental health conditions.
Study Design: The DMIE evaluation has four
distinguishing design features. First, evaluations were
based on randomized assignment into two groups.
One group continued receiving existing services; the
other received the intervention plus existing services.
Second, states submitted a standardized collection of
survey data on participant characteristics. The
uniform data set (UDS) was gathered through
repeated interviews with participants at the time of
enrollment and at defined follow-up periods ranging
from 6 to 12 months. Third, the UDS was linked to
federal disability application and participation and
earnings data using person-level identifiers. Fourth,
each state conducted an independent state-level
evaluation. The materials developed by each
program, coupled with quantitative and qualitative
data assembled by Mathematica Policy Research,
yielded a uniquely rich and detailed documentation of
the implementation and impact of DMIE programs.
Population Studied: Although each state designed
its own intervention for different target populations,
several eligibility requirements were consistent
across all grantees. Participants must have been
between ages 18 and 64, working at least 40 hours
per month, and not rece
Principal Findings: The evaluation highlights five
findings regarding the design and implementation of
early intervention programs for individuals with
disabling mental health conditions. First, by
leveraging existing health programs, early
intervention initiatives can facilitate participant
recruitment, support development of provider
networks, and reduce supplemental state financing.
Second, person-centered case management is an
essential component of early intervention programs
for people with mental health conditions because it
helps participants address individual employment
barriers and obtain services needed to maintain
independence. Third, programs should target working
adults whose impairments place them at risk for
losing their jobs and who are likely to use the
supports available to help them stay employed.
Fourth, programs can enhance the use of early
intervention services by providing subsidies; large
subsidies, however, can undermine program goals.
Fifth, The evaluation highlights five findings regarding
the design and implementation of early intervention
programs for individuals with disabling mental health
conditions. First, by leveraging existing health
programs, early intervention initiatives can facilitate
participant recruitment, support development of
provider networks, and reduce supplemental state
financing. Second, person-centered case
management is an essential component of early
intervention programs for people with mental health
conditions because it helps participants address
individual employment barriers and obtain services
needed to maintain independence. Third, programs
should target working adults whose impairments
place them at risk for losing their jobs and who are
likely to use the supports available to help them stay
employed. Fourth, programs can enhance the use of
early intervention services by providing subsidies;
large subsidies, however, can undermine program
goals. Fifth, by working with public and private
partners, states can expand the scope of support
services and broaden the target population; however,
partnerships with the private sector can create unique
challenges.
Conclusions: DMIE gave states the flexibility to
implement programs designed to build upon existing
health care coverage and delivery systems and to
test innovative models tailored to the health and
employment needs of their targeted populations.
Implications for Policy, Delivery or Practice: DMIE
offers important lessons for other states, or the
federal government, considering implementing similar
programs designed to maintain employment and
promote independence for individuals diagnosed with
conditions, including mental health disorders, that put
them at risk of becoming disabled.
Funding Source(s): CMS
Payment and Physician Behavior
Chair: Robert Berenson, M.D.
Tuesday, June 29 * 9:45 a.m.-11:15 a.m.
Panel Overview: Physician payment drives behavior.
Current health reform legislation proposes changes
to physician payment as well as experimentation with
different payment methodologies to facilitate the
provision of high quality and low cost care. This panel
will discuss how changes in payment affect physician
behavior and the delivery of health services. The first
panelist will discuss the impact of MMA-mandated
changes in Medicare payment rates for
chemotherapy drugs, particularly with regard to
physician-induced demand, and examine whether
payment changes affect utilization. The second
panelist will analyze patterns of outpatient chronic
illness management costs for four conditions to
assess the viability of bundled payments for such
care at the primary care physician level. The third
panelist will discuss an evaluation of the
PROMETHEUS Payment® model, a conditionspecific bundled payment method comprising
allowances for routine treatment and preventable
complications. The panel will discuss how the
findings can inform future payment reforms and
experiments that incent physician behavior in order to
improve the value of health care.
• Reimbursement Policy and Cancer
Chemotherapy Treatment
Mireille Jacobson, Ph.D.; Craig Earle M.D., M.Sc.;
Mary Price, M.A.; Joseph Newhouse, Ph.D.
Presented by: Mireille Jacobson, Ph.D., Senior
Economist, , RAND Corporation, 1776 Main Street,
Santa Monica, CA 90407,; Phone: (301) 393-0411
ext. 7141; Email: mjacobso@rand.org
Research Objective: The Medicare Modernization
Act (MMA) mandated substantial reductions in
payment rates for outpatient chemotherapy drugs in
January 2005. Margins, which varied across agents
prior to the MMA, were capped at 6% above average
transaction prices for all drugs. The goal of this work
is to assess how these payment changes affected the
likelihood and setting of chemotherapy treatment for
Medicare beneficiaries with newly diagnosed lung
cancer, as well as the types of agents dispensed to
them.
Study Design: We analyzed Medicare claims for the
period 2002 through 2006 for all beneficiaries with at
least 1 lung cancer claim in an outpatient hospital
facility or a physician’s office between January 2003
and October 2005. We studied the probability of
chemotherapy treatment, treatment in a physician’s
office and type of agents dispensed within a month of
diagnosis, controlling for age, sex, race/ethnicity,
state, comorbid conditions and metastasis at
diagnosis.
Population Studied: The study sample consisted of
Medicare beneficiaries with newly diagnosed lung
cancer.
Principal Findings: We confirmed 222,478 new lung
cancer diagnoses. Approximately 17% of patients
received chemotherapy within 30 days of a lung
cancer diagnosis. The probability of receiving
chemotherapy increased by about 2 percentage
points (P<0.001) following the implementation of the
new payment regime. This increase came through
increased administration in physicians’ offices.
Conditional on chemotherapy treatment within 30
days, physicians were less likely to dispense
Paclitaxel, an agent that had been reimbursed at over
600% of acquisition cost and, to a lesser extent,
Carboplatin. Use of Docetaxel, a high priced agent,
increased modestly.
Conclusions: Physicians provided chemotherapy
treatment to a greater share of lung cancer patients
after the reduction in chemotherapy payment rates.
The type of agents administered to patients also
changed, with drugs whose margin fell the most used
less commonly after the payment reduction.
Implications for Policy, Delivery or Practice:
Contrary to concerns about access, the MMA actually
increased the share of lung cancer patients receiving
chemotherapy. The payment changes were also
associated with a shift towards more expensive
chemotherapy agents. Thus, while the MMA reduced
margins on cancer chemotherapy agents, it may not
have stemmed Medicare spending. Future work
should determine whether these results generalize to
other cancer sites as well as their implications for
Medicare spending and the health and wellbeing of
Medicare beneficiaries.
Funding Source(s): RWJF
• Primary Care Practitioner Practice Patterns in
Managing Chronic Illnesses: Implications for
Bundling Payment
Harold Luft, Ph.D.; Laura Eaton M.D., M.P.H.
Presented by: Harold Luft, Ph.D., Director, Health
Policy Research, Palo Alto Medical Foundation
Research Institute, 795 El Camino Real, Palo Alto,
CA 94301; Phone: (650) 853-4821; Email:
lufth@pamfri.org
Research Objective: Various policy initiatives
propose using bundled payments to encourage better
coordination of care and more appropriate use of
resources. Such bundling makes intuitive sense in
the management of specific chronic conditions,
especially if the relatively infrequent, but very
expensive costs associated with inpatient care can
be separated from the ongoing chronic illness
management (CIM). A bundled payment would allow
primary care practitioners (PCPs) flexibility in
allocating resources and offer incentives to be
efficient. Such an approach will be of even greater
interest if some PCPs seem to have consistently
higher (or lower) costs for comparable patients. This
study examines patterns of CIM costs (outpatient
services only) for patients with congestive heart
failure (CHF), diabetes, hypertension and
hyperlipidemia.
Study Design: Retrospective observational design.
Population Studied: All patients seen at the Palo
Alto Medical Foundation (PAMF) during the years
2005-2008 with one or more of the target conditions.
Symmetry software from Ingenix was used generate
episodes based on billing data. Services provided
during inpatient stays
Principal Findings: Although patients of all ages
were eligible, too few PCPs have enough patients
with CHF to make physician-specific episode based
payment reasonable for this condition. For patients
with diabetes, hypertension, or hyperlipedemia,
however, the numbers appear sufficient. The
exclusion of inpatient-based services markedly
reduced the coefficient of variation. A larger-thanexpected-by-chance proportion of PCPs appear to be
outliers (high or low) in terms of the costs of their
patients. The consistency in such outlier patterns
across years is also much greater than would be
expected by chance, suggesting opportunities to
learn whether there are clinical or other factors
explaining consistent differences in practice patterns.
Conclusions: Removing inpatient stays from chronic
illness episodes markedly reduces variability and
allows the assessment of the costs of managing
chronic illnesses at the level of PCPs. Some primary
care physicians differ significantly, and consistently,
from their colleagues in the costs incurred for
managing common chronic conditions.
Implications for Policy, Delivery or Practice:
Observing these differences may lead to fruitful
discussions among clinicians about the most effective
ways to manage their patients. Monthly payments for
chronic illness management, particularly if
aggregated across multiple primary care practitioners
working together, or if partially backstopped by
reinsurance, can provide better incentives for the
effective coordination of care.
Funding Source(s): RWJF
• Implications of Bundled Payment: The
PROMETHEUS Payment Model
Meredith Rosenthal, Ph.D.; Zhonghe Li, M.S.
Presented by: Meredith Rosenthal, Ph.D.,
Associate Professor of Health Economics and Policy,
Health Policy and Management, Harvard School of
Public Health, 677 Huntington Avenue, Boston, MA
02115; Phone: (617) 432-3418; Email:
meredith_rosenthal@harvard.edu
Research Objective: PROMETHEUS Payment, a
condition-specific bundled payment model with two
components: (1) a “typical” budget for routine and
recommended services and (2) an allowance for
preventable complications (labeled “potentially
avoidable costs”). PROMETHEUS Payment is being
piloted in several markets around the country. The
objectives of this study were to ascertain: (1) how
PROMETHEUS would change payment flows to
individual providers, (2) how much would be paid out
as a warranty for potentially avoidable costs, and (3)
the association between performance relative to
PROMETHEUS Payment benchmarks and quality of
care.
Study Design: Cross-sectional analysis of episodes
of diabetes mellitus (DM) care using paid claims data.
Population Studied: Providers reimbursed by the
Employer Coalition on Health in Rockford IL and their
patients.
Principal Findings: There were 2,209 episodes of
DM in the Employer Coalition on Health population.
The mean spending for care that corresponds to the
“typical” component of the bundled payment was
$2,894 (SD $4,371). The mean potentially avoidable
cost figure was $2,170 (SD $15,048). Thus, 43% of
payments under fee for service correspond to
potentially avoidable costs. Under the proposed
payment model, the most substantial change in
funding would relate to the warranty, which allows
providers to profit from reducing potentially avoidable
costs below a benchmark set equal to 50% of the
average. Providers with higher performance on
HEDIS-like quality of care measures appear likely to
benefit most from such shared savings. For example,
compliance with HbA1c testing recommendations
was associated with lower potentially avoidable costs
($3,132 vs. $1,889, p=0.09).
Conclusions: Examination of PROMETHEUS
Payment bundled payment rates for DM, including
potentially avoidable costs, suggests that a large
percentage of fee for service payments are to treat
adverse consequences of the condition rather than
recommended and routine maintenance care.
Moreover, these costs are associated negatively with
standard HEDIS-like measures of quality, suggesting
that they may be reduced through evidence-based
care processes. Applying PROMETHEUS Payment
rather than fee for service would result in substantial
redistribution across providers.
Implications for Policy, Delivery or Practice:
Implementation of PROMETHEUS Payment and
potentially other bundled payment models will alter
provider incentives by setting prospective targets for
all costs of care for a specific condition. Depending
upon how providers respond to these incentives (e.g.,
through changing practice patterns), there may be
substantial redistribution across providers, with highquality providers likely to see higher margins through
the explicit warranty against potentially avoidable
costs.
Funding Source(s): RWJF
Whither Cost-Effectiveness in the New
Comparative Effectiveness Research Landscape?
Chair: Steven Pearson, M.D., M.Sc.
Tuesday, June 29 * 9:45 a.m.-11:15 a.m.
Panelists: Lewis Sandy, UnitedHealth Group;
Hemal Shah, Boehringer Ingelheim Pharmaceuticals,
Inc.; Jean Slutsky, Agency for Healthcare Research
and Quality
Panel Overview: The potential role that
considerations of cost-effectiveness might play within
a new federal comparative effectiveness research
initiative has been a question that has provoked
sharp controversy all along the line, from the ARRA
economic stimulus bill to the health care reform
legislation now nearing its final dénouement on
Capitol Hill. Over the past year, nuanced legislative
language and testimony before Congress by AHRQ,
NIH, and Obama administration officials have left
uncertainty in their wake. Although it has been clear
that considerations of cost-effectiveness were not to
be core elements of the comparative effectiveness
research enterprise, whether cost-effectiveness might
have some kind of role at the margins, or in the
future, or in some other complementary initiative such
as an “Independent Medicare Advisory Committee”
has been open to widely differing interpretations.
Within the next several weeks, it now seems likely
that the final form of health care reform legislation will
be finalized and signed into law, and with it will come
a new clarity regarding the future landscape for
federal comparative effectiveness research. Once
that picture has emerged, cost-effectiveness may be
perceived as largely “in” or “out”; but the first months
following the passage (or non-passage) of health
care reform will serve as a critical time during which
the future prospects for cost-effectiveness in the new
comparative effectiveness research landscape will be
hotly debated.
This panel will bring together leading figures
involved in comparative effectiveness research policy
among researchers, health insurers, manufacturers,
and the federal government. Each panelist will
describe their view, and seek to generalize the view
of their fellow stakeholders, on the prospects for costeffectiveness as it relates to comparative
effectiveness research efforts in the United States.
For example, each panelist will comment on: 1) their
impression of what the final form of health care
reform legislation “means” for the role of costeffectiveness; 2) given the existing legislation, what
key questions remain to be answered, whether
through regulations or other means; 3) what the ideal
role of cost-effectiveness research should be,
including their opinion of who should perform it, what
efforts can best advance the methods of the
underlying science, and whether or not costeffectiveness information should ultimately be used in
policy and practice in some way in conjunction with
comparative clinical effectiveness research.
Attendees will come away from the panel with a
chance to hear broad and most likely contrasting
opinions from leading figures in the field on the future
of cost-effectiveness in relation to comparative
effectiveness research. These perspectives will help
inform both research and policy agenda during the
critical early months of the post-health care reform
period.
Incidence and Equity in Health Care Financing
Chair: Patricia Ketsche, Ph.D., M.B.A., M.H.A.
Tuesday, June 29 * 11:30 a.m.–1:00 p.m.
Panel Overview: National health expenditures (2.2
trillion dollars and16 percent of GDP in 2007) are
expected to double by 2018 reaching 25 percent of
GDP by 2025. Although a large portion of funds flow
into the system through employers and government,
ultimately individuals and families bear the final
burden, or incidence, of all health care spending
through taxes, reduced earnings on capital or labor
and direct out of pocket payments and premiums.
This panel will provide evidence from two
different studies on the incidence of financing
national health expenditures, compare the results
from these studies, which used different data sets
and somewhat different tax incidence assumptions,
with each other and with historical incidence studies.
This comparison will be done largely on the basis of
the degree of equity in the incidence of payments
made by families of differing income levels where
families are arrayed by quintiles The panel will then
consider the ensuing policy implications related to the
equity, or fairness, of this financing under our current
as well as alternative financing structures.
Our mixed financing system uses public tax
revenues to fund large programs such as Medicare
and Medicaid as well as smaller programs such as
veterans’ health care. The combination of federal,
state, and local financing sources for public
expenditures implies a need for extensive detail on
spending and revenue sources at each level of
government in order to estimate their incidence.
Private payments fund out-of-pocket health care
spending and privately purchased health insurance.
Theory dictates that employer-provided health
insurance payments are incident on labor as part of
total compensation. The tax treatment of employer
provided health insurance, however, shifts some of
the incidence for employer sponsored coverage back
to the public sector and thereby blurs the distinction
between public and private funding in the system.
Thus, a comprehensive analysis of incidence must
focus on both public and private spending together.
The first panelist will focus on estimations of
public sector financing, addressing the degree of
progressivity, or vertical equity, of tax financed health
care spending across family income quintiles. This
panelist will consider the federal versus the states’
tax structures and the effect of intergovernmental
transfers, especially the FMAP for the Medicaid and
CHIP programs. This panelist will also present results
by groups of states that vary on regressivity of tax
structure, extent of insurance expansion and the
FMAP. The state detail incorporated into the work
presented by panelist one permits discussion of the
implications of different state tax structures and
different levels of state public spending on both
vertical and horizontal equity.
The second panelist will present results from
the same data set and set of analyses but will focus
on the incidence of private payments for health care
and the intersection between public and private
funding resulting from the tax preference for
employer-sponsored insurance. Specifically, the
incidence of the benefit of the tax expenditure will be
compared to the incidence of its financing. This
panelist will provide estimates of the incidence of out
of pocket spending by families and discuss the
implications of including out of pocket payments from
institutionalized populations. This panelist will build
upon the presentation by panelist one by showing the
overall incidence of the system when public and
private payments are considered together and will
use indices of equity [Gini, Kakwani] to show how
current incidence measures compare to those from
historical analysis of the US health care system.
These results will be presented by major sources of
public and private revenue to highlight those which
add progressivity to the overall system.
The third panelist will present estimates of
the overall incidence of financing health care
spending using a different data base and somewhat
different tax incidence assumptions. This panelist will
present both public and private incidence estimates
for comparison with results from panelists one and
two. The data set utilized by panelist three is
sufficiently detailed at the household level to allow for
a thorough discussion of the implications of health
status and utilization on the horizontal equity inherent
in the incidence patterns.
Two discussants will first critique the
estimates of the incidence of public and private
sector payments provided by these researchers.
These discussants will then discuss implications of
the distribution of health care financing on models of
public choice, potential changes in the distribution
under health care reform and its impact on families.
Discussants were identified based on expertise in
public and private health care financing systems and
a detailed understanding of the variation in public
programs and spending levels across the fifty states.
• Incidence and Equity in Health Care Financing
Public Expenditures
E. Kathleen Adams, Ph.D., M.S.; Patricia Ketsche
Ph.D.; Sally Wallace, Ph.D.; Viji Kanaan, M.P.H.;
Harini Kanaan, Ph.D.
Presented by: E. Kathleen Adams, Ph.D., M.S.,
Professor, Rollins School of Public Health, Emory
University, 1518 Clifton Road, N.E., Atlanta, GA
30322; Phone: (404) 121-9370; Email:
eadam01@sph.emory.edu
Research Objective: The financing of over $2 trillion
of health care spending comes from a combination of
private and public revenues ultimately paid by
individuals/families through out of pocket payments,
direct purchase of insurance or foregone wages and
tax payments to federal, state or local governments.
Our objective is to apply conventional theory on
taxation to identify the incidence of health care
spending in the public sector by tax type and by
family income in 2004.
Study Design: We used data from the 2004 and
2005 Current Population Survey (family
characteristics/income), the 2004 Census of
Government (federal, state and local tax composition)
and data on government funded health care (National
Health Accounts, National Association of State
Budget Officers (NASBO) to estimate publicly funded
health care spending supported by each type of tax.
We distributed spending by tax type back to families
based on their ‘shares’ of the total tax base. For
example, health care spending supported by general
sales taxes were distributed based on the family’s
share of total taxed consumption. Adjustments were
made for tax exporting internationally and
domestically. The TAXSIM model was used to
estimate total federal and state income taxes paid
and health care spending supported by these taxes
distributed to families based on their ‘share’ of total
income taxes paid. We use a partial equilibrium
approach that does not account for deficit spending
and we define income broadly to include cash
equivalents.
Population Studied: All 174,031 families (weighted
n = 129 million) in the pooled 2004 and 2005 CPS
data.
Principal Findings: Taxes to support publicly funded
health care absorbs over 9 percent of family income
(broadly defined). Federal financing imposes the
heaviest burden at almost 7 percent while state/local
tax revenues equal just over 2 percent. The incidence
of federal financing is progressive throughout, rising
from 3.3 percent of income in the lowest quintile to
over 9 percent in the highest. In contrast, the pattern
for state funding is mildly regressive, moving from 3
percent to 2 percent across these income groups.
Medicare accounts for around 2.7 percent of family
income and exhibits a progressive financing
incidence. In contrast to a regressive pattern for total
state-supported health care, the Medicaid program,
by using a combination of federal and state tax
revenues, also follows a progressive incidence.
Conclusions: Only tax sources used at the federal
level introduce a progressive element into public
health care financing. The lack of a cap on the payroll
tax base used for Medicare plays a role in this
pattern. The influx of federal tax dollars to help
finance Medicaid, and at a higher rate in poorer
states, plays an important role in not only moderating
the otherwise regressive pattern of state taxes, but
actually reversing it.
Implications for Policy, Delivery or Practice: To
the extent vertical equity is a goal for the financing of
the public sector, maintaining or increasing the share
paid by federal taxes is necessary. It will be important
to consider the level and structure of federal
matching rates should Medicaid expansion be used
as the cornerstone of expanding health insurance.
Funding Source(s): RWJF
• Incidence and Equity in Health Care Financing:
Private Expenditures
Patricia Ketsche, Ph.D., M.B.A., M.H.A.; E.Kathleen
Adams Ph.D.; Sally Wallace, Ph.D.; Viji Kanaan,
M.P.H.; Harinia Kanaan, Ph.D.
Presented by: Patricia Ketsche, Ph.D., M.B.A.,
M.H.A., Associate Professor, Institute of Health
Administration and Georgia Health Policy Center,
Georgia State University, PO Box 3988, Atlanta, GA
30302-3988; Phone: (404) 413-7635; Email:
pketsche@gsu.edu
Research Objective: To estimate the final incidence
of health care spending made through direct (out of
pocket) and private premiums, net of the tax
exclusion of employer-based benefits, as part of a
study of the overall incidence of national health
expenditures.
Study Design: Current Population Survey (CPS)
data for calendar years 2004 and 2005 are used to
create a micro-simulation model representative of US
families. We use MEPS-HC data to generate a model
to predict out-of-pocket payments for health care
services, first estimating the probability of any
expenditure and then the level conditional on any
expenditure. The model controls for demographics,
income, work status, location (state and urban/rural
status), coverage type and health status. Because of
the large out-of-pocket spending made by
institutionalized populations (not in CPS and MEPSHC) we utilize the Medicare Current Beneficiary
Survey (MCBS) to supplement our modeling. We
assume employment based coverage is incident on
workers’ wages unadjusted for age, gender, and
health status. We utilize the data from MEPS-IC,
National Council of State Legislators (NCSL), Federal
Employee Health Benefit Plan (FEHBP), and KaiserHRET to estimate premiums by state, industry, firm
size, and family tier to match to CPS families. We use
the estimate of employer contributions for these
premiums (from CPS) to adjust imputed premiums by
workers’ wages. We use data from America’s Health
Insurance Plans (AHIP) and GAO to impute
premiums for non-group individual and family
coverage and Medigap. We include imputed
Medicare Part B premiums and state specific CHIP
premiums as appropriate. We adjust employment
based premiums for the tax exclusion and distribute
the incidence of financing this tax expenditure
proportionally across federal payroll, and federal and
state (with income taxes) general revenue sources.
Population Studied: All 174,031 families (weighted
n = 129 million) in the pooled 2004 and 2005 CPS
data.
Principal Findings: Total private spending for health
care consumes over 6 percent of family income
(broadly defined). All private spending is highly
regressive, reflecting almost 12 percent of income for
those in the lowest income quintile and even more
when payments from institutionalized patients are
included. Families in the highest income group, in
contrast, pay under 4 percent of income in private
health care spending and very little for out of pocket
costs. The tax preference for group health insurance
is, on net, a middle class benefit once the incidence
of financing the tax expenditure is considered.
When considering public and private together, the
system has become slightly less regressive than prior
estimates using data from the 1980s.
Conclusions: Financing the private portion of the US
health care system represents a significant
expenditure and one that is inversely related to
income. The private financing of US health care is not
consistent with vertical equity although it appears the
US system has improved since the 1980s.
Implications for Policy, Delivery or Practice:
Vertical equity assessments that span all funding
sources for the system (private premiums, out of
pocket payments, state taxes and federal/payroll
taxes) can provide policy guidance for financing
reform.
Funding Source(s): RWJF
• Equity in the Finance and Delivery of Health
Care in the United States
Thomas Selden, Ph.D.
Presented by: Thomas Selden, Ph.D., Center for
Financing, Access and Cost Trends, Agency for
Healthcare Research and Quality, 540 Gaither Road,
Rockville, MD 20850; Phone: (301) 427-1406;
Email: Thomas.Selden@ahrq.hhs.gov
Research Objective: No systematic study of U.S.
equity in the finance and delivery of healthcare has
been conducted since the analysis of 1987 data in
Wagstaff et al. (Journal of Health Economics, 1999).
This gap in the literature is particularly remarkable
given that the U.S. has a complex system for
financing and delivering healthcare, combining an
array of public and private components. The objective
of this paper is to fill this gap.
Study Design: The proposed paper applies the
methodology of Wagstaff et al. to more recent data
from the Medical Expenditure Panel Survey. The data
have been aligned to the National Medical
Expenditure Accounts, and a full array of tax
expenditures has been simulated. The analysis will
report sources of financing by deciles of equivalent
income along with Kakwani concentration indices,
thereby facilitating international comparisons. The
analysis will also present results regarding equity in
the delivery of healthcare, both for measures of
access and for all medical care received (valued
using both total expenditures and total charges). The
paper also breaks new methodological ground by
proposing a nonparametric method for standardizing
differences in need across deciles.
Principal Findings: The overall incidence of U.S.
health care finance is regressive, but the degree of
regressivity appears to have declined over time as a
larger percentage of health care is financed through
taxes. Despite this reduction in regressivity, the
overall growth in health care spending has resulted in
large average burdens among low-income
households.
Conclusions: The United States is currently
considering a wide-reaching set of health system
reforms, motivated by concerns about growing
uninsurance rates, rising out-of-pocket burdens,
increasing premiums for coverage, and sharply rising
government budgets for Medicare, Medicaid, and
other public programs. Understanding the overall
incidence of health care finance and delivery can
offer a valuable perspective on this undertaking.
Funding Source(s): AHRQ
Informing Medicare Policy Through Health
Services Research: Employing National SurveyMedicare Claims Linked Data
Chair: Jason Hockenberry, Ph.D.
Tuesday, June 29 * 11:30 a.m.–1:00 p.m.
Panel Overview: Research in the area of health
services has and continues to have the opportunity to
inform Medicare policy through observational studies.
The ability to link national survey data (i.e. the Health
and Retirement Study, National Health Interview
Survey) to the Medicare claims of the respondents
has proven invaluable in providing more complete
insight into policy issues, but the data are arguably
underutilized. This panel highlights the usefulness of
these linked data with four studies that use them to
address pressing health services questions with
implications for Medicare policy.
The first study analyzes Medicare
beneficiaries use of health services by insurance
status prior to becoming Medicare eligible and
provides evidence that the previously uninsured do
have different use patterns. The second study
addresses the issue of re-hospitalization and
suggests the timing of what could be considered
potentially avoidable re-hospitalization may occur in a
shorter window than currently being discussed for
policy setting purposes, as well as identifying
significant predictors of re-hospitalization that claims
data would not capture. The third study examines
older adult use of the emergency department (ED)
and reveals that a large percentage of ED use by
older adults is for non-emergent conditions. The
fourth study examines end-of-life utilization patterns
by individuals’ cognitive impairment status and finds
no systematic differences in utilization in the last six
months of life between those who are impaired and
those who are not. Each panelist will discuss the
implications their findings have for Medicare-relevant
policy, which are all particularly salient to primary
care.
• Health Service Use among the Previously
Uninsured:
Sandra Decker, Ph.D.; Jalpa Doshi M.S., Ph.D.; Amy
Knaup, M.A.; Daniel Polsky, M.P.P., Ph.D.
Presented by: Sandra Decker, Ph.D., Senior
Service Fellow, National Center for Health Statistics,
3311 Toledo Road (Room 3316), Hyattsville, MD
20782; Phone: (301) 458-4748; Email:
esp4@cdc.gov
Research Objective: Medicare eligibility at age 65
results in an abrupt decline in the probability of being
uninsured in the U.S. Although past research
suggests that the previously uninsured increase their
use of health services when reaching age 65, this
increase does not mean that they then use health
services after age 65 to the same extent and in the
same way compared to individuals who were
previously insured. Difficulty in changing habits or
differences in characteristics of previously uninsured
compared to insured individuals may result in
continued different use of the health care system.
This study analyzes the use of health services after
age 65 for the previously uninsured compared to the
previously insured.
Study Design: We use Medicare claims data to
analyze the use of health services and data on
previous insurance status from data from two
different linked surveys – the Health and Retirement
Survey (HRS) and the National Health Interview
Survey (NHIS). In addition to Medicare expenditures,
we examine several measures of the use of health
services after the age of 65, including the number of
hospitalizations and physician visits. We analyze the
effect of pre-65 insurance status and control
variables on the use of health services using a
generalized linear model and log link and, for
Medicare expenditures, a gamma distribution, and for
counts of physician visits and hospital stays, a
negative binomial distribution.
Population Studied: We use data on privately
insured or uninsured primary respondents and
spouses from the HRS who turned 65 by December
31, 2004, matched to Medicare records for 19932005. Companion analyses were undertaken using
data from individuals aged 59-64 from the
Principal Findings: We find that Medicare
expenditures and the number of hospital stays
beginning at age 65 are similar among the previously
uninsured compared to the previously insured.
However, the previously uninsured have 20% fewer
physician visits after turning 65 compared to the
previously privately insured. The previously
uninsured have fewer visits to office-based
physicians and more visits to hospital outpatient
departments. Results from the HRS indicate that the
lower number of physician visits among the
previously uninsured cannot be explained by
differences in supplementary insurance coverage.
Conclusions: Although the previously uninsured
change their use of health services at age 65, we find
that those uninsured prior to age 65 appear to
continue to use the health care system differently
from those who were privately insured.
Implications for Policy, Delivery or Practice: A key
question for the future may be why the previously
uninsured appear to continue to use the health care
system differently from the previously insured after
the age of 65. Other policies that facilitate access to
physician services among the previously uninsured
may be necessary to substantially alter their use of
health care.
Funding Source(s): CDC
• The Effects of Prior Hospitalizations on
Subsequent Hospitalizations for Hip Fractures,
Strokes, or Heart Attacks in Older Medicare
Beneficiaries
Fredric Wolinsky, Ph.D.; Suzanne Bentler M.S.;
Michael Jones, Ph.D.; Jason Hockenberry, Ph.D.;
Brian Kaskie, Ph.D.; Robert Wallace, M.D., M.S.
Presented by: Fredric Wolinsky, Ph.D., Professor,
Dept of Health Management and Policy, University of
Iowa College of Public Health, 200 Hawkins Drive E
205GH, Iowa City, IA 52242; Phone: (319) 384-5129;
Email: fredric-wolinsky@uiowa.edu
Research Objective: The main objective is to
investigate the effects of prior hospitalization on
subsequent hospitalization. In addition we sought to
analyze the predictors of rehospitalization for these
three acute conditions.
Study Design: we calculated the “gap time” between
the index hospitalization nearest in time to the
targeted subsequent hospital admission for hip
fracture, stroke, or heart attack. We then constructed
a time-dependent covariate that was switched “on”
the day after the index hospitalization to the
subsequent hospital admission for hip fracture,
stroke, or heart attack. Sensitivity analyses were then
performed to calibrate the “gap time” during which the
peak effect of the index hospitalization on the
subsequent hospitalization occurred. We conducted
separate analyses for hip fracture, stroke, or heart
attack, each of which involved on their first steps a
validated condition-specific risk factor model. The
time-dependent prior hospitalization marker was
added on the next step of the proportional hazards
models with competing risks for entry into managed
Medicare plans or death, whichever came first.
Population Studied: We used the baseline data on
5,511 participants in the nationally representative
Survey on Assets and Health Dynamics among the
Oldest Old AHEAD linked to their Medicare 1991 to
2005 claims.
Principal Findings: we found that the gap times at
which the peak effects of the prior hospitalization
were observed were 14 days when predicting hip
fracture, 7 days when predicting stroke by sensitivity
maximization, 14 days when predicting stroke by
specificity maximization and 7-days when predicting
heart attacks. The estimated hazard ratios were 2.51,
5.36, 5.8 and 10.24 respectively. Predictors of
rehospitalization varied for each of the conditions.
Conclusions: Patients hospitalized for these acute
conditions are at high risk of rehospitalization,
particularly within the first two weeks post-discharge.
Implications for Policy, Delivery or Practice:
Based on these results, and consistent with
MedPAC’s view that most re-hospitalizations during
the first two weeks post-index-discharge are
“potentially avoidable,” we recommend a Medicare
demonstration project to provide additional
reimbursement incentives to both the hospital and
community physicians of record. The hospital
physician would have to provide, both verbally and in
writing (manual or electronic), an appropriately
detailed accounting of the hospital episode and
subsequent treatment recommendations directly to
the primary care physician. The community physician
would have to actually see the patient in the office
and generate appropriate evaluation and
management (E&M) codes at least once during the
first two post-discharge weeks.
Funding Source(s): NIA
• Who's at My Door? Older Adults Who Come to
the Emergency Department with Non-Emergent
Conditions
Brian Kaskie, Ph.D.; Maksym Obrizan M.A.; Suzanne
Bentler, M.S.; Michael Jones, Ph.D.; Gary Rosenthal,
M.D.; Frederic Wolinsky, Ph.D.
Presented by: Brian Kaskie, Ph.D., Associate
Professor, Department of Health Management and
Policy, University of Iowa College of Public Health,
200 Hawkins Drive E230GH, Iowa City, IA 52242;
Phone: (319) 384-5134; Email: briankaskie@uiowa.edu
Research Objective: Emergency department (ED)
use has increased substantially, and in 2006, the
IOM reported ED overcrowding was a primary public
health problem. Older adults figure prominently in the
ED crisis. In this study, we characterized older adults
who used the ED as one of three types: (a) persons
who were likely to present to the ED with a severe
condition, (b) persons likely to present with a nonsevere condition, and (c) persons likely to present
with indeterminate levels of severity. We then
examined group differences using 25 variables
representing six common factors employed in health
services research.
Study Design: We created episodes of ED care
pertaining to each individual as they may have
occurred over the 15 year observation period, and
measured the severity of each episode with a
modified-NYU algorithm. Individuals’ ED use was
characterized by determining if 50% or more of the
total number of episodes were high severity, low
severity, or indeterminate severity (e.g., 4 ED
episodes with 2 of 4 defined as high severity resulted
in categorization as someone typically presenting
with severe conditions). Once individuals were
categorized, categorical group differences were
tested using multinomial multiple logistic regression
models including baseline AHEAD interview data as
well as measures reflecting the total number of ED
episodes, continuity of care, change in self-rated
health, and the number of years in the observation
study.
Population Studied: We linked baseline data for
5,511 self-respondents from the Survey on Assets
and Health Dynamics among the Oldest Old to their
Medicare claims for 1991-2005.
Principal Findings: ED use patterns for 3,006 of the
5,511 (54.5%) individuals could be classified--549 of
these individuals were typically presented to the ED
with severe conditions, 1,289 typically presented with
non-severe conditions, and 1,168 typically were
indeterminate. We could not classify ED patterns for
21.5 percent of the sample and 24.0 percent made
no visits to the ED. Multinomial multiple logistic
regression analysis indicated that persons who
currently smoked, displayed poor memory, had a
history of diabetes, and heart disease were more
likely to present to the ED with high levels of clinical
severity relative to persons with low levels of severity.
In contrast, persons with high severity were less likely
to use the ED six or more times during the
observation period and live in a geographic area in
which the population was less than 20,000.
Conclusions: Nearly half of all individuals whose ED
service use could be categorized were more likely to
present with non-severe conditions, and their use of
the ED did not appear to be tied to demographic or
clinical characteristics. In contrast, persons who were
likely present to the ED with severe conditions were a
comparatively small group and their use was
associated with clinical status.
Implications for Policy, Delivery or Practice:
These findings suggest that ED overcrowding might
be alleviated by targeting interventions toward the
substantial number of older persons who typically
present with non-emergent conditions more often.
Funding Source(s): NIA
• Cognitive Impairment and End-of-Life Treatment
Intensity
Lauren Hersch Nicholas, Ph.D.; Theodore Iwashyna
M.D., Ph.D.; Ken Langa, M.D., Ph.D.; David Weir,
Ph.D.
Presented by: Lauren Hersch Nicholas, Ph.D.,
Research Investigator and Post Doctoral Fellow,
Institute for Social Research, University of Michigan,
426 Thompson Street, Room 3005, Ann Arboer, MI
48104; Phone: (734) 764-2562; Email:
lnichola@umich.edu
Research Objective: We compare end of life
hospital care amongst cognitively impaired seniors to
decedents without cognitive impairment.
Study Design: We use survey data from the Health
and Retirement Study linked to administrative
Medicare claims data representing hospitalizations in
the last six months of life. Cognitive status is
assessed through cognitive testing administered as
part of the survey. We use data reported in the
interview wave prior to the end of life period. We
study receipt of several validated measures of end-
of-life treatment intensity: whether a patient received
intubation, tracheostomy, gastrostomy tubes,
hemodialysis, enteral or parenteral nutrition or CPR.
Logistic regressions of treatment intensity on
cognitive status and demographic characteristics are
estimated. Additional analyses will include
administrative and self-reported health status and
prior utilization as well as econometric corrections for
possessing an advance directive, living will or durable
power of attorney for health care.
Population Studied: 2,265 Medicare beneficiaries
who are hospitalized at least once in the last six
months of life between 1998 and 2005. 41 percent of
the sample is unimpaired, 29 percent is borderline
impaired and 30 percent is cognitively impaired. The
sample is 53% fem
Principal Findings: The majority, 59 percent, of
decedents exhibit some degree of cognitive
impairment in the interview prior to the six month end
of life period. Decedents with any cognitive
impairment were just as likely to receive high
intensity interventions as the unimpaired. Findings
are similar for borderline and full cognitive impairment
and when measures of treatment intensity are
considered separately.
Conclusions: Although cognitive impairment may
hinder patients’ abilities to assess treatment options
at the end-of-life, there is no difference in hospital
treatment intensity for the cognitively impaired.
Implications for Policy, Delivery or Practice:
Further study of the appropriateness of end-of-life
interventions is warranted. Given trends in cognitive
function near the end-of-life, discussion of patient
treatment preferences well before hospitalization
should be encouraged.
Funding Source(s): NIA
Health Reform and Delivery System Organization
Chair: Kelly Devers, Ph.D.
Tuesday, June 29 * 11:30 a.m.-1:00 p.m.
Panel Overview: Health reform legislation calls for
delivery system reforms that promote coordinated,
accountable, high quality and low cost care.
Mechanisms for promoting such care include
accountable care organizations (ACOs), medical
homes, and payment for the coordination of care.
This panel will discuss delivery system strategies
designed to engage providers and provider groups to
achieve low cost, high quality care. The first panelist
will discuss a new methodology based on “network
analysis theory” to help identify health care providers
who share a common patient population and that
together could serve as an accountable care team.
The second panelist will examine the influence of
organizational characteristics of medical practices on
resource use and quality of care measures. The final
panelist will discuss the key patient, physician,
practice, and market characteristics associated with
treating high cost Medicare beneficiaries and whether
greater spending translates into better health
outcomes. The panelists will discuss the attributes
that facilitate high quality, low cost care and how the
findings can inform efforts to reform the delivery
system.
• Identifying Accountable Primary Care Groups
and Accountable Primary Care Systems
Douglas Wholey, Ph.D.; David Knutson M.S.;
Jaideep Srivastava, Ph.D.
Presented by: Douglas Wholey, Ph.D., Professor,
Division of Health Policy and Management, University
of Minnesota, 420 Delaware Street SE, MMC 729,
Minneapolis, MN 55455; Phone: (612) 626-4682;
Email: whole001@umn.edu
Research Objective: To create and test a
methodology to identify “accountable primary care
groups” (APCGs) of 4 to 8 primary care physicians;
identify “accountable primary care systems” (APSCs)
of 10 to 15 APCGs; and compare patient attribution
algorithms across individual providers, APCGs, and
APSCs.
Study Design: We conducted analyses of Medicaid
claims data, applying association mining methods to
the relationship of beneficiaries to providers to
identify APCGs and APCSs. Algorithms such as FOG
detection and similar methods were used to identify
APCGs – a set of primary care providers who share
common patients. This approach follows network
analysis theory in which a claims dataset can be
viewed as a two-mode network where vertices in one
mode are patients and vertices in the other mode are
providers. APCGs are then grouped into APCSs on
the basis of the primary hospital used by APCGs.
Conceptually, APCGs are clinics nested into APCSs,
care systems associated with a particular hospital.
Population Studied: The study population was
approximately 70,000 Medicaid (non-dually eligible)
FFS disabled beneficiaries in the state of Minnesota
in 2006 and 2007.
Principal Findings: We have identified 8,891
primary care providers serving this population. Our
findings describe how these providers are grouped
into APCGs based on shared patient service, and
how APCGs are grouped into 140 hospital-affiliated
APCSs. The distribution of APCGs and APCSs in
Minnesota and comparison of patient attribution is
described.
Conclusions: In contrast to alternative
methodologies for identifying ACOs, which identify
large groups of providers organized around hospitals,
the new methodology identifies ACOs (APCSs)
consisting of clinics (APCGs) based first on primary
care utilization patterns and second on hospital
utilization patterns. Organizational research suggests
that ACOs identified in this manner are more easily
organized through incentives than ACOs identified by
alternative methodologies.
Implications for Policy, Delivery or Practice:
Identifying and developing accountable care groups
is a central problem for implementing new incentive
structures in Medicare and Medicaid that focus on
value-based purchasing. APCGs and APCSs
identified through the methods developed in this
study could be stimulated through incentives in valuebased purchasing to form organized relationships
(e.g., medical homes or ACOs) to more effectively
serve their patient population. Because the
methodology for identifying APCGs and APCSs use
basic claims data, they can be used by any
organizations, such as payers or health plans, who
have claims data to support value-based purchasing
and the development of medical homes and ACOs.
Funding Source(s): RWJF, Center for Care
Organization Research & Development (CCORD)
• The Characteristics of Best Medical Practices
John Kralewski, Ph.D.; Bryan Dowd Ph.D.; David
Knutson, M.S.
Presented by: John Kralewski, Ph.D., Professor,
Division of Health Policy and Management, University
of Minnesota, 420 Delaware Street SE, MMC 729,
Minneapolis, MN 55455; Phone: (612) 624-2912;
Email: krale001@umn.edu
Research Objective: This project was designed to
identify the organizational characteristics of medical
group practices that provide high quality care at low
costs, i.e., best medical group practices.
Study Design: This study analyzed the influence of
medical group practice structural and cultural
characteristics on the use of resources to care for
risk-adjusted patient populations and on nine quality
of care measures for those patients. Cost and quality
data were obtained from claims for services and
practice characteristics were obtained from a survey
of the practices. Resource use per member per year
(PMPY) was calculated by identifying services
provided for the patients cared for by each practice
and then assigning those services standardized
prices. Structural variables included practice size,
specialty mix, ownership, and productivity data.
Population Studied: Sixty upper Midwest medical
group practices with primary care components were
studied. Claims data for 1.3 million patients cared for
by these practices were obtained from a claims
management firm. Forty percent of the practices are
single specialty prima
Principal Findings: Both the structure and culture of
medical practices influence costs and quality, but
only about one-third of the low cost practices were
also in the high quality category. Moreover, the
quality scores vary considerably within practices; a
practice with high Diabetes scores may not have high
Cancer Screening scores. There was over a $1000
difference in the costs of care PMPY between the 15
highest cost and the 15 lowest cost practices. It
appears that much of this difference in costs results
from variances in the use of high cost technologies.
Medical group practices that are part of the integrated
delivery systems do not provide the lowest cost care
but they are somewhat more efficient in producing
units of services. It doesn’t appear that the costs of
producing units of services influence patient level
costs.
Conclusions: There is a great deal of variance in the
PMPY costs of care provided by different medical
group practices and quality of care is only weakly
related to those costs. Much of this variance is
explained by the structure, culture, and incentive
systems in the practices. Significant savings can be
achieved by encouraging enrollees in health
insurance plans to use best practices for their care
and practices can improve their performance by
attending to the practice characteristics identified by
this study. An important finding is that some low cost
practices are in the top quality of care tier.
Implications for Policy, Delivery or Practice:
Health insurance plans and self-insured employers
should identify best medical practices in their
communities and design incentive programs that
encourage enrollees to select those practices for
care. Accountable Health Care Organizations can
use the findings from this research to improve the
performance of their provider system.
Funding Source(s): RWJF
• Cost and Efficiency in Treating High-Cost
Medicare Beneficiaries: The Role of Physician,
Practice, and Health System Factors
Jim Reschovsky, Ph.D.; Jack Hadley Ph.D.; Cynthia
Saiontz-Martinez, Sc.M.; Ellyn Boukus, M.A.
Presented by: Jim Reschovsky, Ph.D., Senior
Health Researcher, , Center for Studying Health
System Change, 600 Maryland Avenue SW,
Washington, DC 20024; Phone: (202) 484-4233;
Email: jreschovsky@hschange.org
Research Objective: About 85% of Medicare
spending is on the most expensive 25% of
beneficiaries. This study assesses patient, physician,
practice, and market factors associated with the costs
of treating these “high cost” Medicare beneficiaries
and explores whether greater spending in this group
translates into better outcomes.
Study Design: We estimated models of annual total
standardized cost of treating high and, for
comparison, lower-cost Medicare beneficiaries,
investigating patient, physician, practice, and market
factors. Using IV estimation, we then assessed
whether higher costs result in better outcomes (lower
mortality and ambulatory sensitive hospitalization
rates). Linked data from Medicare claims, the 2004-
05 Community Tracking Study (CTS) Physician
Survey, CMS’s provider of services file, and other
secondary sources were used. To avoid selection
bias, we divided the sample into high and low cost
groups based on predicted costs using CMS’s HCC
model.
Population Studied: Elderly Medicare beneficiaries
in the traditional FFS program whose medical home
physician was located in nationally representative 60
CTS sites. Costs were calculated for CY 2006 or, for
2006 decedents, the last 12 months of life. The
analysis sample in
Principal Findings: Average annual costs were
$47,674 for predicted high-cost beneficiaries; $7,115
for predicted low-cost beneficiaries. Beneficiary
health characteristics were dominant predictors of
annual costs. Relatively few physician or practice
characteristics were significantly related to costs;
high-cost beneficiaries whose medical home
physicians were medical specialists or who indicated
inadequate time with patients during office hours had
significantly higher costs. At the market level,
provider supply per capita generally was not
important, but the percentage of physicians in
medical specialties, the percentage of supply in forprofit entities and measures of hospital concentration,
care fragmentation, and Medicare payment
generosity were associated with costs. Effects
estimated for low-cost beneficiaries often differed in
sign and relative magnitude. After controlling for
endogeneity bias, greater medical spending
significantly reduced the likelihood of a preventable
hospitalization for both high- and low-cost
beneficiaries. Effects on mortality were also negative
but statistically insignificant (biased observational
estimates were positive and significant).
Conclusions: Although we identified a number of
factors significantly associated with the cost of
treating high-cost Medicare patients, most are
market-level characteristics that would be difficult to
modify in the short term. Moreover, the magnitudes of
the effects are relatively small compared to average
patient medical spending. Reducing treatment costs
may also reduce the quality of care, at least as
measured by the likelihood of an avoidable
hospitalization.
Implications for Policy, Delivery or Practice: Our
findings suggest that it will be difficult to find silver
bullets that can reduce beneficiary costs without the
risk of reducing quality of care. Policymakers should
proceed cautiously before adopting proposals for
reducing Medicare costs without careful prior study of
the potential tradeoff between cost savings and
adverse health effects. More detailed research is
needed to identify cost-effective medical practices for
patients with complex or multiple health conditions.
Funding Source(s): RWJF
Prior Authorization Policies in Medicaid:
Implications for Mental Health and
Cardiovascular Disease Management
Chair: Stephen Soumerai, Sc.D.
Tuesday, June 29 * 11:30 a.m.–1:00 p.m.
Panel Overview: State Medicaid programs are
experiencing an unprecedented financial crisis. To
address the rising cost of health care in a time of
budget deficits, Medicaid programs are turning to
prior authorization before reimbursement of specific
drugs, step therapy requirements (that an
inexpensive drug be tried before an expensive one) ,
increased patient cost sharing and other mechanisms
to contain health care costs. Prescription drugs have
become a popular target for state Medicaid cost
containment programs. However, previous studies
have demonstrated that increased patient cost
sharing (e.g., caps on the number of reimbursable
medications) reduces the use of clinically essential
medications and actually increase total health care
costs, particularly among the chronically ill. Less is
known about the impact of prior authorization, step
therapy and other administrative cost-containment
strategies on chronic disease management.
Many Medicaid programs and Medicare Part
D plans have instituted prior authorization and/or step
therapy requirements for higher cost medications,
including mental health drugs and cardiovascular
agents. However, there is little previous evidence to
guide Medicaid administrators regarding whether
these policies are safe. For example, a key
assumption of prior authorization is that medications
within a class are relatively interchangeable. Yet,
there is considerable variation in the availability of
medications within a class and lack of comparative
effectiveness across medications may lead to less
optimal matching of patients with appropriate
treatment. Further, there are costs associated with
the administration of prior authorization programs and
failures in communication regarding these programs
may lead to disruptions in therapy, particularly for the
most vulnerable patients.
The objective of this panel is to summarize
new evidence from several rigorous longitudinal
evaluations of the impact of prior authorization and
step therapy in four Medicaid programs. These
studies focus on economically and clinically important
medications (i.e., antihypertensives, statins,
antidepressants, and antipsychotics, anticonvulsants)
used to treat major chronic conditions. Measured
outcomes include medication access and
discontinuation, adherence, adverse health events,
and costs among patients at high risk for unintended
effects, including those with severe mental illness,
the permanently disabled, and racial minorities. The
findings provide strong evidence regarding the
intended and unintended effects of these policies and
strategies for minimizing harm to patients. We will
present several evidence-based guidelines to guide
policymakers in the development of PA and step
therapy policies that can maximize cost savings while
minimizing patient risks.
• Prior Authorization for Mental Health Drugs:
Recommendations for Policy Makers
Alyce Adams, Ph.D.; Dennis Ross-Degnan Sc.D.;
Stephen Soumerai, Sc.D.
Presented by: Alyce Adams, Ph.D., Research
Scientist, Division of Research, Kaiser Permanente,
2000 Broadway, Oakland, CA 94612; Phone: (510)
891-5921; Email: Alyce.S.Adams@nsmtp.kp.org
Research Objective: Rising pharmaceutical costs,
particularly for psychotropic medications, have
prompted many Medicaid and Medicare Part D
prescription drug programs to institute prior
authorization before dispensing of specific drugs to
discourage the use of more costly medications. Yet,
little is known about the effectiveness and safety of
these policies, particularly for mentally ill populations.
We recently conducted a series of studies, the
objective of which was to evaluate the impact of prior
authorization before dispensing of select nonpreferred psychotropic medications.
Study Design: Using an interrupted time series with
comparison series design, we evaluated the intended
and unintended impacts of the policy. We used time
series models to assess the population-level effects
and patient-level Cox proportional hazards models
and generalized estimating equations to directly link
changes in prescribing due to the policy with
individual-level behavior changes and outcomes.
Population Studied: Our study populations included
Medicaid and Medicare dual enrollees with
depression in Michigan and Indiana Medicaid, and
Medicaid enrollees with schizophrenia and bipolar
disorder in Maine and New Hampshire. We examined
health services use (i.e., medica
Principal Findings: Among newly treated patients
with severe mental illness (i.e., schizophrenia, bipolar
disorder) the policy was associated with higher rates
of disruptions in therapy. For the cohort of patients
with bipolar disorder, there was also a statistically
significant 30% decline in the proportion of patients
initiating therapy over time. Among patients with
severe mental illness, there was a very small cost
savings associated with PA. Among newly treated
patients with depression, we found no impact of PA
on disruptions in antidepressant therapy or adverse
psychiatric events. We did, however, observe small
declines in the proportion of patients initiating
antidepressants each month and a short term
increase in unintended switching of medications
among those using antidepressants pre-policy.
Conclusions: Our findings suggest that for patients
with severe mental illness, the increased disruptions
in therapy may not be worth the cost savings of PA
programs. Use of PA to reduce antidepressant
spending may require ongoing evaluation, particularly
during the initial stages of policy implementation.
There were small medication cost savings associated
with PA and step therapy for patients with
schizophrenia and bipolar disorder.
Implications for Policy, Delivery or Practice:
Based on these findings, we make the following
recommendations to minimize harm and maximize
cost savings. (1) Avoid prior authorization for classes
of psychotropic medications with considerable
heterogeneity in clinical response or where
disruptions in treatment can have clinically important
health or social consequences. (2) Create explicit
criteria for exemptions to avoid unintended switching
of patients already established on therapy. (3) Use
available claims data to systematically monitor
medication use before and after PA policies are
implemented in order to identify unintended adverse
effects, such as reductions in treatment initiation or
premature discontinuation of therapy.
Funding Source(s): National Institute of Mental
Health
• Racial Disparities in Antidepressant Treatment
and Outcomes: Pre-Policy Trends and
Unanticipated Prior Authorization Policy Impacts
Connie Trinacty, Ph.D.; Fang Zhang Ph.D.; Robert
LeCates, M.A.; Amy Johnson, M.P.H.; Alyce Adams,
Ph.D.
Presented by: Connie Trinacty, Ph.D., Assistant
Professor, Department of Population Medicine,
Harvard Medical School and Harvard Pilgrim Health
Care Institute, 133 Brookline Avenue, 6th Floor,
Boston, MA 02215; Phone: (617) 509-9955; Email:
connie_trinacty@hphc.org
Research Objective: Prior authorization (PA) of
costly medications is an increasingly popular strategy
to control prescription drug spending, but the impact
of these policies on pre-existing disparities in
treatment are unknown. This study examined: (1)
whether there were racial differences in
antidepressant (AD) use prior to implementation of
the Michigan Medicaid PA program; and (2) whether
there was a differential response to the PA on new
prescriptions for non-preferred antidepressants
among blacks compared to whites among a highly
vulnerable, permanently disabled population.
Study Design: Using linked 2000-2003 Medicaid and
Medicare claims for dual enrollees in Michigan, we
used longitudinal data analyses to estimate blackwhite differences in antidepressant medication use,
treatment initiation, and discontinuation before and
after the policy. Among those with a depression
diagnosis, we examined racial differences in
persistence of AD use, using two guidelinerecommended indicators (effective acute treatment:
continuous use for 12 weeks after initiation; effective
continuous treatment: continuous use for 6 months).
Population Studied: We studied 3,563 newly treated
(NT) Medicaid-Medicare dual enrolled black (23.5%)
and white (76.5%) adults in Michigan.
Principal Findings: At baseline, blacks were more
likely to have a diagnosis of depression, and had
more multiple comorbidities than whites. Baseline
initiation of non-preferred, more costly AD was the
same for blacks. After the policy, whites were more
likely to use newer, more expensive AD therapies
than blacks. Baseline risk of discontinuation among
newly treated patients was twice as high for blacks
compared to whites [2.15 (1.87, 2.48)]. However, the
policy was associated with a modest decrease in the
relative risk [1.72 (1.53, 1.93)], resulting in a 20%
[95% CI: (4%, 33%)] decline in the relative disparity.
Irrespective of policy, blacks had lower odds of
adhering to effective acute and continuous phase
treatment targets than whites. For both groups,
overall adherence rates fell after the policy. However,
blacks experienced greater drops after the policy in
adhering to effective acute phase and continuous
phase treatments (pre-policy vs. post-policy absolute
change: -4% and -7%, respectively).
Conclusions: Racial differences in discontinuation
existed prior to the policy and narrowed slightly after
the policy. This difference may be due to higher rates
of discontinuation of whites. Guideline adherence to
treatment worsened for both groups post policy, but
the rate of decline was greater for blacks.
Implications for Policy, Delivery or Practice:
Underuse of antidepressants among blacks is an
ongoing clinical challenge. Our findings highlight the
persistence of these disparities and the potential for
widely used PA policies to have unintended impacts
on blacks and whites. New strategies are needed to
improve antidepressant adherence among blacks
and future investigations will explore potential
mechanisms that explain the differential response to
the policy.
Funding Source(s): National Institute of Mental
Health
• Impact of Prior Authorization on the Use of Lipid
Lowering Medications among Dual Enrollees
Christine Lu, Ph.D.; Michael Law Ph.D.; Stephen
Soumerai, Sc.D.; Fang Zhang, Ph.D.; Dennis RossDegnan, Sc.D.; Alyce Adams, Ph.D.
Presented by: Christine Lu, Ph.D., Research
Fellow, Department of Population Medicine, Harvard
Medical School and Harvard Pilgrim Health Care
Institute, G.P.O. Box 2471, Adelaide, 0 5001,
Australia; Phone: (618) 830-21335; Email:
Christine.Lu@unisa.edu.au
Research Objective: Many Medicaid programs have
adopted prior authorization (PA) requirements for
certain medications to manage rising pharmaceutical
expenditures. This study examined the effect of PA
policies for lipid-lowering medications, primarily
targeting brand-name agents, in Michigan and
Indiana Medicaid.
Study Design: Interrupted time series analysis to
examine changes in prescription rates (number of
prescriptions per 1,000 enrollees per month) and
pharmacy costs (pharmacy reimbursement per 1,000
enrollees per month) for lipid-lowering medications
before and after policy implementation. As the
Michigan and Indiana PA policies occurred 6 months
apart, they were treated as two distinct interventions
in separate models.
Population Studied: Individuals continuously duallyenrolled in both Medicaid and Medicare programs
from July 2000 through September 2003 (Michigan,
n=38,684; Indiana, n=29,463).
Principal Findings: The PA policy led to an
immediate 58% reduction in prescriptions for nonpreferred medications in Michigan (-28.96
prescriptions per 1,000 enrollees [95% confidence
interval, -32.96 to -24.95; p<0.001]) and a
corresponding increase in prescriptions for preferred
agents. The observed switch was predominantly
driven by a shift from simvastatin (non-preferred) to
atorvastatin (preferred). However, the PA policy had
no apparent effect in Indiana, likely because there
was little use of non-preferred medications in the prepolicy period (3%). We estimated that the policies led
to a reduction of $315,820 in prescription
expenditures in Michigan in the first post-policy year
and an immediate post-policy reduction of $16,070 in
Indiana.
Conclusions: While the PA policy led to substantially
lower use of non-preferred drugs in Michigan, this
change was offset by increases in the use of
preferred drugs. While we did not detect changes in
overall utilization, further research is warranted to
determine the impact of the policy on medication
discontinuation, drug initiation and health outcomes.
In both states, PA policies led to some reductions in
pharmacy reimbursements, though we did not include
the costs of PA administration or burden on patients
and providers.
Implications for Policy, Delivery or Practice: Our
analysis of the use of PA policy for lipid-lowering
medications suggests that when the policy allows a
choice of several drugs that are deemed clinically
interchangeable, it can effectively reduce drug costs
through a shift in use from non-preferred agents to
preferred medications. Future research should
investigate the impact of such medication switches
following PA policies on patient outcomes.
Funding Source(s): RWJF
• Impact of Two Medicaid Prior Authorization
Policies on Antihypertensive Use and Costs
Michael Law, Ph.D.; Christine Lu Ph.D.; Stephen
Soumerai, Sc.D.; Amy Graves, M.P.H.; Fang Zhang,
Ph.D.; Alyce Adams, Ph.D.
Presented by: Michael Law, Ph.D., Assistant
Professor, School of Population and Public Health,
University of British Columbia, 201-2206 East Mall,
Vancouver, BC, 0 V6T 1Z3, Canada; Phone: (604)
822-3514; Email: mlaw@chspr.ubc.ca
Research Objective: In response to rising
pharmaceutical costs, many state Medicaid programs
have implemented policies requiring prior
authorization for high cost medications, even for
established users. Little is known about the impacts
of these policies on use of antihypertensive
medicines. We studied the impact of two policies
restricting access to antihypertensive medicines
implemented in both Michigan and Indiana Medicaid.
Study Design: We used interrupted time series
analysis to study policy-related changes in the total
number and cost of antihypertensive prescriptions.
Population Studied: Our study cohort included
individuals continuously enrolled in both Medicaid
and Medicare programs from July 2000 through
September 2003.
Principal Findings: Both policies caused large and
immediate reductions in the use of non-preferred
medications of 85% in Michigan and 36% in Indiana.
As expected, use of preferred medications also
increased substantially in both states. Overall
antihypertensive therapy dropped 0.2% per quarter in
Michigan and 1.8% in Indiana. The policies led to
reductions in pharmacy reimbursement of $616,000
in Michigan and $868,000 in Indiana in the first postpolicy year.
Conclusions: Both prior authorization policies led to
substantially lower use of non-preferred
antihypertensive drugs that were largely offset by
increases in the use of preferred drugs. This
contrasts with other studies showing prior
authorization sometimes leads to decreases in
overall drug use within the affected classes.
Implications for Policy, Delivery or Practice:
Future study is needed to investigate whether
switching medicines following prior authorization
policies have any long-term health effects among
patients on established therapy.
Funding Source(s): National Institute of Mental
Health
Partners in Health: How Physicians and Hospitals
can be Accountable Together
Chair: Laura Tollen, M.P.H.
Tuesday, June 29 * 11:30 a.m.–1:00 p.m.
Panelists: Robert Berenson, Urban Institute; Jay
Crosson, Kaiser Permanente; William Sage,
University of Texas at Austin
Panel Overview: This roundtable will focus on the
concept of Accountable Care Organizations (broadly
defined) and on the new relationships physicians and
hospitals must forge with one another to build such
organizations.
As this proposal is being written, it seems
likely that the 2009/2010 federal health reform
process will result in an expansion of coverage.
That’s the good news. The bad news is that most
experts agree that the final bill will likely do very little
to address cost containment or quality improvement
through delivery system reform. It is promising to
note, however, that the current version of the
Senate’s health reform bill includes the creation of a
CMS Center for Innovation, with the power to test
new approaches to delivery system reform under
Medicare, including accountable care organizations.
The Spring and Summer of 2010 will therefore be an
excellent time to develop concrete ideas about what
regulators, payers, and providers can each do to
create ACOs that are clinically and fiscally
accountable for the entire continuum of care that a
given population of patients may need.
Any approach to sustained quality
improvement and cost containment in health care
must involve hospitals and physicians.
Hospitalizations are the most costly form of care
delivery, and conventional wisdom is that physician
care decisions directly drive over 80 percent of total
health care costs. Accordingly, there is a growing
consensus that changes in payment incentives to
hospitals and physicians are required, and that such
changes must be more than superficial. Most such
payment reforms involve either prepayment for
services to be rendered, with some form of risk
sharing, or episode-based payments such as case
payments to physicians and hospitals together.
But there is a problem; advanced payment
methodologies are most feasible in an environment of
highly organized providers. Such payment
methodologies are much less feasible in the
disaggregated delivery model that exists in much of
the United States today. It is therefore critical that
providers – in particular physicians and hospitals –
find new ways to work together to accept the new
payment methodologies that will enable them to
jointly improve quality.
However Congress chooses to support and
implement ACOs in the future, physician/hospital
collaboration will be required to make the model
work. The more comprehensive the reform and the
faster the change in payment incentives evolves, the
more important will be the development of the
knowledge base for making this change successful.
The proliferation of ACOs will require substantial
changes in how physicians and hospitals relate to
and seek to integrate with each other. Integration
must occur at the operational, financial, and cultural
levels, each of which faces a number of barriers.
This roundtable will focus specifically on
regulatory/legal and payment-related barriers and
solutions to improved integration.
The first panelist (or, roundtable chair) is the
former executive director of the physician arm of the
largest private integrated delivery system in the
nation. He will set the stage for the discussion by
making the case that improved physician/hospital
collaboration is a key ingredient in delivery system
reform in general, and in ACOs in particular. This
speaker is the co-editor of a forthcoming book on
physician/hospital collaboration (with the same title
as this panel). Based on his own work and that of the
book’s contributing authors, he will present views on
improved physician/hospital integration from both the
physician and the hospital perspectives. Specifically,
he will discuss what changes each type of provider
needs to make in order to work more collaboratively
with the other.
The next three panelists will respond to and
build off of the first presentation. They will discuss,
respectively: the legal and regulatory challenges to
improved physician/hospital collaboration;
government payers’ role in encouraging such
collaboration; and private payers’ role in doing the
same.
The second panelist, on legal and regulatory
barriers, will be a prominent attorney and expert in
health care antitrust issues and other relevant laws
that are of concern to physicians and hospitals
hoping to collaborate more closely – particularly
when such collaboration involves shared finances.
The third panelist, on the role of government
payers in encouraging improved physician/hospital
collaboration, is a prominent Medicare payment
expert, MedPAC Commissioner, and former
administrator of HCFA.
The fourth panelist, on the role of private
payers, will be a representative of a private health
plan that has experimented with various new
payment models designed to encourage joint
accountability between physicians and hospitals for
episodes of care, for example, BCBS of
Massachusetts or similar.