September 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 Care

Who Uses Emergency Care and Why

Long, S.K, Stockley, K. , Robert Wood Johnson Foundation, Policy Brief. September, 2009

Massachusetts residents are frequent users of emergency department (ED) care. High use levels continue despite significant improvements in access to care as a result of the state's 2006 health reform initiative. In an effort to better understand ED use in Massachusetts, this policy brief looks at ED use among working-age adults, focusing on reported reasons for using the ED and barriers to obtaining needed health care among ED users. Findings show adult ED users in Massachusetts are a sicker, more disabled, and more chronically ill population and report more difficulties obtaining care in the community and more unmet need for care than other adults in the state. These findings, which held for adults regardless of their insurance coverage, suggest that access problems in the community may play a significant role in ED use in Massachusetts. Potential strategies for addressing preventable ED use include efforts targeted to specific care settings and particular population groups.

Understanding The Current Population Survey's Insurance Estimates And The Medicaid "Undercount"

Klerman, J.A., et.al., Health Affairs, doi: 10.1377/hlthaff.28.6.w991 (web exclusive, published online September 10, 2009) (Subscription required to view full text)

Widely cited Census Bureau estimates (based on the Current Population Survey) probably overstate the number of uninsured due to Medicaid "undercount," that is, fewer people reporting they are covered by Medicaid than program administrative data show are enrolled. This study finds that the undercount can be explained by people's inability to recall their insurance status accurately from the previous year. The authors suggest that other data sources, such as Census's American Community Survey, should be studied to determine whether they would provide better estimates of the uninsured.

Health Care Costs

Using Clinical Information To Project Federal Health Care Spending

Huang, E.S., et. al, Health Affairs, 28, no. 5 (2009): w978–w990 (Published online 1 September 2009) doi: 10.1377/hlthaff.28.5.w978 (Subscription required to view full text)

The high costs associated with caring for people with chronic diseases is one of the most pressing health policy issues in the U.S. today. Medicare and other payers are under significant financial pressure as costs rise from predictable demographic and epidemiological forces. However, complications that result from chronic illnesses often do not emerge for many years. Current federal cost projection methods are constrained by ten-year cost estimates, which capture increases in near-term intervention costs but not changes in long-term costs. Current methods also cannot easily capture the cost implications of changes in disease progression. This study was undertaken to develop a new approach for estimating the incidence of type 2 diabetes and related health care costs in the future and use it to stimulate discussion on ways to improve the information base and process for policy making. This study presents results from an epidemiologically-based model that projects federal costs for diabetes under alternative policies, and the authors discuss the potential changes in the federal budget process needed to capture the full impact of these interventions.

Increased Spending On Health Care: Long-Term Implications For The Nation

Chernew, M.E., et. al, Health Affairs, 28, no. 5 (2009): 1253–1255 doi: 10.1377/hlthaff.28.5.1253

If the growth rate in U.S. health care spending continues at current levels, a vastly greater share of personal income and economic resources will be devoted to health care, according to a this new analysis published in Health Affairs. And even if that growth rate could be slowed to a pace of just one percentage point faster than annual per capita growth in the gross domestic product, more than half of any increase in personal income would still go to health care over the next 75 years. This analysis is an update to earlier research from 2003. Researchers project health spending in relation to economic growth over the period 2007 to 2083. They find that if health spending grows about two percentage points faster than real per capita GDP, 119 percent of the real increase in per capita income would be devoted to health spending. This means, in effect, that the entire net increase in income over the period would go to consumption of health care resources, as well as a portion of what currently goes to other goods and services.

Health Care Reform

21st-Century Health Care – The Case for Integrated Delivery Systems

Crosson, F.J, New England journal of Medicine, published on September 23, 2009, at NEJM.org. (Subscription required to view full text)

This article presents the case for two fundamental changes in health care as part of national health care reform: movement away from fee-for-service payment of physicians toward prospective payment, and multispecialty integration of physicians combined with hospitals to form new "accountable" systems of care. The author advocates that this can take place through rapid transition for established integrated delivery systems, as well as more gradual, "stepwise," changes for the transition from fee-for-service and solo or small-group practices to prospective payment and integrated delivery systems. He contends that the development of more integrated, accountable care systems should bring other benefits in addition to the opportunity to reduce costs. A number of studies have shown that integrated care is positively correlated with improved quality, which is achieved through the coordination of care among specialties, the effective use of information technology-based decision-support tools, and other key aspects of integrated systems. The article concludes with recommendations for the Centers for Medicare and Medicaid Services to build on the Medicare Physician Group Practice Demonstration by developing new models that will allow the agency to share financial risk with delivery systems, and for private payers to adopt models that ultimately are shown to be successful.

Radiology

Is All That Scanning Putting Us at Risk?

Boston Globe, Sept. 14, 2009

As the number of imaging scans has spiked in recent years, some doctors have become concerned about the volume of radiation some patients are receiving. Now, studies and anecdotal evidence are suggesting the problem may be more serious than previously suspected. Brigham and Women's has become one of the first hospitals in the U.S. to notify doctors of their patients' imaging history. This notification comes in response to a study conducted by hospital researchers concluding that high levels of radiation exposure are more common than some professionals might expect. The study, which was published in August in the New England Journal of Medicine, looked at insurance records from almost 1 million adults, ages 18 to 64. It found that 20 percent of those patients had gotten moderate radiation doses, and 2 percent received high or very high doses that exceeded the annual amount allowed for healthcare and nuclear industry workers. Extrapolating from this data, researchers concluded that about 4 million Americans are being exposed to large amounts of radiation from imaging tests.