Issue brief (Center for Studying Health System Change)最新文献

Price variation for medical procedures performed in both hospital outpatient departments and freestanding facilities has not decreased in New Hampshire since the state launched the HealthCost price transparency program in early 2007, according to new research jointly conducted by the New Hampshire Insurance Department and the Center for Studying Health System Change (HSC). New Hampshire stakeholders cited weak provider competition as the key reason for lack of impact. The state's hospital market is geographically segmented in rural areas and has few competitors even in urban areas. In addition, few consumers have strong incentives to shop based on price: Only 5 percent of the state's privately insured residents were enrolled in high-deductible plans in 2007. However, some observers suggested that HealthCost--along with other state price transparency initiatives--has helped to focus employer and policy maker attention on provider price differences and has caused some hospitals to moderate their demands for rate increases.

In the last decade, growing evidence that the quality of U.S. health care is uneven at best has prompted greater attention to quality improvement, especially in the nation's hospitals. While physicians are integral to hospital quality improvement efforts, focusing physicians on these activities is challenging because of competing time and reimbursement pressures. To overcome these challenges, hospitals need to employ a variety of strategies, according to a Center for Studying Health System Change (HSC) study of four communities--Detroit, Memphis, Minneapolis-St. Paul and Seattle. Hospital strategies include employing physicians; using credible data to identify areas that need improvement; providing visible support through hospital leadership; identifying and nurturing physician champions to help engage physician peers; and communicating the importance of physicians' contributions. While hospitals are making gains in patient care quality, considerably more progress likely could be made through greater alignment of hospitals and physicians working together on quality improvement.

Among the many health care quality transparency initiatives introduced in recent years, two state-based programs stand out for thoughtful design, implementation and usable, useful data: CalHospitalCompare, a report card for California hospitals, and Massachusetts Health Quality Partners, a report card for Massachusetts primary care physician groups. According to a new Center for Studying Health System Change (HSC) analysis, both programs share key elements that contribute to their effectiveness: engaging and collaborating with the provider community from the outset; paying particular attention to the caliber of the quality data reported; presenting the quality data to consumers in formats that are easy to understand and remember; and providing hospitals and physicians with detailed information on their own performance. Quality transparency initiatives that do not focus sufficiently on these key design and implementation elements are unlikely to influence quality improvement in a meaningful way.

The growing prevalence of chronic health conditions--about 60 percent of the adult U.S. population had at least one chronic condition in 2005--has added costs to the U.S. health care system. Prevention and better management of chronic conditions are often cited as ways to improve health outcomes and slow U.S. health care spending growth--or at least generate better value for the $2.1 trillion spent annually on health care in the United States. Yet, the health care system remains largely focused on acute, episodic care, according to experts at a Center for Studying Health System Change (HSC) conference titled, Rising Rates of Chronic Health Conditions: What Can Be Done? Panelists explored the role of obesity in rising rates of chronic conditions, the need for better information on how to treat patients with multiple chronic conditions, how to help patients improve self-management skills and how difficult changing unhealthy behaviors can be.

Passage of health reform legislation in Massachusetts required significant bipartisan compromise and buy in among key stakeholders, including employers. However, findings from a recent follow-up study by the Center for Studying Health System Change (HSC) suggest two important developments may threaten employer support as the reform plays out. First, improved access to the non-group--or individual--insurance market, the availability of state-subsidized coverage, and the costs of increased employee take up of employer-sponsored coverage and rising premiums potentially weaken employers' motivation and ability to provide coverage. Second, employer frustration appears to be growing as the state increases employer responsibilities. While the number of uninsured people has declined significantly, the high cost of the reform has prompted the state to seek additional financial support from stakeholders, including employers. Improving access to health care coverage has been a clear emphasis of the reform, but little has been done to address escalating health care costs. Yet, both must be addressed, otherwise long-term viability of Massachusetts' coverage initiative is questionable.

While hospitals are evaluating strategies to help physicians purchase electronic medical records (EMRs) following recent federal regulatory changes, they are proceeding cautiously, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. Hospital strategies to aid physician EMR adoption include offering direct financial subsidies, extending the hospital's ambulatory EMR vendor discounts and providing technical support. Two key factors driving hospital interest in supporting physician EMR adoption are improving the quality and efficiency of care and aligning physicians more closely with the hospital. A few hospitals have begun small-scale, phased rollouts of subsidized EMRs, but the burden of other hospital information technology projects, budget limitations and lack of physician interest are among the factors impeding hospital action. While it is too early to assess whether the regulatory changes will spur greater physician EMR adoption, the outcome will depend both on hospitals' willingness to provide support and physicians' acceptance of hospital assistance.

Poor oral health among low-income people is gaining attention as a significant health care problem. Key barriers to dental services include low rates of dental insurance coverage, limited dental benefits available through public insurance programs, and a lack of dentists willing to serve low-income patients, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. Communities are attempting to provide more dental services to low-income residents. Along with state efforts to increase dentists' participation in Medicaid and the State Children's Health Insurance Program (SCHIP), hospitals, community health centers, health departments, dental schools and others are working to expand dental services, with some focusing on basic preventive services and others pursuing more comprehensive dental care. Many community efforts rely on increasing the number of dental professionals available to treat low-income people. Without additional involvement from the dental community and state and federal policy makers, however, many low-income people likely will continue to lack access to dental care and suffer the consequences.

Despite an acknowledged lack of evidence of investment payoff, health plan initiatives to promote health and wellness are now commonplace, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. Much of the impetus has come from employers--primarily large employers--that are incorporating health and wellness activities into benefit designs that place more responsibility on employees for health care decisions and costs. Health plans now offer a range of health and wellness activities, including traditional worksite health fairs, screenings and educational seminars; access to behavior modification programs, such as weight management and smoking cessation; and online tools, including health risk assessments. Engaging enrollees in these activities, however, is challenging because participation typically is voluntary. Another barrier is employee privacy concerns. More health plans and employers are turning to financial incentives to secure greater participation. Ultimately, however, the credibility of health and wellness activities as mechanisms to improve health and contain costs is dependent on evidence demonstrating their clinical and financial effectiveness, as well as consumers' acceptance and validation of their legitimacy.

Hospital emergency departments (EDs) are caring for more patients, including those with non-urgent needs that could be treated in alternative, more cost-effective settings, such as a clinic or physician's office. According to findings from the Center for Studying Health System Change's 2007 site visits to 12 nationally representative metropolitan communities, many emergency departments at safety net hospitals--the public and not-for-profit hospitals that serve large proportions of low-income, uninsured and Medicaid patients--are attempting to meet patients' non-urgent needs more efficiently. Safety net EDs are working to redirect non-urgent patients to their hospitals' outpatient clinics or to community health centers and clinics, with varied results. Efforts to develop additional primary, specialty and dental care in community settings, along with promoting the use of these providers, could stem the use of emergency departments for non-urgent care, while increasing access to care, enhancing quality and containing costs.

Health plans have expanded consumer-directed health plan (CDHP) product offerings--typically high-deductible health plans coupled with a spending account--and more employers are offering these products to workers, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. In developing CDHPs, health plans are responding to a broader employer strategy to confer more responsibility on workers for their health care costs, lifestyle choices and treatment decisions. CDHP adoption by employers and consumers depends on a range of factors, including product features and employer characteristics, and varies across the 12 communities. While more large employers are introducing CDHPs into health benefit programs, adoption of CDHPs remains modest. Health plans and employers expect CDHP enrollment to grow as employers and employees become more knowledgeable about CDHP features, health plans develop more sophisticated support tools for plan enrollees, and there are more opportunities to learn from early adopters' experiences.early