March 2009

Healthcare Topics and Trends Update

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

Past Issues »

Taking Stock Of Pay-For-Performance: A Candid Assessment From The Front Lines

Health Affairs 28, no. 2 (2009):517–525; 10.1377/hlthaff.28.2.517 (Subscription required to view full text)

Pay-for-performance (P4P) has been widely adopted, but it remains unclear how providers are responding and whether results are meeting expectations. Physician organizations involved in the California Integrated Healthcare Association's (IHA) P4P program reported having increased physician-level performance feedback and accountability, speeded up information technology adoption, and sharpened organizational focus and support for improvement in response to P4P; however, after three years of investment, these changes had not translated into breakthrough quality improvements. This study included interviews with 35 unique physician organizations, seven health plans, and two purchasers. As we move into second-generation P4P program designs, these programs must be evaluated: If the strength of incentives is increased, will this lead to better results or adverse consequences? Does paying for improvement lead to greater improvements among the lowest performers? How does the number of measures affect physician engagement or influence the likelihood of broader system improvements?

Benefit Design

Retiree Health VEBAs: A New Twist On An Old Paradigm Implications for Retirees, Unions and Employers

Kaiser Family Foundation Website, March 2009

As the Big Three automakers struggle for survival in the current economic climate, there is renewed interest in policies that could have important implications for workers and retirees, including the trusts established to provide retiree health benefits, known as a Voluntary Employees' Beneficiary Associations (VEBAs). An issue brief prepared for the Kaiser Family Foundation provides an overview of stand-alone VEBA trusts, vehicles through which employers have been able to rid themselves of future obligations to pay retiree health benefits in exchange for making a significant payment to designed to approximate the projected cost of these benefits. The paper looks at three case studies, including the Big Three VEBAs, and highlights some of the pros and cons of such arrangements for retirees, unions and employers.

Research Translation

Why Does the Quality of Health Care Continue to Lag? Insights from Management Research

Academy of Management Perspectives Volume 23, Number 1 February 2009 (Subscription required to view full text)

This study draws on management research to explain why it has been so difficult to improve quality of care, despite a burgeoning body of scientific evidence on practices that result in better outcomes and the widespread adoption of quality-improving innovations based on those practices. The analysis points to the prevalence of "innovation implementation failure" — described as organizational members' inconsistent or improper use of innovations — as a primary cause, rather than, for example, an innovation that simply is ineffective. In their review, the authors identify the organizational sources of this failure and offer six strategies for avoiding innovation implementation failure in health care. The authors of the study conclude that management research shows that each of the contributors to implementation failure can be overcome through the targeted use of selected implementation strategies, and that being predisposed to implementation failure does not pre-determine failure.

Medicare PPO

Treating an Illness Is One Thing. What About a Patient With Many?

New York Times, March 31, 2009

This article highlights the challenges of treating multi-morbidity. Two-thirds of people over age 65, and almost three-quarters of people over 80, have multiple chronic health conditions, and 68 percent of Medicare spending goes to people who have five or more chronic diseases. As a group, patients with comorbidities linger in hospitals longer, experience more serious preventable health complications and die younger than patients with less complex medical profiles. Yet people with multiple health problems are largely overlooked both in medical research and in the nation's clinics and hospitals. A 2007 study found that 81 percent of the randomized trials published in the most prestigious medical journals excluded patients because of coexisting medical problems. The default position is to treat for each disease, rather than integrating care for elderly patients with multiple chronic conditions. The article concludes that changing this approach will require a major investment in research, guidelines, and quality measures that include the kinds of complicated cases doctors see every day.

The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses

Randall Brown, Mathematica Policy Research, Inc., March 2009

Numerous studies have documented that a relatively small percent of Medicare beneficiaries with multiple chronic conditions account for the vast majority of Medicare spending. This paper synthesizes evidence on cost-effective interventions and their components, identifies issues that must be resolved for ongoing research, and presents recommendations for care coordination policies in health care reform that can be supported by available evidence. The author highlights three interventions that have reduced hospitalizations for the target population: transitional care, self-management education, and coordinated care. Policy recommendations include offering ways for small practice physicians to participate in an effective care coordination intervention, targeting medical homes and care coordination interventions to beneficiaries at substantial risk of hospitalization in the coming year, and creating incentives for hospitals to participate in transitional care interventions.

Rehospitalizations among Patients in the Medicare Fee-for-Service Program

N Engl J Med 2009;360:1418–28. (Subscription required to view full text)

Readmissions among Medicare beneficiaries are prevalent and costly. Reducing rates of rehospitalization has attracted attention from policymakers as a way to improve quality of care and reduce costs. This study is an analysis of Medicare claims data from 2003–04 to describe the patterns of rehospitalization
and the relation of rehospitalization to demographic characteristics of the patients and to characteristics of the hospitals. The article is important because it is one of the first studies that provides this descriptive data of the readmission pattern in our country.