February 2010

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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Benefit Design

Giving Teeth to Comparative-Effectiveness Research — The Oregon Experience

New England Journal of Medicine, Feburary 3, 2010

In 1989, Oregon developed an approach to evidence-based health care coverage. The state was designing the Oregon Health Plan (OHP), in which Medicaid-funded health care is administered mainly by private health plans. The principle behind the OHP was: when funds are limited, the state should deliver fewer services to more people rather than more services to fewer people. When costs rise or revenues are diminished, cuts should be made to lower-priority services, not to the number of people covered. To prioritize services, Oregon created the Health Services Commission (HSC), a volunteer group of seven health professionals and four consumer representatives. Coupling these priorities with scientific evidence and expert opinion about treatment effectiveness, the HSC developed a prioritized list of approximately 700 condition–treatment pairs, rank-ordered according to importance. Actuarial calculations of the cost of services for patients in the target population are made every 2 years in developing the Medicaid program’s proposed budget. The state legislature then draws a line on the list, and services above the line constitute the benefits package. Participating health plans must cover all services above the line, with some flexibility afforded when more than one treatment option is available. They can also cover services below the line, but in practice most health plans do so infrequently. Comparative effectiveness research holds the potential for improving the quality and controlling the costs of health care but only if its results influence health care delivery. As health care reform proceeds, policymakers should consider empowering local, state, and regional benefits boards to use CER findings in shaping coverage policies.

Health Care Costs

Chronic Conditions Account For Rise In Medicare Spending From 1987 To 2006

Health Affairs Web Exclusive, February 18, 2010 (Subscription required to view full text)

According to this study that analyzed data from the 1987 National Medical Expenditures Survey and the 1997 and 2006 Medical Expenditure Panel Survey, Medicare beneficiaries’ medical needs, and where beneficiaries undergo treatment, have changed dramatically over the past two decades. Among the key findings: Twenty years ago, most spending growth was linked to intensive inpatient (hospital) services, mainly for heart disease. More recently, much of the growth has been attributable to chronic conditions such as diabetes, arthritis, hypertension, and kidney disease. These conditions are primarily treated in outpatient settings and by patients at home with prescription drugs. The authors conclude, "The changing mix of medical conditions driving the rise in Medicare spending had consequential effects. More than half of the beneficiaries are treated for five or more chronic conditions each year. System fragmentation means that chronically ill patients receive episodic care from multiple providers who rarely coordinate the care they deliver, and chronic disease management programs are notably absent in traditional fee-for-service Medicare. As Congress, the administration, providers, insurers, and consumers debate reshaping the U.S. health system, they must address these changed health needs through evidence-based preventive care."

Obesity

Childhood Obesity, Other Cardiovascular Risk Factors, and Premature Death

New England Journal of Medicine, Feb. 11, 2010

This study assessed the association of body-mass index (BMI), glucose tolerance, and blood pressure and cholesterol levels with premature death. The study examined a cohort of 4857 American Indian children without diabetes who were born between 1945 and 1984. Risk factors were standardized according to sex and age. The researchers found that obesity, glucose intolerance, and hypertension in childhood were strongly associated with increased rates of premature death from endogenous causes in this population. In contrast, childhood hypercholesterolemia was not a major predictor of premature death from endogenous causes. The effect of childhood risk factors for cardiovascular disease on adult mortality is poorly understood. This study adds to the body of knowledge that is growing on this topic.

Health Care Reform

Can States Pick Up the Health Reform Torch?

New England Journal of Medicine, February 24, 2010

This essay states that as the White House and Congress struggle to move forward, some observers have once again focused on the states. Saying that the Senate bill, unlike its House counterpart, uses a state-based approach to the operation of health insurance exchanges, the purchasing marts through which eligible individuals and small businesses would gain access to affordable coverage. But unlike independent state reforms, the House and Senate bills offer a national solution for the residents of all states, not just those who live in jurisdictions with the political and financial means to pursue change. The author concludes that while states may be health system innovators, "innovation in health care can happen only if it rests on a solid financial base. As in banking and other matters of national economic security, only the President and Congress — acting on behalf of an electorate possessed of the political will to move forward — can create the financial conditions on which a 21st-century health care system necessarily rests."

Unchecked Provider Clout In California Foreshadows Challenges To Health Reform

Health Affairs Web Exclusive, February 25, 2010 (Subscription required to view full text)

This study, funded by the California Health Care Foundation, examined the growing market power of many California hospitals and physicians, finding that providers are using various strategies, such as tighter alignment of hospitals and physician groups, to negotiate significantly higher payment rates from private insurers. The study also points out that California offers a cautionary tale for reform proposals that encourage hospitals and physicians to form tighter relationships through accountable care organizations. The authors conclude that "unless market mechanisms can be found to discipline providers' use of their growing market power, it seems inevitable that policy makers will need to turn to regulatory approaches, such as putting price caps on negotiated private-sector rates and adopting all-payer rate setting. Indeed, some purchasers who believe strongly in the long-term merits of increased integration of care delivery believe that price regulation may be a prerequisite for payment reforms that encourage integration."

Radiology

Low back pain and best practice care: A survey of general practice physicians

Archives of Internal Medicine, February 8, 2010

The goal of this study was to describe the usual care provided by general practitioners (GPs) and to compare this with recommendations of best practice in international evidence-based guidelines for the management of acute low back pain (LBP). The researchers reviewed care provided in 3533 patient visits to GPs for a new episode of LBP, and mapped these visits to key recommendations in treatment guidelines. The proportion of patient encounters in which care arranged by a GP aligned with these key recommendations was determined for the period 2005 through 2008 and separately for the period before the release of the local guideline in 2004 (2001-2004). The study found that Although guidelines discourage the use of imaging, over one-quarter of patients were referred for imaging. Guidelines recommend that initial care should focus on advice and simple analgesics, yet only 20.5% and 17.7% of patients received these treatments, respectively. Instead, the analgesics provided were typically nonsteroidalanti-inflammatory drugs (37.4%) and opioids (19.6%). This pattern of care was the same in the periods before and after the release of the local guideline. The authors conclude that the usual care provided by GPs for LBP does not match the care endorsed in international evidence-based guidelines and may not provide the best outcomes for patients. Furthermore, the situation has not improved over time.