Research brief最新文献

Patient activation refers to a person's ability to manage their health and health care. Engaging or activating consumers has become a priority for employers, health plans and policy makers. The level of patient activation varies considerably in the U.S. population, with less than half of the adult population at the highest level of activation, according to a new study by the Center for Studying Health System Change (HSC). Activation levels are especially low for people with low incomes, less education, Medicaid enrollees, and people with poor self-reported health. Higher activation levels are associated with much lower levels of unmet need for medical care and greater support from health care providers for self-management of chronic conditions.

Responding to large employers' interest in greater health care price and quality transparency, health plans are developing consumer tools to compare price and quality information across hospitals and physicians, but the tools' pervasiveness and usefulness are limited, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. Many large employers view price and quality transparency as key to a broader consumerism strategy, where employees take more responsibility for medical costs, lifestyle choices and treatment decisions. Some health plans believe providing price and quality information to enrollees is a competitive advantage, while others are skeptical about the benefits and are proceeding cautiously to avoid potential unintended consequences. Health plans are in various stages of making price information available to enrollees. Plans generally provide some type of price information on inpatient and outpatient procedures and services from data based on their own negotiated prices or through aggregated health plan claims data obtained through a vendor; few plans provide price information on services in physician offices. However, the information provided often lacks specificity about individual providers, and its availability is often limited to enrollees in specific geographic areas. Health plans generally rely on third-party sources to package publicly available quality information instead of using information gleaned from their own claims or other data. Health plans' ability to advance price and quality comparison tools to the point where a critical mass of consumers trust and use the information to choose physicians and hospitals will likely have considerable influence on the ultimate success of broader health consumerism efforts.

Despite wide recognition that existing physician and hospital payment methods used by health plans and other payers do not foster high-quality and efficient care for people with chronic conditions, little innovation in provider payment strategies is occurring, according to a new study by the Center for Studying Health System Change (HSC) commissioned by the California HealthCare Foundation. This is particularly disconcerting because the nation faces an increasing prevalence of chronic disease, resulting in continued escalation of related health care costs and diminished quality of life for more Americans. To date, most efforts to improve care of patients with chronic conditions have focused on paying vendors, such as disease management firms, to intervene with patients or redesigning care delivery without reforming underlying physician and hospital payment methods. While there is active discussion and anticipation of physician and hospital payment reform, current efforts are limited largely to experimental or small-scale pilot programs. More fundamental payment reform efforts in practice are virtually nonexistent. Existing payment systems, primarily fee for service, encourage a piecemeal approach to care delivery rather than a coordinated approach appropriate for patients with chronic conditions. While there is broad agreement that existing provider payment methods are not well aligned with optimal chronic disease care, there are significant barriers to reforming payment for chronic disease care, including: (1) fragmented care delivery; (2) lack of payment for non-physician providers and services supportive of chronic disease care; (3) potential for revenue reductions for some providers; and (4) lack of a viable reform champion. Absent such reform, however, efforts to improve the quality and efficiency of care for chronically ill patients are likely to be of limited success.

Since Sept. 11, 2001, communities have responded to the federal call to enhance health care surge capacity--the space, supplies, staffing and management structure to care for many injured or ill people during a terrorist attack, natural disaster or infectious disease pandemic. Communities with varied experience handling emergencies are building broad surge capacity, including transportation, communication, hospital care and handling mass fatalities, according to a new study by the Center for Studying Health System Change (HSC). Communities rely on federal funding to help coordinate and plan across agencies and providers, conduct training and drills, recruit volunteers, and purchase equipment and stockpile supplies. The current federal focus on pandemic influenza has helped prepare for all types of emergencies, although at times communities struggle with fragmented and restrictive funding requirements. Despite progress, communities face an inherent tension in developing surge capacity. The need for surge capacity has increased at the same time that daily health care capacity has become strained, largely because of workforce shortages, reimbursement pressures and growing numbers of uninsured people. Payers do not subsidize hospitals to keep beds empty for an emergency, nor is it practical for trained staff to sit idle until a disaster hits. To compensate, communities are trying to develop surge capacity in a manner that supports day-to-day activities and stretches existing resources in an emergency. Many of these efforts--including integrating outpatient providers, expanding staff roles and adapting standards of care during a large-scale emergency--require greater coordination, guidance and policy support. As time passes since 9/11 and Hurricane Katrina, federal funding for surge capacity has waned, and communities are concerned about losing surge capacity they have built.

After the 9/11 terrorist attacks, interest in the state of America's public health system spiked, especially related to emergency preparedness. Significant new federal funding flowed to state and local agencies to bolster public health activities. But the spotlight on shoring up the nation's public health system has faded, and the public appears unaware of escalating threats to such basic services as disease surveillance. Local health departments face a mounting workforce crisis as they struggle to recruit, train and retain qualified workers to meet their communities' needs, according to a new study by the Center for Studying Health System Change (HSC). Factors influencing the workforce shortage include inadequate funding, uncompetitive salaries and benefits, an exodus of retiring workers, insufficient supply of trained workers, and lack of enthusiasm for public health as a career choice. Local public health agencies have pursued strategies to improve workforce monitoring and planning, recruitment, retention, development and training, and academic linkages. However, little progress has been made to alleviate the shortages. Without additional support to address workforce issues, including the recruitment of the next generation of public health leaders, it is unlikely that local public health agencies will succeed in meeting growing community need, a situation potentially imperiling the public's health.

As the nation's hospitals face increasing demands to participate in a wide range of quality improvement activities, the role and influence of nurses in these efforts is also increasing, according to a new study by the Center for Studying Health System Change (HSC). Hospital organizational cultures set the stage for quality improvement and nurses' roles in those activities. Hospitals with supportive leadership, a philosophy of quality as everyone's responsibility, individual accountability, physician and nurse champions, and effective feedback reportedly offer greater promise for successful staff engagement in improvement activities. Yet hospitals confront challenges with regard to nursing involvement, including: scarcity of nursing resources; difficulty engaging nurses at all levels--from bedside to management; growing demands to participate in more, often duplicative, quality improvement activities; the burdensome nature of data collection and reporting; and shortcomings of traditional nursing education in preparing nurses for their evolving role in today's contemporary hospital setting. Because nurses are the key caregivers in hospitals, they can significantly influence the quality of care provided and, ultimately, treatment and patient outcomes. Consequently, hospitals' pursuit of high-quality patient care is dependent, at least in part, on their ability to engage and use nursing resources effectively, which will likely become more challenging as these resources become increasingly limited.

Local health information exchanges (HIEs) hold the promise of collecting patient clinical data across sites of care to provide more complete and timely information for treatment, as well as supporting quality improvement and reporting, public health activities, and clinical research. Findings from a study of stakeholder perspectives on participation in four HIEs by the Center for Studying Health System Change (HSC) and the National Institute for Health Care Management (NIHCM) Foundation suggest, however, that barriers to achieving data exchange remain high. Concerns about loss of competitive advantage and data misuse impede provider and health plan willingness to contribute patient data. Additionally, uncertainty about who benefits from HIEs is affecting stakeholder willingness to fund the exchanges. The more mature exchanges--Cincinnati-based HealthBridge and the Indiana Health Information Exchange (IHIE)--have achieved some viability by meeting a specific business need--more efficient delivery of hospital test results to physicians. The newer exchanges--CareSpark, serving northeast Tennessee and southwest Virginia, and the Tampa Bay Regional Health Information Organization (RHIO)--have struggled to identify and finance initial services without a similar critical mass of hospital participation. While narrow data exchange efforts that improve transaction efficiency may be a pragmatic first step to overcome barriers to stakeholder participation, expanding HIEs to achieve the broad-based data exchange necessary for quality reporting and pay-for-performance (P4P) activities raises more challenges.

To aid consumers in comparing prescription drug costs, many states have launched Web sites to publish drug prices offered by local retail pharmacies. The current push to make retail pharmacy prices accessible to consumers is part of a much broader movement to increase price transparency throughout the health-care sector. Efforts to encourage price-based shopping for hospital and physician services have encountered widespread concerns, both on grounds that prices for complex services are difficult to measure and compare accurately and that quality varies substantially across providers. Experts agree, however, that prescription drugs are much easier to shop for than other, more complex health services. However, extensive gaps in available price information--the result of relying on Medicaid data--seriously hamper the effectiveness of state drug price-comparison Web sites, according to a new study by the Center for Studying Health System Change (HSC). An alternative approach--requiring pharmacies to submit price lists to the states--would improve the usefulness of price information, but pharmacies typically oppose such a mandate. Another limitation of most state Web sites is that price information is restricted to local pharmacies, when online pharmacies, both U.S. and foreign, often sell prescription drugs at substantially lower prices. To further enhance consumer shopping tools, states might consider expanding the types of information provided, including online pharmacy comparison tools, lists of deeply discounted generic drugs offered by discount retailers, and lists of local pharmacies offering price matches.