The Commonwealth Fund Annual Report

Actors' Fund of America
$208,201
Creating Web-Based Information on Health Insurance and Policy Initiatives
In 2000, The Commonwealth Fund supported the redesign of the Actors' Fund of America's health insurance website to make it more complete and more useful to all people-not just entertainment professionals-seeking insurance information. About 700 visitors use the site each day. Information is currently most comprehensive in the two markets where the majority of entertainment professionals live, New York and California. Detailed information needs to be provided for the other 48 states, however, where workers without health insurance face many of the same barriers as these professionals do. This project will enable the Actors' Fund to engage six graduate students and their mentors, each based at a different U.S. university, to compile information on private and public health insurance options for eight states in their respective geographic regions. The students and mentors will also help raise awareness about the uninsured and the resources available through the website by holding campus forums and writing articles for their student newspapers and for online outlets. The website will be renamed to signal that it serves a broader audience. Cofunding is being sought from local foundations in the communities where the universities are located.

Center for Health Policy Development
$159,857
Support for Implementation of Maine's Dirigo Health Plan
Maine recently enacted comprehensive health reform that addresses insurance coverage, health care costs, and quality of care in the state. The goal of this initiative is to achieve universal access to health care within five years through the creation of the Dirigo Health Plan. The legislation includes a series of steps in the first year that will require new information and guidance for the state's Office of Health Policy and Finance, which is charged with implementing the initiative. This grant will fund essential analysis to help the state move from legislation to action. In addition, it will help set the stage for an evaluation that will determine if Maine's efforts could be a model for the country. Maine has received funding from the U.S. Health Resources and Services Administration and is seeking cofunding from two other foundations.

Center for Health Policy Development
$219,654
Using Evidence-Based Medicine to Control Pharmaceutical Program costs, Phase 1 of 2
By making better use of available scientific evidence regarding the relative efficacy of prescription drugs, some states believe they can save money on their pharmaceutical assistance programs while ensuring the quality of care provided to enrollees. The Drug Effectiveness Review Project, a multistate collaborative effort initiated by former Oregon state officials, is attempting to use evidence-based research to help states design their pharmaceutical programs. In Phase 1 of this two-phase project, investigators will examine how participating states incorporate evidence-based research into their drug purchasing strategies and measure the preliminary impact on costs and utilization. If the first phase is successful, in the second phase the project team will examine the impact of a full year of evidence-based purchasing on costs, drug utilization, and quality of care. Project findings will inform all states about the benefits and challenges of using evidence-based research to control the costs of their prescription drug benefits.

Columbia University
$197,393
Commonwealth Fund Task Force on the Future of Health Insurance: Data Analysis and Technical Assistance
The Fund's Task Force on the Future of Health Insurance is exploring ways to extend health insurance coverage to uninsured working Americans and their families. This core grant to Columbia University funds analysis of data and policy options, as well as technical support for Task Force staff and grantees. In the past year, the Columbia team, led by Sherry Glied, has examined trends in insurance coverage related to income level and employer size and analyzed policy options for insuring Hispanics and young adults. In the year ahead, the team will assess the impact of policy options across states and continue to track coverage trends, with a focus on the erosion and instability of coverage for middle-income families. The grant also will support analysis for Task Force staff and grantees. Together, these activities will yield new information for policymakers about the future course of health coverage in the United States.

Economic and Social Research Institute
$149,015
Leveraging State Dollars to Strengthen Health Coverage in an Economic Downturn
States that have implemented health insurance coverage expansions over the past few years have developed creative strategies for using a portion of state money to leverage private, federal, and additional state dollars to cover the uninsured. While these are smart strategies for any economy, they are critical now that states are cutting programs to help close deficits. This project will examine lessons gained from these innovations, with the goal of helping states stretch limited dollars in order to maintain or expand coverage, or to enhance the cost-effectiveness of care. Three categories of innovation will be studied: 1) new state premium assistance programs that help low-wage workers buy into job-based or Medicaid coverage; 2) the use of uncompensated care funds, for example, to enable patients to visit primary care doctors rather than rely on emergency rooms; and 3) new state purchasing and care delivery strategies to foster cost-effective delivery of high-quality services. Project staff will develop up to 10 state profiles and four in-depth case studies that will provide state and federal policymakers with ideas about viable models of coverage as they weather the economic downturn.

Economic and Social Research Institute
$107,156
Trade Act Health Coverage Project
Some policymakers have proposed federal income tax credits to help uninsured workers purchase health coverage. Analysis of such proposals can now benefit from real-world experience following enactment of the Trade Act of 2002, which created a tax credit to pay 65 percent of health insurance premiums for roughly 300,000 early retirees and unemployed workers. For this project, the Economic and Social Research Institute will: 1) describe early state plans for implementing Trade Act coverage; 2) identify key concerns with initial federal implementation; and 3) identify and assess Trade Act issues that are relevant to broader coverage expansions. In addition to producing three state case studies, project staff will prepare a policy report to articulate findings pertinent to future decisions about the use of tax credits to cover large numbers of uninsured workers and their families. Cofunding is expected to be provided by the Nathan Cummings Foundation.

Georgia State University Research Foundation, Inc.
$146,088
Assessing the Strategic Role of Community Safety Net Networks
In dozens of U.S. localities, community leaders and health care providers have organized a system of free or discounted health care services for people who cannot get private coverage because they are too sick or work for an employer that does not offer it, or because their modest incomes disqualify them from public programs. A key feature of these safety net initiatives is that they enroll people in case management programs and reduce future need for urgent care. For this grant, the investigators will examine: 1) the importance of leveraging state or federal funding in sustaining such community efforts, and 2) community approaches to delivering cost-effective care on tight budgets. The project team will conduct case studies in three communities where financing-whether through Medicaid disproportionate share hospital payments, employer contributions, or a reinsurance mechanism-has been most innovative. The findings will be disseminated to the hundreds of health care access projects around the country to help them achieve sustainability, as well as to states and localities that may, over the longer term, find these programs beneficial for covering more of the uninsured.

Health Research and Educational Trust
$172,802
Assessing the Implications of Patient Cost-Sharing and Care Patterns for Benefit Design, Phase 1
With the retreat from managed care, employers and health insurance plans are turning more and more to patient cost-sharing as a way to control rising health care expenses. In some cases, patients are put at such financial risk that it may be limiting their ability to adhere to recommended care. For this project, the investigators will examine the claims database of a large private health insurance carrier to assess the impact of various cost-sharing models, focusing on patients who have high-cost chronic conditions or low income. The grant, which will cofund the first 15 months of a two-year project, will help inform the design of public and private health insurance that meets the financial needs of vulnerable populations.

New York Academy of Medicine
$71,384
Investigation of the Extent of Churning and the Costs of Re-enrollment
For this project, a research team at the New York Academy of Medicine will analyze data from selected states on the cycling of children on and off Medicaid coverage. The investigation will focus on the frequency and duration of gaps in coverage and the amount spent by states and health plans to reenroll families who lost coverage due to administrative barriers. Differences among states' coverage eligibility rules will enable project staff to compare the effects of various policies, such as income verification and six-month versus 12-month eligibility periods. This project complements a Georgetown University grant (see above) to analyze the causes and consequences of churning and develop solutions.

The President and Directors of Georgetown College
$128,648
Examining the Causes and Consequences if Unstable Insurance Coverage and Identifying Solutions
Instability in health insurance coverage is a chronic concern for low-income families and often creates problems for the providers trying to serve them. Many states have attempted to help families and individuals remain enrolled in coverage for which they qualify by ensuring continuous coverage for children, simplifying eligibility renewal processes, and other reforms. State budget pressures, however, have stalled or reversed progress in many cases. This project, together with a complementary study by the New York Academy of Medicine (see below), seeks to gain a better understanding of how turnover, or churning, in insurance coverage affects families and health systems. Using data obtained from program administrators, health plans, and providers, Georgetown University researchers will analyze the causes and consequences of churning in public programs serving low-income families with children. These data, along with findings from interviews, roundtables, and site visits, will help project staff develop a set of policy recommendations for state and federal policymakers to help stabilize public coverage.

AcademyHealth
$5,000
2004 National Health Policy Conference

Economic and Social Research Institute
$28,272
Updating State Planning Grant Report

Employee Benefit Research Institute Education and Research Fund
$7,000
2004 Health Confidence Survey

Employee Benefit Research Institute Education and Research Fund
$28,500
Sustaining Membership for The Commonwealth Fund at The Employee Benefit Research Institute

The President and Directors of Georgetown College
$46,369
Discount Health Plans: A Recent Development In Health 'Coverage'

Universal Health Care Action Network
$25,615
State Perspectives on Federal Initiatives to Promote Universal Coverage

Fund for the City of New York
$221,110
Using Community Surveys to Identify Health and Access Disparities in New York City
In 2002 and 2003, the New York City Department of Health and Mental Hygiene collected data on residents' health behaviors, health conditions, and service use through their annual Community Health Surveys. The surveys, which allow comparison of results across 32 neighborhoods, help city officials establish more effective public health policies and programs while supporting the decision-making of private organizations concerned about health disparities. Through two small grants, the Fund supported production of a chartbook on health disparities from the 2002 survey, as well as the addition of questions on health care access to the 2003 survey. This new project will disseminate findings from the 2003 survey by producing two additional chartbooks, one on access to care and coverage and a second on women's health. Project staff also will supplement the 2004 survey by including questions about New Yorkers' access to primary care services and producing a third chartbook describing primary care access across New York's neighborhoods and racial/ethnic groups. Survey findings will help the Fund as it adds a new area of focus to the Health Care in New York City program. Findings also will aid city officials as they develop programs for underserved communities. The Department of Health and Mental Hygiene will provide cofunding.

Mayor's Fund to Advance New York City
$231,338
Increasing Access to Health Coverage and Care for New York City Students
Commonwealth / Health Services Improvement Fund Grant
In 2001, about 246,000 children in New York City were eligible for, but not enrolled in, one of the public insurance programs offered by New York State. The Mayor's Office of Health Insurance Access and the Office of School Health will conduct a demonstration project in 23 schools to develop systems for covering uninsured children and connecting those most in need with a medical home. These schools, located in the city's poorest neighborhoods, are the sites for implementation of a new automated school health record that will allow the city to track information about student's insurance and overall health status. The project has three parts: 1) creating systems to track children's insurance and health status; 2) conducting outreach activities, enrolling children in coverage, connecting children with a medical home, and following up to see that needs are met; and 3) evaluating findings for possible citywide rollout. If successful, these new systems could improve the health of underserved schoolchildren in New York City.

MetroPlus Health Plan, Inc.
$166,682
Improving Asthma Management for Children in New York City: Evaluation of the Asthma Buddy Program
Asthma continues to be the leading cause of emergency department visits and hospitalizations for children and places serious limitations on normal childhood activities, including school attendance. With evidence showing that improved patient self-management is critical to better health outcomes, experts have devised a handheld computer that prompts patients to answer a series of questions and then reports this information to the doctor who helps manage their care. This new 'Asthma Buddy' technology was used recently to reduce emergency visits and hospitalizations for a small group of children with asthma seen at Coney Island Hospital. For this project, the Asthma Buddy will be tested more widely for a sample of children seen in five hospitals run by the city's Health and Hospitals Corporation (HHC). MetroPlus Health Plan, HHC's managed care plan that primarily serves publicly insured New Yorkers, will conduct a scientific study to measure changes in health care use, asthma knowledge, symptoms, and quality of life, as well as the intervention's cost-effectiveness. These findings will help determine if systemwide implementation is warranted.

Coleman Associates
$22,950
Medicaid Enrollment Process Redesign Project, Final Phase

Greater New York Hospital Association
$1,000
GNYHA -UHF Symposium Planning Committee

Joan and Sanford I. Weill Medical College of Cornell University
$15,000
David Rogers Health Policy Colloquium

Primary Care Development Corporation
$20,000
Learning Collaborative Planning Project

International Communications Research
$173,550
2004 Survey of Health Insurance Experiences of Older Adults Before and After Enrolling in Medicare
In late 1999, the Fund conducted a survey of older Americans, ages 50 to 70, to examine their health insurance experiences before and after enrolling in Medicare. A number of events have occurred since that survey: the economy has weakened, health care costs have risen, physicians have threatened to drop or not enroll new Medicare patients, and employer-based health insurance and retiree coverage have eroded. In the meantime, the absence of a Medicare prescription drug benefit remains a concern. A new survey will examine changes that have occurred since the earlier survey and explore emerging areas of policy concern. This information will inform legislative debate over the future of health insurance coverage for older Americans.

National Academy of Social Insurance
$199,978
Medicare/Medicaid Dual Eligibles: Reaching All Who Qualify
Most low-income Medicare beneficiaries are entitled to help from Medicaid or from Medicaid-administered Medicare Savings Programs to pay for some or all of their uncovered health care expenses. Despite their need for such assistance, only about 60 percent of eligible beneficiaries are enrolled. For this project, the National Academy of Social Insurance will examine options for strengthening the federal role in the identification and enrollment of eligible people in these programs. Possibilities include: 1) simplification of eligibility, for example, by implementing presumptive eligibility or removing asset tests; 2) increasing federal operating responsibility, such as requiring the Social Security Administration to enroll eligible beneficiaries; and 3) increasing federal financing, for example, by making federal government fully responsible for Medicare Savings Programs. An advisory panel will assist project staff in identifying the issues, commissioning papers on the options, synthesizing conclusions, and evaluating their implications and feasibility.

The National Council on the Aging, Inc.
$250,041
BenefitsCheckUp: Helping Low-Income Seniors Receive Health Benefits, Phase 3
BenefitsCheckUp is a breakthrough Internet application that screens seniors for their eligibility for 1,200 public benefit programs, including those that help pay medical and prescription drug expenses. A multisite demonstration launched in 2001 by the National Council on the Aging (NCOA) is testing whether community-based groups can enhance the Web tool's usefulness by assisting the most vulnerable seniors with eligibility screening and follow-through to ensure enrollment. In the third and final project phase, the model communities will conduct an extensive outreach campaign to sign up as many seniors as possible for the new Medicare drug discount card. The effort's focus will be those low-income beneficiaries who are eligible for the $600 Medicare drug subsidy. Through surveys and database analysis, project staff also will determine whether this community-based approach is more effective than the Web site alone in enrolling eligible people in public programs. Project cofunding will be provided by the U.S. Department of Commerce, Atlantic Philanthropies, and local foundations.

The President and Directors of Georgetown College
$307,711
Program Direction Grant for The Commonwealth Fund's Program on Medicare's Future
Changes to Medicare now under consideration could fundamentally alter the program's future role in insuring and financing the health care needs of the nation's elderly and disabled populations. While much of the discussion is focused on federal or state budget costs, the Fund's Program on Medicare's Future provides independent analysis of reforms from the perspective of beneficiaries, particularly those who are vulnerable because of low income or poor health. Under the leadership of Barbara S. Cooper, this program direction grant will provide overall strategic direction, develop new projects, coordinate ongoing work, and direct efforts to disseminate findings of program-supported work to policy leaders and the public. The program director will also participate in the critical review of reports considered for Fund publication, prepare issue briefs and summaries of Fund work, and represent the program in public forums.

The Urban Institute
$86,400
Fostering Medicare-Private Collaboration in Value Based Purchasing
Medicare and private purchasers have both adopted innovations to constrain costs and ensure they are receiving good value for their health care dollar. Medicare, the nation's largest health care purchaser, uses electronic claims processing and prospective payment systems for most types of health care providers. Many private purchasers, meanwhile, have implemented disease and care management programs. But the two sectors have rarely tried to work together, learn from each other, and leverage one another's efforts. This project seeks to identify and foster value-based purchasing activities that could be implemented by Medicare and private purchasers. In advisory group meetings and interviews with a variety of experts, the investigators will focus primarily on three approaches: 1) provider-based information technology, to manage administrative and clinical information; 2) multipayer claims databases, to identify efficient, high-quality providers; and 3) paying for performance.

University of Maryland
$278,757
Evaluation of the Effect of Medicare Drug Policy Decisions on Vulnerable Seniors
Whatever the outcome of Medicare prescription drug legislation in Congress, policymakers will want to know what the impact of the proposed benefit will be, particularly with respect to the poorest and sickest beneficiaries, as well as the pros and cons of alternative benefit designs. For this project, Bruce Stuart and colleagues at the University of Maryland School of Pharmacy will update their benefit impact simulation model and develop quick-response analyses as policy questions arise. They also will explore the role of improved drug formulary management in lowering costs and improving outcomes and examine the experiences of long-term care residents. The project team will assess the possible impact of alternative benefit designs on use and on out-of-pocket expenses, as well as the likely impact on vulnerable beneficiaries.