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Newsletter Article


Publications of Note

Medicaid Expansion Increases Outpatient, ED Visits While Reducing Hospital Use
An analysis of Wisconsin's public insurance program for childless adults found that the program increased outpatient visits by 29 percent and emergency department visits by 46 percent, while reducing inpatient hospitalizations by 59 percent and preventable hospitalizations by 48 percent. The study, which compared the claims of 9,600 residents who received coverage with a similar number who did not, suggests such programs have the potential to improve health and reduce costs by increasing access to outpatient care and reducing hospitalizations. T. DeLeire, L. Dague, L. Leininger et al., "Wisconsin Experience Indicates That Expanding Public Insurance to Low-Income Childless Adults Has Health Care Impacts," Health Affairs, June 2013 32(6):1037–45.

Few Physicians Believe They Have a "Major Responsibility" to Reduce Health Care Costs
A survey that gauged physicians' views of their role in addressing health care costs found that only 36 percent of the 2,556 physicians surveyed said they thought physicians have a "major responsibility" in reducing health care costs. Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) had such a responsibility. The survey also found little support for eliminating fee-for-service payment models (7%) and greater interest in promoting continuity of care (75%), expanding access to quality and safety data (51%), and limiting access to expensive treatments with little net benefit (51%) as a means of reducing health care costs. J. C. Tilburt, M. K. Wynia, R. D. Sheeler et al., "Views of U.S. Physicians About Controlling Health Care Costs," Journal of the American Medical Association, July 24/31, 2013 310(4):380–88.

Physician Leadership on Cost Containment Urged
A commentary addressing the results of a survey that found only 36 percent of physicians believe they have a "major responsibility" in controlling health care costs says doctors must take a leadership role in this work because their decisions determine which patients are seen in the office, how frequently, and by what practitioners; which patients are hospitalized; which laboratory tests, diagnostic procedures, and surgical operations are administered; which medications are prescribed; and which patients will be visited at home for care. E. J. Emanuel and A. Steinmetz, "Will Physicians Lead on Controlling Health Care Costs?" Journal of the American Medical Association, July 24/31, 2013 310(4):374–75.

Hospital Readmission Rates Not a Reliable Proxy for Hospital Quality

A study that sought to assess the extent to which risk-standardized readmission rates serve as a reliable measure of overall hospital quality assessed whether changes in readmission rates between 2009 and 2011 were the result of changes in quality or random variation. The authors found regression to the mean accounted for a portion of the changes in hospital performance. The researchers also found that readmission rates were higher in teaching hospitals and were weakly correlated with the other indicators of hospital quality. They recommend policymakers augment efforts to reduce readmissions with efforts to monitor hospital performance during care transitions and take a communitywide approach, rather than a hospital-specific approach. M. J. Press, D. P. Scanlon, A. M. Ryan et al., "Limits of Readmission Rates in Measuring Hospital Quality Suggest the Need for Added Metrics," Health Affairs, June 2013 32(6):1083–91.

Studies of Value-Based Insurance Design Find Equivocal Results
An analysis of 13 studies that assessed the impact of value-based insurance design on medication adherence and medical expenditures found that such programs were consistently associated with improved adherence as well as with lower out-of-pocket spending for drugs, but the study found that reduced beneficiary cost-sharing and out-of-pocket spending did not lead to significant changes in overall medical spending for patients and insurers—at least in the short term. The authors suggest further research is needed to understand how best to structure such programs so that they both improve quality and reduce spending. J. L. Lee, M. L. Maciejewski, S. S. Raju et al., "Value-Based Insurance Design: Quality Improvement But No Cost Savings," Health Affairs, July 2013 32(7):1251–57.

Patients with High Activation Scores Give Physicians Higher Ratings
A study that examined the relationship between patient activation levels and care experiences found that more highly activated patients reported more positive experiences than patients at lower levels when seeing the same clinician. The results suggest that perception of the care experience is shaped by both clinicians and patients. The authors suggest that efforts to improve care experiences, which are increasingly being targeted for public reporting and payment design, should focus not only on engaging providers, but also on improving patients' ability to elicit what they need from their providers. J. Greene, J. H. Hibbard, R. Sacks et al., "When Seeing the Same Physician, Highly Activated Patients Have Better Care Experiences Than Less Activated Patients," Health Affairs, July 2013 32(7):1299–1305.

Providing Intensive Medical Services to Sick Elderly Leads to Lower Costs and Higher Quality
The authors of this Health Affairs article described how focusing their practice on elderly patients with low-to-moderate incomes and five or more chronic conditions enabled the practice to offer more intensive services to these patients, which resulted in reduced hospital stays, higher scores on the Healthcare Effectiveness Data and Information Set (HEDIS) scores, and increased rates of medication adherence. The practice, ChenMed, has eight Miami-area centers and receives capitation payments through the Medicare Advantage program. Its primary care doctors have smaller panels of patients (350–400) than do typical primary care physicians, which enables ChenMed physicians to see their patients more frequently and to offer longer office visits. Patients can also access dental care and X-ray and imaging services and see specialists at the centers. C. Tanio and C. Chen, "Innovations at Miami Practice Show Promise for Treating High-Risk Medicare Patients," Health Affairs, June 2013 32(6):1078–82.

Peer Coaching More Effective on Subgroups of Diabetic Patients
A study that sought to determine whether peer coaching benefits all patients with diabetes or is most effective for certain subgroups, such as those with poor glycemic control, found patients with low levels of medication adherence and support to manage their condition themselves derived the most benefit from health coaching, as measured by changes in hemoglobin A1c levels. The study suggests peer health coaching interventions may be most effective if they are targeted to high-risk patients with poor glycemic control and with poor self-management and medication adherence. D. Moskowitz, D. H. Thom, D. Hessler et al., "Peer Coaching to Improve Diabetes Self-Management: Which Patients Benefit Most?" Journal of General Internal Medicine, July 2013 28(7):938–42.

Loophole Means Some Medicaid Beneficiaries Will Not Have Access to No-Cost Preventive Health Care
A review of Medicaid programs across the country found that most states do not cover all of the most important services recommended by the U.S. Preventive Services Task Force. Without adjustment, current Medicaid beneficiaries may not benefit from the provisions in the Affordable Care Act that require private health insurance plans, Medicare, and Medicaid expansion programs to cover these services. The authors say a concerted effort could be made to increase voluntary coverage of preventive services by Medicaid managed care plans. Congress could also grant all Medicaid beneficiaries the same rights as those covered by Medicare. S. E. Wilensky and E. A. Gray, "Existing Medicaid Beneficiaries Left Off the Affordable Care Act's Prevention Bandwagon," Health Affairs, July 2013 32(7):1188–95.

Process-of Care Measures in Nursing Homes Not Linked to Improved Outcomes

A study that sought to test the extent to which improvements in outcomes of care are explained by changes in nursing home processes found a large portion of the improvements in outcomes were not associated with changes in measured processes of care. The authors suggest developing quality measures that are related to improved patient outcomes would likely strengthen quality improvement efforts. R. M. Werner, R. T. Konetzka, and M. Kim, "Quality Improvement Under Nursing Home Compare: The Association Between Changes in Process and Outcome Measures," Medical Care, July 2013 51(7):582–88.

Early Review of Specialty Care Referrals Improves Access and Efficiency
A commentary in the New England Journal of Medicine suggests that accountable care organizations and other provider groups seeking to deliver better care at lower costs could learn from the safety-net systems that have used "e-referral" systems to rationalize use of specialty care. At San Francisco General Hospital, where wait times to see some specialists were nearly a year long, designated specialists began reviewing referrals to determine whether to schedule a routine or expedited visit, ask for clarification or additional information, recommend additional evaluation, or provide education and management strategies to the primary care physician. The program resulted in reduced demand for clinic visits and faster access to specialists when a consultation was needed. A. H. Chen, E. J. Murphy, H. F. Yee et al., "eReferral—A New Model for Integrated Care," New England Journal of Medicine, June 27, 2013 368(26):2450–53.

Pharmacist Case Management and Telemonitoring of Blood Pressure Patients Lead to Improved Outcomes
A study that sought to determine whether pharmacist-directed case management and telemonitoring of blood pressure patients at home resulted in improved blood pressure control found that the intervention led to better results during the 12 months of intervention and that the results persisted six months after the trial ended. The study found blood pressure was controlled at both six and 12 months in 57.2 percent of patients in the telemonitoring intervention group versus 30 percent of patients in the usual care group. Six months after the program ended, blood pressure was controlled in 71.8 percent of the patients in the monitored groups and 30 percent in the usual care group. K. L. Margolis, S. E. Asche, A. R. Bergdall et al., "Effect of Home Blood Pressure Telemonitoring and Pharmacist Management on Blood Pressure Control: A Cluster Randomized Clinical Trial," Journal of the American Medical Association, July 3, 2013, 310(1):46–56.

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