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

The proportion of physicians in group practice whose compensation is based in part on quality measures increased from 17.6 percent in 2000-01 to 20.2 percent in 2004-05, according to a new national study from the Center for Studying Health System Change (HSC). Despite this small but statistically significant increase, quality-related physician compensation is much less common than financial incentives tied to physicians' individual productivity, which has consistently affected 70 percent of physicians in non-solo practice since 1996-97. Examining the trend in quality-related physician compensation since 1996-97 suggests that quality incentives are most prevalent among primary care physicians and in large practices that receive a substantial share of revenue from capitated payments, or fixed per patient, per month payments.

Despite the buzz about empowering consumers and controlling rising health costs, consumer-directed health plans (CDHPs)--defined as high-deductible plans coupled with savings accounts--have barely gained a toehold among Americans with employer-sponsored insurance, according to a new national study by the Center for Studying Health System Change (HSC). CDHP proponents often assert the plans offer employees greater choice and autonomy in the health care marketplace, but 39 percent of the estimated 2.7 million workers enrolled in employer-sponsored CDHPs had no choice of another type of health plan in 2006. Moreover, among workers with a choice of plans, relatively few (19%) choose CDHPs when offered another type of plan option, such as preferred provider organizations (PPOs) or health maintenance organizations (HMO). Comparable take-up rates for PPO and HMO plans when employees have a choice of another plan type were 55 percent and 40 percent, respectively.

Physicians in smaller practices continue to lag well behind physicians in larger practices in reporting the availability of clinical information technology (IT) in their offices, according to a new national study from the Center for Studying Health System Change (HSC). The proportion of physicians reporting access to IT for each of five clinical activities increased across all practice settings between 2000-01 and 2004-05. Adoption gaps between small and large practices persisted, however, for two of the clinical activities--obtaining treatment guidelines and exchanging clinical data with other physicians--and widened for the other three--accessing patient notes, generating preventive care reminders and writing prescriptions. In contrast, clinical IT was generally as likely or more likely to be available to physicians in practices treating larger proportions of vulnerable and underserved patients as other physicians, a pattern that did not change between the two periods

While the new Medicare drug benefit has helped alleviate concerns about prescription drug access for elderly and disabled Americans, many low-income, uninsured people under age 65 continue to rely on community safety nets to get needed medications. As the number of uninsured Americans increases, safety net providers are stretching limited resources to meet growing prescription drug needs, according to findings from the Center for Studying Health System Change's (HSC) 2005 site visits to 12 nationally representative communities. Despite redoubled efforts--centered on obtaining discounted drugs and donated medications--to make affordable drugs available to needy patients, safety net providers and community advocates report that many low-income, uninsured people continue to face major barriers to obtaining prescription drugs.

A small but increasing proportion of immigrants to the United States is undocumented. Because most undocumented immigrants lack health insurance, they primarily rely on safety net providers for care. Communities with more developed safety nets and historically large numbers of immigrants appear more adept at caring for both legal and undocumented immigrants, according to Center for Studying Health System Change's (HSC) 2005 site visits to 12 nationally representative communities. Communities with less experience caring for immigrant populations and less-developed safety nets face challenges caring for this population, but many are taking steps to improve their ability to meet immigrant needs. As the number of immigrants in the U.S. grows, the need to develop community health care capacity for immigrants will intensify.

Policy makers continue to debate the correct public policy toward physician-owned heart, orthopedic and surgical specialty hospitals. Do specialty hospitals offer desirable competition for general hospitals and foster improved quality, efficiency and service? Or do specialty hospitals add unneeded capacity and increased costs while threatening the ability of general hospitals to deliver community benefits? In three Center for Studying Health System Change (HSC) sites with significant specialty hospital development--Indianapolis, Little Rock and Phoenix--recent site visits found that purchasers generally believe specialty hospitals are contributing to a medical arms race that is driving up costs without demonstrating clear quality advantages.

While pay for performance (P4P) has created a nationwide buzz among health plans, physicians and hospitals, most P4P initiatives are still on the drawing board, according to findings from the Center for Studying Health System Change's (HSC) 2005 site visits to 12 nationally representative communities. HSC focused on performance-based payment for physicians, finding that only two HSC communities-Orange County, Calif., and Boston-have significant physician P4P programs. In the other 10 communities, where almost no physicians have received quality-related payments to date, physician attitudes about P4P ranged from skeptical to hostile. P4P, a concept best suited to larger physician groups, may be difficult to implement in markets dominated by small physician practices. In spite of substantial barriers to initiating performance-related payment for physicians, most large health plans and Medicare are planning P4P programs.

Pressures--ranging from persuading specialists to provide on-call coverage to dealing with growing numbers of patients with serious mental illness--are building in already-crowded hospital emergency departments (EDs) across the country, according to findings from the Center for Studying Health System Change's (HSC) 2005 site visits to 12 nationally representative communities. As the number of ED visits rises significantly faster than population growth, many hospitals are expanding emergency department capacity. At the same time, hospitals face an ongoing nursing shortage, contributing to tight inpatient capacity that in turn hinders admitting ED patients. In their role as hospitals' "front door" for attracting insured inpatient admissions, emergency departments also increasingly are expected to help hospitals compete for insured patients while still meeting obligations to provide emergency care to all-comers under federal law. Failure to address these growing pressures may compromise access to emergency care for patients and spur already rapidly rising health care costs.

A barrage of publicity about aggressive hospital billing and collection practices and a spate of lawsuits alleging hospitals overcharged uninsured patients have put hospitals in a harsh national spotlight. In the wake of a campaign by hospital associations to encourage hospitals to create formal policies for billing uninsured patients, many hospitals have modified billing and collection practices for low-income, uninsured patients, according to the Center for Studying Health System Change's (HSC) 2005 site visits to 12 nationally representative communities. Almost all of the hospitals interviewed that had adopted more generous charity care policies indicated expenses previously classified as bad debt have shifted to charity care write-offs. To date, these changes have had little impact on hospital bottom lines, and the impact on access to care for uninsured people remains unclear.

While considerable research shows that uninsured people are less likely to seek and receive medical care, some contend that the uninsured are uninsured by choice and can obtain care when needed. A new study by the Center for Studying Health System Change (HSC), however, undercuts the validity of this contention, finding that there is no difference between insured and uninsured people's perception of the need to see a medical provider when they experience a serious new symptom. However, among people who believed that they needed medical care, the uninsured were less than half as likely to see or talk to a doctor, indicating that lack of insurance is a major barrier to uninsured people getting needed medical care.