July 30, 2008

Healthcare Topics and Trends Update

CHRT's monthly online newsletter, providing convenient access to recently-published articles relating to healthcare quality, sustainability and access.

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General Interest Topics

Electronic Health Records in Ambulatory Care – a National Survey of Physicians

New England Journal of Medicine, July 3 2008

This study assessed physicians' adoption of and satisfaction with outpatient electronic health records (EHRs), perceived barriers to adoption, and the perceived effect of the systems on the quality of care. The study found physicians who use EHRs believe they improve the quality of care and are generally satisfied with the systems; however, EHRs have been adopted by only a small minority of U.S. physicians, who may differ from later adopters. Monitoring the prevalence and growth trend of electronic records adoption is important, since they are often associated with the potential to improve the delivery of health care services, and specifically, successful implementation of the patient centered medical home model.

The Impact of Consumer-Directed Health Plans on Prescription Drug Use

Health Affairs – July/August 2008; 27(4): 1111–1119.

This study examined patterns in prescription drug use in the first year that consumer directed health plans were offered alongside traditional plans within a large company. Using pharmacy claims data, the authors found that enrollees in high-deductible consumer directed health plans were more likely than those with other coverage to discontinue two of five drug classes. Enrollment in a consumer directed health plan did not, however, reduce adherence among those continuing their medication, nor did it greatly influence the use of generic drugs. Although consumer directed health plans are a benefit design trend, there is little empirical evidence of their influence on health care use. Monitoring the outcome of such studies is important as it relates to CHRT's benefit design work.

CMS to Pay Physicians More than $36M in Incentives for Participating in Quality Reporting Initiative

Kaiser Daily Health Policy Report – July 16, 2008

CMS officials announced more than $36 million will be paid out to health professionals who reported data on the quality of care delivered between July 2007 and December 2007, in accordance with its Physician Quality Reporting Initiative (PQRI). The new bonuses for e-prescribing will be among the top of those paid as part of PQRI and other Medicare reimbursements. Medicare expects to save up to $156 million over the life of the e-prescribing program in fewer adverse drug events. Although physicians acknowledge the overall advantage of e-prescribing, they often cite the high cost as a barrier to implementation. The CMS incentives should assist physicians and small practices.

Patient Centered Primary Care Collaborative (PCPCC) Releases Health Plan Purchasing Guide for Employers – goal to advance medical home

Patient Centered Primary Care Collaborative – July 16, 2008

Patient Centered Primary Care Collaborative (PCPCC), a coalition representing the country's national business leaders, consumer groups, and organizations representing primary care physicians and other health care stakeholders released its purchaser guide to the patient-centered medical home. In addition to providing an overview of the patient-centered medical home, the guide explains why purchasers should consider supporting it. The Blue Cross and Blue Shield Association is working collaboratively with the PCPCC in medical home projects across the country. The guide offers an opportunity to encourage discussion on how the Blues can potentially work with the employer community around payment reform and the PCMH.

The Next Step in Guideline Development – Incorporating Patient Preferences

JAMA. July 23/30 2008;300(4):436–438. (Subscription required to view full text)

This article examines the process of developing clinical practice guidelines (CPGs), and reveals the few studies available on this topic support the idea that guidelines do not consistently take patient preferences into account. The author goes on to suggest that patients' perspectives, experiences, and choices should be more fully incorporated into CPGs; guideline developers should indicate whether or not recommendations are preference-sensitive. This would distinguish between recommendations that nearly all patients would accept and those that are likely to vary depending on an individual patient's preferences; for example, when the evidence is unclear or conflicting, or when there may be tradeoffs between risks and benefits of a particular treatment. This article is relevant in light of CHRT's work in and the current trend toward patient-centered medicine, characterized by an increased emphasis on patient experience and an increased role for patients in decision making.

Medicare and Medicaid Move Aggressively To Encourage Greater Patient Safety in Hospitals and Reduce Never Events – expands list of no-pay conditions to 11

CMS, July 31, 2008

The CMS added three additional hospital-acquired conditions for which Medicare will no longer reimburse beginning Oct. 1, bringing that total to 11. The agency also will require hospitals to report on 13 more quality measures under the inpatient prospective payment system 2009 final rule. The three additional conditions are: surgical-site infections following certain orthopedic and bariatric surgeries; certain manifestations of poor control of blood sugar levels; and deep-vein thrombosis or pulmonary embolism following total knee and hip replacements. While many agree that Medicare shouldn't be paying for preventable errors, such as leaving items inside patients during surgery (one of the conditions on the initial no-pay list), there are those that view the new items as not always preventable, and therefore not belonging on the "never events" list. (e.g., according to the Society of Hospital Medicine, blood clots remain relatively common in patients after knee and hip replacements).

Trying to Save by Increasing Doctors' Fees

New York Times, July 21 2008

This article provides examples of several medical home pilot projects that include enhanced reimbursement for primary care physicians: a Medicaid pilot in North Carolina, a Philadelphia pilot expanding to other parts of Pennsylvania over the next three years, and the Blue Cross Blue Shield of Michigan PCMH initiative. The article cites "a reasonable body of evidence" suggesting that primary care (as a foundation for health care) will improve quality and access to care, and at the same time acknowledges the need for rigorous evaluation to address questions about the model's clinical and economic effectiveness.

Second National Scorecard on U.S. Health Care System Finds No Overall Improvement; Steep Decline in Access, Scores on Efficiency Especially Low

The Commonwealth Fund, July 17 2008

The Commonwealth Fund Commission on a High Performance Health System finds that the U.S. health care System has failed to improve overall and that scores on access have declined significantly since the first national scorecard in 2006. Despite spending more on health care than any other industrialized nation, the U.S. overall continues to fall far short on key indicators of health outcomes and quality, with particularly low scores on efficiency. The number of uninsured and underinsured continues to rise. As of 2007, 42 percent of all working age adults were either uninsured or underinsured-up from 35 percent in the four years since 2003. The scorecard trends present a case for change in the way U.S. health care is financed, organized, and delivered. The report concludes that, if all of the U.S. were brought up to benchmark levels, there would be substantial benefits in terms of health, patient experiences, and savings.

Projecting Health Care Cost Trends: Observations on the Society of Actuaries New Model

Watson Wyatt Insider, July 2008

Financial Accounting Statement 106 requires companies to report and accrue their obligations for post employment benefits — including retiree health plans — for current and future retirees. The rate of growth in the cost of health care benefits, which must be projected well into the future, can be the most significant assumption in calculating the obligation, so the model and assumptions used in these projections are critical. Currently, most corporate plan sponsors assume that health care costs will grow at 9 percent in the near term. They also assume that the rate of growth will tamp down to 5 percent over the next six years and remain there for the long term. The focus in this article is on the long-term projections. Watson Wyatt is used by many employers as they design their benefit plans. Their projections are important because they can be a leading indicator of what health benefit managers will be considering as they consider health benefit design changes.

Special Interest Topics

State Smoking Restrictions for Private-Sector Worksites, Restaurants, and Bars – United States, 2004 and 2007

JAMA. July 23/30 2008; 300(4):387–388.

This report focuses on smoking restrictions in indoor areas in private-sector worksites, restaurants, and bars. These three settings were selected because worksites are a major source of second hand smoke (SHS). The smoking restrictions in effect in each of the 50 states and D.C. as of December 31, 2004, and December 31, 2007, were compiled from CDC's State Tobacco Activities Tracking and Evaluation (STATE) System database, which contains tobacco-related epidemiologic and economic data and information on state tobacco-related legislation. The findings indicated a substantial increase in the number and restrictiveness of state laws regulating smoking in these three settings, providing nonsmokers with increased protection from the health risks posed by SHS. If current trends continue, achieving the national health objective by 2010 might be possible. This is in line with the Michigan Healthy Communities Initiave that is examining a policy for a smoke free UM campus within this same timeframe.