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Newsletter Article


Publications of Note

U.S. Health Care, Dissected
This study explores the "anatomy" of U.S. health care by using public data to track spending, the people receiving and organizations providing care, and the resulting value created, including health outcomes. The researchers find that, from 2000 to 2011, the rising prices of health care services—not growing demand or an aging population—produced the vast majority of cost increases; consumers' out-of-pocket health care costs declined; and chronic illnesses accounted for 84 percent of overall health care costs. They attribute the results to consolidation among providers and insurers; widespread investment in information technology; and empowerment of patients as consumers. A national conversation is needed to balance competing demands, such as patients' desire for personal care, providers' desire for autonomy, and payers' desire to demonstrate value. H. Moses III, D. H. M. Matheson, E. R. Dorsey et al., "The Anatomy of Health Care in the United States," Journal of the American Medical Association, Nov. 13, 2013 310(18):1947–64.

Changing Skill Mix of Providers Requires Careful Planning
The authors of this analysis and commentary say the U.S. has much to learn from the results of England's health care workforce redesign initiatives, which led to increases in the number of health care professionals serving patients, the expanded use of unskilled and unlicensed staff such as health care assistants, and greater investments in teamwork. They say results demonstrated that if not carefully planned, these initiatives can increase costs and reduce quality. To avoid this, the authors suggest that changes in skill mix and role definitions should be preceded by a detailed analysis and redesign of the work performed by health care professionals. Efforts should also be made to overcome opposition from professional bodies, individual practitioners, and regulators. R. M. J. Bohmer and C. Imison, "Lessons from England's Health Care Workforce Redesign: No Quick Fixes," Health Affairs, Nov. 2013 32(11):2025–31.

Low Health Literacy Affects Hypertension Outcomes But Not Interest in Medical Decisionmaking
A study that sought to determine how health literacy affects patients' desire for involvement in decisionmaking, communication with their providers, and patient-reported visit outcomes found that, among those with hypertension, a smaller percentage of patients with low versus adequate literacy had controlled blood pressure. However, patients with low and adequate literacy were similarly interested in participating in medical decisionmaking. Their communication behaviors did not differ markedly, except that those with low literacy asked fewer medical questions. Overall, patients' ratings of care did not differ based on health literacy. H. J. Aboumatar, K. A. Carson, M. C. Beach et al., "The Impact of Health Literacy on Desire for Participation in Healthcare, Medical Visit Communication, and Patient Reported Outcomes Among Patients with Hypertension," Journal of General Internal Medicine, Nov. 2013 28(11):1469–76.

Refinements in Quality Measurement Needed
The authors of this article outline current challenges to quality measurement that strain resources, including its diverse purposes, the limited availability of true clinical measures, fragmentation of measurement systems and registries, and the rapid expansion of required measures. Among many recommendations, they suggest raising the bar for quality measurement to achieve transformational rather than incremental change, promoting a logical set of measures for various levels of the health system, and harmonizing various national and local quality measurement systems. R. J. Panzer, R. S. Gitomer, W. H. Greene et al., "Increasing Demands for Quality Measurement, Journal of the American Medical Association, Nov. 13, 2013 310(18):1971–80.

Financial Incentives Improve Adherence to Maintenance Treatment with Antipsychotics
A study that tested whether offering financial incentives to patients with psychotic disorders is effective in improving adherence to maintenance treatment with antipsychotics found that, among patients with a diagnosis of schizophrenia, schizoaffective disorder, or bipolar disorder, adherence increased—from an average baseline of 69 percent in the intervention group to 85 percent during the 12-month intervention period, while treatment adherence in the control group rose from 67 percent to 71 percent. The study recruited patients who were prescribed long-acting antipsychotic injections but had received 75 percent or less of the prescribed injections. Participants were offered £15 (€17; $22) for each injection over a 12-month period, while participants in the control group received treatment as usual. S. Priebe, K. Yeeles, S. Bremner et al., "Effectiveness of Financial Incentives to Improve Adherence to Maintenance Treatment with Antipsychotics: Cluster Randomised Controlled Trial," BMJ, Oct. 7, 2013 347:f5847.

More Research on Shared Decisionmaking Necessary to Establish Its Effectiveness in Reducing Overtreatment and Costs
The authors of this commentary say that while there are some well-documented benefits to shared decisonmaking, research does not support its potential to reduce overtreatment and costs. They say more study is necessary to clarify whether the measured impact of these programs is a function of patient-level or clinician-level effects. In addition, they say that there has been inadequate consideration of the complexity of how patients construct and express their preferences for treatment. S. J. Katz and S. Hawley, "The Value of Sharing Treatment Decision Making with Patients: Expecting Too Much?" Journal of the American Medical Association, Oct. 16, 2013 310(15):1559–60.

Fostering Price Transparency in Health Care
The author of this commentary argues that high per capita health care spending is in the U.S. is a function of fragmentation in the regional insurance markets, which makes it harder for individual insurers to resist the market power of local providers. The longstanding practice of treating health care pricing as a trade secret also contributes to the fact that the U.S. pays about twice that of other developed countries for medical care. He suggests that reference-based pricing models, which require patients to make up the difference between insurance reimbursement and provider rates, is likely to increase consumers' awareness of pricing, as will the efforts of entrepreneurial start-ups to publish local pricing information. Mandating the use of Medicare's diagnostic-related group system for all patients, so that hospitals would be using the same relative value scale, may facilitate a comparison of pricing, he says. U. E. Reinhardt, "The Disruptive Innovation of Price Transparency in Health Care," Journal of the American Medical Association, Nov. 13, 2013 310(18):1927–28.

Using Population-Based Measures May Improve Outcomes and Allocation of Limited Resources
The authors of this commentary suggest that focusing on population health may improve patient outcomes by helping to determine the frequency, causes, and consequences of common medical conditions and by bringing attention to social factors such as poverty, education, and social networks that are strong determinants of health. Applying a population-focused approach to health care may also provide a framework to balance the needs of individuals with the needs of society, because it may require providers to carefully allocate resources such that medical screening and treatment are offered to those who are mostly likely to benefit from them. H. C. Sox, "Resolving the Tension Between Population Health and Individual Health Care," Journal of the American Medical Association, Nov. 13, 2013 310(18):1933–34.

Addressing the Downsides of Hospital Consolidation
An analysis of market consolidation of hospitals found that because of horizontal and vertical consolidation, 60 percent of hospitals in the United States are now part of health systems, up seven percentage points from a decade ago. In addition, hospital ownership of physician practices increased from 24 percent in 2004 to 49 percent in 2011. While there are many potential benefits of consolidation, including cost savings and improved quality, the authors point out potential harms to consumers and suggest that local governments consider introducing new policies that help ensure consumers gain protection in the event of consolidation, including encouraging the use of insurance products that charge consumers more for high-priced clinicians and health care centers, bundling payments to clinicians and health care organizations to eliminate the incentives of big institutions to simply provide more care, and establishing area-specific price or spending targets. D. M. Cutler and F. S. Morton, "Hospitals, Market Share, and Consolidation," Journal of the American Medical Association, Nov. 13, 2013 310(18):1964–70.

Shared Decisionmaking May Require More Personalized Guidance for Patients
The authors of this commentary argue that current efforts to help consumers make informed decisions are not providing the information they most value, which is the answer to the question: Is the proposed treatment or procedure the best option given my condition, my financial status, and my social or family situation? Providing metrics that reflect the varied concerns and preferences of consumers is a prerequisite for shared decisionmaking, the authors say. R. S. Huckman and M. A. Kelley, "Public Reporting, Consumerism, and Patient Empowerment," New England Journal of Medicine, Nov. 14, 2013 369(20):1875–77.

Chronic Disease Self-Management Program Reduces Hospitalization and ED Visits
A national study that sought to assess the effectiveness of the Chronic Disease Self-Management Program on patients with chronic conditions found that it led to improvement in health measures and a significant reduction in emergency department (ED) visits up to 12 months after the program concluded. Reductions in hospitalization rates were observed up to six months afterwards. M. G. Ory, S. Anh, L. Jiang et al., "Successes of a National Study of the Chronic Disease Self-Management Program: Meeting the Triple Aim of Health Care Reform," Medical Care, Nov. 2013 51(11):992–98.

Improving Hospital Accountability Using Population-Based Metrics
While population-based clinical performance measures are often seen as distinct from if not in conflict with provider-based quality measures, the authors of this commentary suggest the former can help improve the accuracy of the latter. They use hospital readmission rates to illustrate: when hospitals reduce readmissions, their admissions and hospital discharges are reduced as well, making the ratio of readmissions to discharges unstable, which in turn may lead to penalties for hospitals that have reduced Medicare costs and beneficiary readmissions. To avoid this distortion, they suggest using area population as a consistent denominator. To address the concern that hospitals are being penalized for having patients with elevated risk for readmission, they suggest avoiding benchmarking hospitals against peers, and instead measuring performance against a hospital's own baseline. S. F. Jencks and J. E. Brock, "Hospital Accountability and Population Health: Lessons from Measuring Readmission Rates," Annals of Internal Medicine, Nov. 5, 2013 159(9):629–30.

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