May 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.

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Access to Health Care

The Geographic Accessibility of Retail Clinics for Underserved Populations

Arch Intern Med. 2009;169(10):945–949 (Subscription required to view full text)

The extent to which retail clinics provide access to care for underserved populations remains largely unknown. The purpose of this study was to determine whether retail clinics tend to be located in census tracts with higher medical need. The study mapped locations of retail clinics, linked them to U.S. Census (2000) and Health Resources and Services Administration (2008) data, and compared the characteristics of census tracts with and without retail clinics. Eighteen states had no retail clinics, and 17 states had 25 or more clinics. Of the 932 retail clinics in the U.S., 930 were successfully mapped. Within counties with at least one retail clinic, census tracts had a lower black population percentage, lower poverty rates, higher median incomes, and were less likely to be medically underserved than census tracts without retail clinics. Similarly, stores with retail clinics were less likely to be located in medically underserved areas compared with stores without retail clinics. These results indicate that retail clinics, which might otherwise provide an increase in access to health care, are currently located in more advantaged neighborhoods, which may make them less accessible for those most in need.

Health Care Reform

Wealth, Income, And The Affordability Of Health Insurance

Health Affairs 28, no. 3 (2009): 887–896; 10.1377/hlthaff.28.3.887 (Subscription required to view full text)

Experts disagree on the number of uninsured people who can afford insurance but refuse to purchase it. By examining the difference in asset holdings between the privately insured and the uninsured, this study reports the difference in purchasing power is not fully revealed by income comparisons. Median income among the privately insured is almost three times that of the uninsured, but median wealth among those with private insurance is 23.2 times that of the uninsured. The results suggest that assets are an important determinant of effective affordability, undermining the notion that many people are uninsured by choice. The article provides a descriptive overview of the differences in financial assets between the privately insured and the uninsured, separately for those with and without access to employer coverage. The data used in the study show that those with insurance have dramatically higher assets than those who are uninsured. These results have important policy implications for defining affordability thresholds in future reforms requiring individual premium or cost-sharing contributions.

Health System Modernization Will Reduce the Deficit

David M. Cutler Harvard University, Center for American Progress Action Fund, May 2009

Health care will be the major challenge in the federal budget in coming decades, with rising health costs accounting for nearly all of the expected increase in government spending relative to gross domestic product. Health care currently accounts for 16 percent of GDP, and that share is forecast to nearly double in the next quarter century. Estimates suggest that a third or more of medical spending — perhaps $700 billion per year — is not known to be worth the cost. A bipartisan consensus has coalesced around the idea of modernizing the health system as a way of stimulating cost savings. Health care modernization involves four broad steps: investing in infrastructure; measuring what is done and how well it is performed; rewarding high-value care, not just high-volume care; and realigning consumer incentives to encourage better health behavior. This report analyzes how such reforms would affect the federal budget over time. It shows that health system modernization could increase productivity growth in health care by 1.5 to 2.0 percentage points annually starting in four to five years. According to the authors, the impact of such productivity improvement would be substantial — an estimated savings of nearly $600 billion in health spending over the next decade, and $9 trillion over the next 25 years. Cutler contends that, over time, these savings would more than offset the cost of providing insurance coverage to all Americans and put the United States on a path to long-term fiscal balance.

Achieving Health Care Reform -- How Physicians Can Help

NEJM Volume 360:2495–2497 June 11, 2009 Number 24 (Subscription required to view full text)

Physicians should help lead the effort to establish affordable, high-quality health care in the United States, say three leading experts in health reform and policy in a New England Journal of Medicine "Perspectives" column published online. Elliott S. Fisher, M.D, M.P.H., of the Dartmouth Institute for Health Policy and Clinical Practice, Donald M. Berwick, M.D., M.P.P., of the Institute for Healthcare Improvement, and Karen Davis, Ph.D., of The Commonwealth Fund suggest that physicians help create consensus around "doctrinal divides" — such as the creation of a public insurance option — and bring providers together to create a health system that better serves both the public's needs and physicians' values. The authors conclude that physicians should acknowledge health care delivery reform is a win-win that can improve primary care while maintaining physicians' incomes, and that reducing health care costs at a rate of 1.5 percentage points a year will not be detrimental to patients or providers.

Medicare PPO

Continuity of Outpatient and Inpatient Care by Primary Care Physicians for Hospitalized Older Adults

JAMA. 2009;301(16):1671–1680. (Subscription required to view full text)

The objective of this study was to describe continuity of care in older hospitalized patients, change in continuity over time, and factors associated with discontinuity. The study included a retrospective cohort study of 3,020,770 hospital admissions between 1996 and 2006 using enrollment and claims data for a five percent national sample of Medicare beneficiaries older than 66 years. Data files were constructed to include the patients' demographic and enrollment information (denominator file) and claims for hospital stays (MEDPAR file) and physician services (carrier claims file). Characteristics of the hospitals were included in annual provider of services files. Being seen by a physician was defined as when a physician had submitted a bill for evaluation and management services for that patient. Results indicate that in 1996, 50.5 percent of hospitalized patients were seen by at least one physician that they had visited in an outpatient setting in the prior year, and 44.3 percent of patients with an identifiable PCP were seen by that physician while hospitalized. These percentages decreased to 39.8 percent and 31.9 percent, respectively, in 2006. Greater absolute decreases in continuity with any outpatient physician between 1996 and 2006 occurred in patients admitted on weekends and those living in large metropolitan areas and in New England. In conclusion, in multivariable multilevel models, increasing involvement of hospitalists was associated with approximately one-third of the decrease in continuity of care between 1996 and 2006. This study adds to the body of knowledge surrounding what is known about the impact of the extent of continuity of care across the transition from outpatient care to hospitalization.

The Continuing Cost of Privatization: Extra Payments to Medicare Advantage Plans Jump to $11.4 Billion in 2009

The Commonwealth Fund, May 2009

The Medicare Modernization Act of 2003 explicitly increased Medicare payments to private Medicare Advantage (MA) plans. As a result, MA plans have, for the past six years, been paid more for their enrollees than they would be expected to cost in traditional fee-for-service Medicare. Payments to MA plans in 2009 are projected to be 13 percent greater than the corresponding costs in traditional Medicare — an average of $1,138 per MA plan enrollee, for a total of $11.4 billion. Although the extra payments are used to provide enrollees additional benefits, those benefits are not available to all beneficiaries but they are financed by general program funds. If payments to MA plans were instead equal to the spending level under traditional Medicare, the more than $150 billion in savings over 10 years could be used to finance improved benefits for the low-income elderly and disabled, or for expanding health-insurance coverage.

Patient Centered Medical Home

What Patient-Centered Should Mean: Confessions Of An Extremist

Health Affairs 28, no. 4 (2009): w555–w565 published online 19 May 2009

This essay describes the concept of "Patient-Centeredness" as a dimension of health care quality in its own right, not just because of its connection with other desired aims, like safety and effectiveness. According to Berwick, its proper incorporation into new health care designs will involve some radical, unfamiliar, and disruptive shifts in control and power, out of the hands of those who give care and into the hands of those who receive it. Such a consumerist view of the quality of care, itself, has important differences from the more classical, professionally dominated definitions of "quality." The author contends that new designs, like the "medical home", should incorporate that change.

Radiology

Rapidity and Modality of Imaging for Acute Low Back Pain in Elderly Patients

Arch Intern Med. 2009;169(10):972–981 (Subscription required to view full text)

This study analyzed Medicare claims from 2000–02 and 2004–06 for fee-for-service Medicare beneficiaries with acute low back pain (LBP). The researchers modified a measure of inappropriate imaging developed by the National Committee on Quality Assurance. They characterized the rapidity (imaging within 28 days, 29-180 days, none within 180 days) and modality of imaging (computed tomography or magnetic resonance imaging [CT/MRI], only radiograph, or no imaging). They used statistical models to assess relationships between imaging and patient demographics and physician/practice characteristics including exposure to financial incentives based on patient satisfaction, clinical quality, cost profiling, or productivity. The study found that rapidity and modality of imaging for LBP is associated with patient and physician characteristics, but the directionality of associations with desirable care processes is opposite of associations for measures targeting underuse. Metrics that encompass overuse may suggest new areas of focus for quality improvement.