Research brief最新文献

A key provision of the national health reform law is the creation of state-based exchanges to provide more affordable insurance options for people, especially the uninsured. Despite premium subsidies for people with incomes up to 400 percent of the poverty level, or $88,200 for a family of four in 2010, and an individual requirement to enroll in coverage, no one knows who will enroll in the exchanges and who will not, at least initially. Almost 40 percent of uninsured people eligible to receive subsidies through the exchanges have chronic conditions or report fair or poor health, and another 28 percent report recent problems with access to care or paying medical bills, according to a new national study by the Center for Studying Health System Change (HSC). However, about one-third of uninsured people eligible for subsidies have had no recent problems with their health, access to medical care or paying medical bills. Enrolling these apparently healthy uninsured people is likely to be challenging but essential to avoiding adverse selection, or enrolling sicker-than-average people, in the exchanges. Otherwise, health insurance costs in the exchanges could be higher than expected. Contrary to popular perception, many of these healthy and low-cost uninsured people view themselves as risk-averse, which could motivate them to gain coverage in the absence of health or access problems. Also, most uninsured people believe they need health coverage, although fewer believe that health insurance is currently worth the cost, a situation that could change once premium subsidies are available in 2014.

Interest in workplace clinics has intensified in recent years, with employers moving well beyond traditional niches of occupational health and minor acute care to offering clinics that provide a full range of wellness and primary care services. Employers view workplace clinics as a tool to contain medical costs, boost productivity and enhance companies' reputations as employers of choice. The potential for clinics to transform primary care delivery through the trusted clinician model holds promise, according to experts interviewed for a new qualitative research study from the Center for Studying Health System Change (HSC). Achieving that model is dependent on gaining employee trust in the clinic, as well as the ability to recruit and retain clinicians with the right qualities--a particular challenge in communities with provider shortages. Even when clinic operations are outsourced to vendors, initial employer involvement--including the identification of the appropriate scope and scale of clinic services--and sustained employer attention over time are critical to clinic success. Measuring the impact of clinics is difficult, and credible evidence on return on investment (ROI) varies widely, with very high ROI claims made by some vendors lacking credibility. While well-designed, well-implemented workplace clinics are likely to achieve positive returns over the long term, expecting clinics to be a game changer in bending the overall health care cost curve may be unrealistic.

Wide variation in private insurer payment rates to hospitals and physicians across and within local markets suggests that some providers, particularly hospitals, have significant market power to negotiate higher-than-competitive prices, according to a new study by the Center for Studying Health System Change (HSC). Looking across eight health care markets--Cleveland; Indianapolis; Los Angeles; Miami; Milwaukee; Richmond, Va.; San Francisco; and rural Wisconsin--average inpatient hospital payment rates of four large national insurers ranged from 147 percent of Medicare in Miami to 210 percent in San Francisco. In extreme cases, some hospitals command almost five times what Medicare pays for inpatient services and more than seven times what Medicare pays for outpatient care. Variation within markets was just as dramatic. For example, the hospital with prices at the 25th percentile of Los Angeles hospitals received 84 percent of Medicare rates for inpatient care, while the hospital with prices at the 75th percentile received 184 percent of Medicare rates. The highest-priced Los Angeles hospital with substantial inpatient claims volume received 418 percent of Medicare. While not as pronounced, significant variation in physician payment rates also exists across and within markets and by specialty. Few would characterize the variation in hospital and physician payment rates found in this study to be consistent with a highly competitive market. Purchasers and public policy makers can address provider market power, or the ability to negotiate higher-than-competitive prices, through two distinct approaches. One is to pursue market approaches to strengthen competitive forces, while the other is to constrain payment rates through regulation.

While the recession increased demands on the health care safety net as Americans lost jobs and health insurance, the impact on safety net providers has been mixed and less severe--at least initially--than expected in some cases, according to a new study of five metropolitan communities by the Center for Studying Health System Change (HSC). Even before the recession, many safety net providers reported treating more uninsured patients and facing tighter state and local funding. Federal expansion grants for community health centers during the past decade, however, have increased capacity at many health centers. And, programs to help direct people to primary care providers may have helped stem the expected surge in emergency department use by the uninsured during the downturn. Federal stimulus funding--the 2009 American Recovery and Reinvestment Act--has assisted hospitals and health centers in weathering the economic storm, helping to offset reductions in state, local and private funding. And, the economic downturn has generated some potential benefits, including lower rents and broader employee applicant pools. While safety net providers have adopted strategies to stay financially viable, many believe they have not yet felt the full impact of the deepest recession since the Great Depression.

Individual insurance is the only source of health coverage for people without access to employer-sponsored insurance or public insurance. Individual insurance traditionally has been sought by older, sicker individuals who perceive the need for insurance more than younger, healthier people. The attraction of a sicker population to the individual market creates adverse selection, leading insurers to employ medical underwriting--which most states allow--to either avoid those with the greatest health needs or set premiums more reflective of their expected medical use. Recently, however, several factors have prompted insurers to recognize the growth potential of the individual market: a declining proportion of people with employer-sponsored insurance, a sizeable population of younger, healthier people forgoing insurance, and the likelihood that many people receiving subsidies to buy insurance under proposed health insurance reforms would buy individual coverage. Insurers are pursuing several strategies to expand their presence in the individual insurance market, including entering less-regulated markets, developing lower-cost, less-comprehensive products targeting younger, healthy consumers, and attracting consumers through the Internet and other new distribution channels, according to a new study by the Center for Studying Health System Change (HSC). Insurers' strategies in the individual insurance market are unlikely to meet the needs of less-than-healthy people seeking affordable, comprehensive coverage. Congressional health reform proposals, which envision a larger role for the individual market under a sharply different regulatory framework, would likely supersede insurers' current individual market strategies.

Although suburban poverty has increased in the past decade, the availability of health care services for low-income and uninsured people in the suburbs has not kept pace. According to a new study by the Center for Studying Health System Change (HSC) of five communities--Boston, Cleveland, Indianapolis, Miami and Seattle--low-income people living in suburban areas face significant challenges accessing care because of inadequate transportation, language barriers and lack of awareness of health care options. Low-income people often rely on suburban hospital emergency departments (EDs) and urban safety net hospitals and health centers. Some urban providers are feeling the strain of caring for increasing numbers of patients from both the city and the suburbs. Both urban and suburban providers are attempting to redirect patients to more appropriate care near where they live by expanding primary care capacity, improving access to specialists, reducing transportation challenges, and generating revenues to support safety net services. Efforts to improve safety net services in suburban areas are hampered by greater geographic dispersion of the suburban poor and jurisdictional issues in funding safety net services. To improve the suburban safety net, policy makers may want to consider flexible and targeted approaches to providing care, regional collaboration to share resources, and geographic pockets of need when allocating resources for community health centers and other safety net services and facilities.

In the past decade, the rapid growth of specialty hospitals focused on profitable service lines, including cardiac and orthopedic care, has prompted concerns about general hospitals' ability to compete. Critics contend specialty hospitals actively draw less-complicated, more-profitable patients with Medicare and private insurance away from general hospitals, threatening general hospitals' ability to cross-subsidize less-profitable services and provide uncompensated care. A contentious debate has ensued, but little research has addressed whether specialty hospitals adversely affect the financial viability of general hospitals and their ability to care for low-income, uninsured and Medicaid patients. Despite initial challenges recruiting staff and maintaining service volumes and patient referrals, general hospitals were generally able to respond to the initial entry of specialty hospitals with few, if any, changes in the provision of care for financially vulnerable patients, according to a new study by the Center for Studying Health System Change (HSC) of three markets with established specialty hospitals--Indianapolis, Phoenix and Little Rock, Arkansas. In addition, safety net hospitals--general hospitals that care for a disproportionate share of financially vulnerable patients--reported limited impact from specialty hospitals since safety net hospitals generally do not compete for insured patients.

Despite calls from numerous organizations and payers to improve coordination of care, there are few published accounts of how care is coordinated in real-world primary care practices. This study by the Center for Studying Health System Change (HSC) documents strategies that a range of physician practices use to coordinate care for their patients. While there was no single recipe for coordination given the variety of patient, physician, practice and market factors, some cross-cutting lessons were identified, such as the value of a commitment to interpersonal continuity of care as a foundation for coordination. Respondents also identified the importance of system support for the standardization of office processes to foster care coordination. While larger practices may have more resources to invest, many of the innovations described could be scaled to smaller practices. Some coordination strategies resulted in improved efficiency over time for practices, but by and large, physician practices currently pursue these efforts at their own expense. In addition to sharing information on effective strategies among practices, the findings also provide policy makers with a snapshot of the current care coordination landscape and implications for initiatives to improve coordination. Efforts to provide technical support to practices to improve coordination, for example, through medical-home initiatives, need to consider the baseline more typical practices may be starting from and tailor their support to practices ranging widely in size, resources and presence of standardized care processes. If aligned with payment incentives, some of these strategies have the potential to increase quality and satisfaction among patients and providers by helping to move the health care delivery system toward better coordinated care.

Sponsors of health care price and quality transparency initiatives often identify all consumers as their target audiences, but the true audiences for these programs are much more limited. In 2007, only 11 percent of American adults looked for a new primary care physician, 28 percent needed a new specialist physician and 16 percent underwent a medical procedure at a new facility, according to a new national study by the Center for Studying Health System Change (HSC). Among consumers who found a new provider, few engaged in active shopping or considered price or quality information--especially when choosing specialists or facilities for medical procedures. When selecting new primary care physicians, half of all consumers relied on word-of-mouth recommendations from friends and relatives, but many also used doctor recommendations (38%) and health plan information (35%), and nearly two in five used multiple information sources when choosing a primary care physician. However, when choosing specialists and facilities for medical procedures, most consumers relied exclusively on physician referrals. Use of online provider information was low, ranging from 3 percent for consumers undergoing procedures to 7 percent for consumers choosing new specialists to 11 percent for consumers choosing new primary care physicians

Affordability of medical care is a central focus of health care reform efforts. As health care costs continue to increase and the economy declines sharply, there is very little cushion in family budgets for health care costs, even for families with insurance coverage. Financial pressures on families from medical bills increase sharply when out-of-pocket spending for health care services exceeds 2.5 percent of family income, according to a new national study by the Center for Studying Health System Change (HSC). Low-income families and people in poor health experience financial pressures at even lower levels of spending, largely because they have already accumulated large medical debts they are unable to pay off. Many Californians also incur substantial burdens from health care expenses, although the rate of medical bill problems is somewhat lower in California compared with the overall United States. Extended interviews with a select number of families facing problems with medical bills provide additional detail on how families are forced to make difficult trade-offs with other family necessities, put off paying other bills, cut down on other expenses and delay getting needed medical care