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1.  Overview 
This overview discusses articles published in this special 30th Anniversary of Medicare issue of the Health Care Financing Review. The authors whose work appears in this special commemorative issue all participated in a policy symposium held on May 6, 1996, at the Lyndon B. Johnson Library in Austin, Texas. The symposium, Medicare: Advancing Towards the 21st Century, was held in honor of the 30th anniversary of the implementation of the Medicare program. Co-sponsors of the symposium included the Health Care Financing Administration, the Lyndon B. Johnson Library, the Lyndon B. Johnson School of Public Affairs at the University of Texas at Austin, the Commonwealth Fund, the Robert Wood Johnson Foundation, and the Henry J. Kaiser Family Foundation.
PMCID: PMC4193647  PMID: 25372221
2.  Physician Awareness of Drug Cost: A Systematic Review 
PLoS Medicine  2007;4(9):e283.
Pharmaceutical costs are the fastest-growing health-care expense in most developed countries. Higher drug costs have been shown to negatively impact patient outcomes. Studies suggest that doctors have a poor understanding of pharmaceutical costs, but the data are variable and there is no consistent pattern in awareness. We designed this systematic review to investigate doctors' knowledge of the relative and absolute costs of medications and to determine the factors that influence awareness.
Methods and Findings
Our search strategy included The Cochrane Library, EconoLit, EMBASE, and MEDLINE as well as reference lists and contact with authors who had published two or more articles on the topic or who had published within 10 y of the commencement of our review. Studies were included if: either doctors, trainees (interns or residents), or medical students were surveyed; there were more than ten survey respondents; cost of pharmaceuticals was estimated; results were expressed quantitatively; there was a clear description of how authors defined “accurate estimates”; and there was a description of how the true cost was determined. Two authors reviewed each article for eligibility and extracted data independently. Cost accuracy outcomes were summarized, but data were not combined in meta-analysis because of extensive heterogeneity. Qualitative data related to physicians and drug costs were also extracted. The final analysis included 24 articles. Cost accuracy was low; 31% of estimates were within 20% or 25% of the true cost, and fewer than 50% were accurate by any definition of cost accuracy. Methodological weaknesses were common, and studies of low methodological quality showed better cost awareness. The most important factor influencing the pattern and accuracy of estimation was the true cost of therapy. High-cost drugs were estimated more accurately than inexpensive ones (74% versus 31%, Chi-square p < 0.001). Doctors consistently overestimated the cost of inexpensive products and underestimated the cost of expensive ones (binomial test, 89/101, p < 0.001). When asked, doctors indicated that they want cost information and feel it would improve their prescribing but that it is not accessible.
Doctors' ignorance of costs, combined with their tendency to underestimate the price of expensive drugs and overestimate the price of inexpensive ones, demonstrate a lack of appreciation of the large difference in cost between inexpensive and expensive drugs. This discrepancy in turn could have profound implications for overall drug expenditures. Much more focus is required in the education of physicians about costs and the access to cost information. Future research should focus on the accessibility and reliability of medical cost information and whether the provision of this information is used by doctors and makes a difference to physician prescribing. Additionally, future work should strive for higher methodological standards to avoid the biases we found in the current literature, including attention to the method of assessing accuracy that allows larger absolute estimation ranges for expensive drugs.
From a review of data from 24 studies, Michael Allan and colleagues conclude that doctors often underestimate the price of expensive drugs and overestimate the price of those that are inexpensive.
Editors' Summary
Many medicines are extremely expensive, and the cost of buying them is a major (and increasing) proportion of the total cost of health care. Governments and health-care organizations try to find ways of keeping down costs without reducing the effectiveness of the health care they provide, but their efforts to control what is spent on medicines have not been very successful. There are often two or more equally effective drugs available for treating the same condition, and it would obviously help keep costs down if, when a doctor prescribes a medicine, he or she chose the cheapest of the effective drugs available. This choice could result in savings for whoever is paying for the drugs, be it the government, the patient, or a medical insurance organization.
Why Was This Study Done?
Doctors who prescribe drugs cannot be expected to know the exact cost of each drug on the market, but it would he helpful if they had some impression of the cost of a treatment and how the various alternatives compare in price. However, systems deciding how drugs are priced are often very complex. (This is particularly the case in the US.) The researchers wanted to find out how aware doctors are regarding drug costs and the difference between the alternatives. They also wanted to know what factors affected their awareness.
What Did the Researchers Do and Find?
They decided to do a systematic review of all the research already conducted that addressed this issue so that the evidence from all of them could be considered together. In order to do such a review they had to specify precise requirements for the type of study that they would include and then comprehensively search the medical literature for such studies. They found 24 studies that met their requirements. From these studies, they concluded that doctors were usually not accurate when asked to estimate the cost of drugs; doctors came up with estimates that were within 25% of the true cost less than one-third of the time. In particular doctors tended to underestimate the cost of expensive drugs and overestimate the cost of the cheaper alternatives. A further analysis of the studies showed that many doctors said they would appreciate more accurate information on costs to help them choose which drugs to prescribe but that such information was not readily available.
What Do These Findings Mean?
The researchers concluded that their systematic review demonstrates a lack of appreciation by prescribing doctors of the large difference in cost between inexpensive and expensive drugs, and that this finding has serious implications for overall spending on drugs. They call for more education and information to be provided to doctors on the cost of medicines together with better processes to help doctors in making such decisions.
Additional Information.
Please access these Web sites via the online version of this summary at
A brief guide to systematic reviews has been published by the BMJ (British Medical Journal)
The Web site of the Cochrane Collaboration is a more detailed source of information on systematic reviews; in particular there is a newcomers' guide and information for health-care consumers
The Kaiser Family Foundation, a nonprofit, private operating foundation focusing on the major health care issues in the US, has a section on prescription drugs and their costs
PMCID: PMC1989748  PMID: 17896856
3.  Uninsured and unstably insured: the importance of continuous insurance coverage. 
Health Services Research  2000;35(1 Pt 2):187-206.
OBJECTIVE: To examine the importance of continuous health insurance for access to care by comparing the access and cost experiences of insured adults with a recent time uninsured to the experiences of currently uninsured adults and experiences of adults with no time uninsured within a reference time period (continuously insured). DATA SOURCES: Adults ages 18-64. Data draw from three different survey databases: the Robert Wood Johnson Foundation 1996-1997 Community Tracking Survey, the Kaiser/Commonwealth 1997 National Survey of Health Insurance, and the 1995-1997 Kaiser/Commonwealth State Low Income Surveys. STUDY DESIGN: The study groups individuals into three insurance categories based on respondents' reports of insurance coverage within a reference time period: continuously insured; insured when surveyed but with recent time uninsured; and currently uninsured. In the two Kaiser/Commonwealth surveys the recently uninsured group included any insured respondent with a time uninsured in the past two years. In the Community Tracking Survey, the recently uninsured group included any insured respondent with a time uninsured in the past year. Measures of access include foregoing health care when needed, usual source of care, use of health care services, difficulties paying for medical care, and satisfaction with care. DATA COLLECTION: All three surveys were conducted primarily by telephone. The Community Tracking Survey drew from 60 community sites, with an additional random national sample. The Kaiser/Commonwealth National Survey was a random national sample; the Kaiser/Commonwealth State Low Income Surveys included adults ages 18-64 with incomes at or below 250 percent of poverty in seven states: Minnesota, Oregon, Tennessee, Florida, Texas, New York, and California. PRINCIPAL FINDINGS: Compared to the continuously insured, those insured but with a recent time uninsured were at high risk of going without needed care and of having problems paying medical bills. This group was two to three times as likely as those with continuous coverage to report access problems. Rates of access and cost problems reported by insured adults with a recent time uninsured neared levels reported by those who were uninsured at the time of the survey. These two groups also rated care received more negatively than did adults with continuous insurance coverage. In general, the access gap between persons insured and uninsured widened as a result of distinguishing insured adults with a recent time uninsured from insured adults with no time uninsured. CONCLUSION: Studies that focus on current insurance status alone will underestimate the extent to which having a time uninsured during the year contributes to access difficulties and undermines quality of care, and will underestimate the proportion of the population at risk because they are uninsured. Policy reforms are needed to maintain continuous insurance coverage and avoid spells uninsured. Currently uninsured and unstably insured adults are both at high risk.
PMCID: PMC1089095  PMID: 10778809
4.  Early Start: An Integrated Model of Substance Abuse Intervention for Pregnant Women 
The Permanente Journal  2007;11(3):5-11.
Untreated perinatal substance abuse is associated with serious adverse maternal and neonatal outcomes. Historically, many barriers have prevented pregnant women from seeking treatment. Early Start (ES) breaks new ground by sidestepping these barriers with a fully integrated service delivery model.
ES is the largest HMO-based prenatal substance-abuse program in the United States targeting all pregnant women seen at Kaiser Permanente Northern California (KPNC) prenatal clinics, currently screening more than 39,000 women each year. The program is based on the premise that substance abuse is a treatable disease and addresses it in a nonjudgmental, accepting manner. A substance-abuse counselor is located in each obstetrics clinic providing accessible one-to-one counseling to pregnant women screened at risk for alcohol, tobacco, or drug use as part of the routine prenatal care package offered to all patients.
A 2006 ES study, sponsored by the Kaiser Foundation Research Institute, evaluated program effectiveness in terms of its impact on neonatal and maternal outcomes. Preliminary results that included 49,986 KPNC patients indicate that compared with pregnant women whose results on screening for substance use were positive but who were untreated, ES-treated women had significantly lower rates on a number of outcome measures.
The originality and transferability of ES has led to both local and national recognition. Universal screening of all pregnant women with access to an integrated model of substance-abuse treatment should be the standard of care for every prenatal patient because of the significant benefits for mothers and their babies.
PMCID: PMC3057720  PMID: 21461106
5.  New Technology Review Process: The Laparoscopic Adjustable Gastric Band 
The Permanente Journal  2011;15(4):54-60.
The Interregional New Technologies Committee (INTC) is one evaluation route for new medical technologies or technologies with expanded indications within Kaiser Permanente (KP). The primary focus of the INTC is to consider all available published evidence on a particular technology, surgical technique, or implantable device for a specific clinical indication and provide a recommendation on the sufficiency of the evidence for determining net medical benefit to Permanente Medical Group leaders and Kaiser Foundation Health Plan management throughout KP Regions. This iterative process provides an objective, evidence-based assessment to inform decision making by physicians and support the most appropriate care for KP members. This overview illustrates the INTC process and how it supports clinical decision making using implantation of laparoscopic adjustable gastric bands (LAGBs) as an example. In February 2011, the US Food and Drug Administration (FDA) approved lowering the acceptable body mass index for the Lap-Band from 35 to 30 kg/m2 for patients with at least one comorbid condition. It is difficult to find published studies on medical technologies that have been recently approved by the FDA. The manufacturer often submits clinical data to the FDA, but details are frequently not publicly available at the time of approval. The LAGB example demonstrates the complex issues addressed by the INTC, particularly when there is some evidence of short-term improvement in outcomes with a medical device but little if any confirmation of long-term safety or effectiveness.
PMCID: PMC3267562  PMID: 22319417
6.  Questioning the claims from Kaiser 
Background: The article by Feachem et al, published in the BMJ in 2002, claimed to show that, compared with the United Kingdom (UK) National Health Service (NHS), the Kaiser Permanente healthcare system in the United States (US) has similar healthcare costs per capita, and performance that is considerably better in certain respects.
Aim: To assess the accuracy of Feachem et al's comparison and conclusions.
Method: Detailed re-examination of the data and methods used and consideration of the 82 letters responding to the article.
Results: Analyses revealed four main areas in which Feachem et al's methodology was flawed. Firstly, the populations of patients served by Kaiser Permanente and by the NHS are fundamentally different. Kaiser's patients are mainly employed, significantly younger, and significantly less socially deprived and so are healthier. Feachem et al fail to adjust adequately for these factors. Secondly, Feachem et al have wrongly inflated NHS costs by omitting substantial user charges payable by Kaiser members for care, excluding the costs of marketing and administration, and deducting the surplus from Kaiser's costs while underestimating the capital charge element of the NHS budget and other costs. They also used two methods of converting currency, the currency rate and a health purchasing power parity conversion. This is double counting. Feachem et al reported that NHS costs were 10% less per head than Kaiser. Correcting for the double currency conversion gives the NHS a 40% cost advantage such that per capita costs are $1161 and $1951 for the NHS and Kaiser, respectively. Thirdly, Feachem et al use non-standardised data for NHS bed days from the Organisation for Economic Cooperation and Development, rather than official Department of Health bed availability and activity statistics for England. Leaving aside the non-comparability of the population and lack of standardisation of the data, the result is to inflate NHS acute bed use and underestimate the efficiency of performance by at least 10%. Similar criticisms apply to their selective use of performance measures. Finally, Feachem et al claim that Kaiser is a more integrated system than the NHS. The NHS provides health care to around 60 million people free at the point of delivery, long-term and psychiatric care, and continuing care after 100 days whereas Kaiser provides care to 6 million people, mainly employed and privately insured. Important functions, such as health protection, education and training of healthcare professionals, and research and development are not included or properly costed in Feachem et al's integrated model.
Conclusion: We have re-examined the statements made by Feachem et al and show that the claims are unsupported by the evidence. The NHS is not similar to Kaiser in coverage, costs or performance.
PMCID: PMC1266198  PMID: 15186560
costs and cost analysis; health care quality; health services; national health service; personal health service; quality indicators, health care
7.  Implications of mortality transition for primary health care in rural South Africa: a population-based surveillance study 
Lancet  2008;372(9642):893-901.
In southern Africa, a substantial health transition is underway, with the heavy burden of chronic infectious illness (HIV/AIDS and tuberculosis) paralleled by the growing threat of non-communicable diseases. We investigated the extent and nature of this health transition and considered the implications for primary health care.
Health and sociodemographic surveillance started in the Agincourt subdistrict, rural South Africa, in 1992. In a population of 70 000, deaths (n=6153) were rigorously monitored with a validated verbal autopsy instrument to establish probable cause. We used age-standardised analyses to investigate the dynamics of the mortality transition by comparing the period 2002–05 with 1992–94.
Mortality from chronic non-communicable disease ranked highest in adults aged 50 years and older in 1992–94 (41% of deaths [123/298]), whereas acute diarrhoea and malnutrition accounted for 37% of deaths (59/158) in children younger than 5 years. Since then, all-cause mortality increased substantially (risk ratio 1·87 [95% CI 1·73–2·03]; p<0·0001) because of a six-fold rise in deaths from infectious disease affecting most age and sex groups (5·98 [4·85–7·38]; p<0·0001), and a modest increase in deaths from non-communicable disease (1·15 [0·99–1·33]; p=0·066). The change in female risk of death from HIV and tuberculosis (15·06 [8·88–27·76]; p<0·0001) was almost double that of the change in male risk (8·13 [5·55–12·36]; p<0·0001). The burden of disorders requiring chronic care increased disproportionately compared with that requiring acute care (2·63 [2·30–3·01]; p<0·0001 vs 1·31 [1·12–1·55]; p=0·0003).
Mortality from non-communicable disease remains prominent despite the sustained increase in deaths from chronic infectious disease. The implications for primary health-care systems are substantial, with integrated chronic care based on scaled-up delivery of antiretroviral therapy needed to address this expanding burden.
The Wellcome Trust, UK; University of the Witwatersrand, Medical Research Council, and Anglo American and De Beers Chairman's Fund, South Africa; the European Union; Andrew W Mellon Foundation, Henry J Kaiser Family Foundation, and National Institute on Aging, National Institutes of Health, USA.
PMCID: PMC2602585  PMID: 18790312
8.  Project LEAN--lessons learned from a national social marketing campaign. 
Public Health Reports  1993;108(1):45-53.
The Henry J. Kaiser Family Foundation initiated a social marketing campaign in 1987 to reduce the nation's risk for heart disease and some cancers. Consensus on recommendations for dietary change have stimulated the development of a variety of social marketing campaigns to promote behavior change. Project LEAN (Low-Fat Eating for America Now) is a national campaign whose goal is to reduce dietary fat consumption to 30 percent of total calories through public service advertising, publicity, and point-of-purchase programs in restaurants, supermarkets, and school and worksite cafeterias. The public service advertising reached 50 percent of the television viewing audience and the print publicity, more than 35 million readers. The toll-free hotline received more than 300,000 calls. Thirty-four organizations joined the foundation in partnership and raised $350,000 for collaborative activities. Thirteen States implemented local campaigns. Lessons have been learned about the use of the media, market segmentation, effective spokespersons, and successful partnerships. These lessons will be valuable to others planning social marketing campaigns on nutrition and other preventive behaviors.
PMCID: PMC1403329  PMID: 8434097
9.  Interlibrary loan in primary access libraries: challenging the traditional view 
Introduction: Primary access libraries serve as the foundation of the National Network of Libraries of Medicine (NN/LM) interlibrary loan (ILL) hierarchy, yet few published reports directly address the important role these libraries play in the ILL system. This may reflect the traditional view that small, primary access libraries are largely users of ILL, rather than important contributors to the effectiveness and efficiency of the national ILL system.
Objective: This study was undertaken to test several commonly held beliefs regarding ILL system use by primary access libraries.
Hypotheses: Three hypotheses were developed. H1: Colorado and Wyoming primary access libraries comply with the recommended ILL guideline of adhering to a hierarchical structure, emphasizing local borrowing. H2: The closures of two Colorado Council of Medical Librarians (CCML) primary access libraries in 1996 resulted in twenty-three Colorado primary access libraries' borrowing more from their state resource library in 1997. H3: The number of subscriptions held by Colorado and Wyoming primary access libraries is positively correlated with the number of items they loan and negatively correlated with the number of items they borrow.
Methods: The hypotheses were tested using the 1992 and 1997 DOCLINE and OCLC data of fifty-four health sciences libraries, including fifty primary access libraries, two state resource libraries, and two general academic libraries in Colorado and Wyoming. The ILL data were obtained electronically and analyzed using Microsoft Word 98, Microsoft Excel 98, and JMP 3.2.2.
Results: CCML primary access libraries comply with the recommended guideline to emphasize local borrowing by supplying each other with the majority of their ILLs, instead of overburdening libraries located at higher levels in the ILL hierarchy (H1). The closures of two CCML primary access libraries appear to have affected the entire ILL system, resulting in a greater volume of ILL activity for the state resource library and other DOCLINE libraries higher up in the ILL hierarchy and highlighting the contribution made by CCML primary access libraries (H2). CCML primary access libraries borrow and lend in amounts that are proportional to their collection size, rather than overtaxing libraries at higher levels in the ILL hierarchy with large numbers of requests (H3).
Limitations: The main limitations of this study were the small sample size and the use of data collected for another purpose, the CCML ILL survey.
Conclusions: The findings suggest that there is little evidence to support several commonly held beliefs regarding ILL system use by primary access libraries. In addition to validating the important contributions made by primary access libraries to the national ILL system, baseline data that can be used to benchmark current practice performance are provided.
PMCID: PMC35251  PMID: 11055297
10.  Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data 
BMJ : British Medical Journal  2003;327(7426):1257.
Objective To compare the utilisation of hospital beds in the NHS in England, Kaiser Permanente in California, and the Medicare programme in the United States and California.
Design Analysis of routinely available data from 2000 and 2001 on inpatient admissions, lengths of stay, and bed days in populations aged over 65 for 11 leading causes of use of acute beds.
Setting Comparison of NHS data with data from Kaiser Permanente in California and the Medicare programme in California and the United States; interviews with Kaiser Permanente staff and visits to Kaiser facilities.
Results Bed day use in the NHS for the 11 leading causes is three and a half times that of Kaiser's standardised rate, almost twice that of the Medicare California's standardised rate, and more than 50% higher than the standardised rate in Medicare in the United States. Kaiser achieves these results through a combination of low admission rates and relatively short stays. The lower use of bed days in Medicare in California compared with Medicare in the United States suggests there is a “California effect” as well as a “Kaiser effect” in hospital utilisation.
Conclusion The NHS can learn from Kaiser's integrated approach, the focus on chronic diseases and their effective management, the emphasis placed on self care, the role of intermediate care, and the leadership provided by doctors in developing and supporting this model of care.
PMCID: PMC286244  PMID: 14644968
11.  New Technology for Multiphasic Health Testing 
This paper comments on the early technology used in multiphasic health testing and reviews the more significant advances in biomedical instrumentation, computer technology, programming techniques and medical protocols which have taken place over the past few years. Multiphasic health testing in itself is still a new systems technology-first applied within the Kaiser-Permanente Foundation in the 50's and 60's, given a spurt during the late 60's and early 70's when industry decided it was a product ready to market, then languishing due to lack of physician acceptance and lack of third party reimbursement, and recently given new impetus through the growing popularity of Fitness programs and the increased emphasis on environmental health monitoring. The theme has shifted away from early disease detection and toward health monitoring, and most technological advances have supported this shift.
PMCID: PMC2578309
12.  Is the Kaiser Permanente model superior in terms of clinical integration?: a comparative study of Kaiser Permanente, Northern California and the Danish healthcare system 
Integration of medical care across clinicians and settings could enhance the quality of care for patients. To date, there is limited data on the levels of integration in practice. Our objective was to compare primary care clinicians' perceptions of clinical integration and three sub-aspects in two healthcare systems: Kaiser Permanente, Northern California (KPNC) and the Danish healthcare system (DHS). Further, we examined the associations between specific organizational factors and clinical integration within each system.
Comparable questionnaires were sent to a random sample of primary care clinicians in KPNC (n = 1103) and general practitioners in DHS (n = 700). Data were analysed using multiple logistic regression models.
More clinicians in KPNC perceived to be part of a clinical integrated environment than did general practitioners in the DHS (OR = 3.06, 95% CI: 2.28, 4.12). Further, more KPNC clinicians reported timeliness of information transfer (OR = 2.25, 95% CI: 1.62, 3.13), agreement on roles and responsibilities (OR = 1.79, 95% CI: 1.30, 2.47) and established coordination mechanisms in place to ensure effective handoffs (OR = 6.80, 95% CI: 4.60, 10.06). None of the considered organizational factors in the sub-country analysis explained a substantial proportion of the variation in clinical integration.
More primary care clinicians in KPNC reported clinical integration than did general practitioners in the DHS. Focused measures of clinical integration are needed to develop the field of clinical integration and to create the scientific foundation to guide managers searching for evidence based approaches.
PMCID: PMC2907761  PMID: 20374667
13.  Changes in Drug Utilization during a Gap in Insurance Coverage: An Examination of the Medicare Part D Coverage Gap 
PLoS Medicine  2011;8(8):e1001075.
Jennifer Polinski and colleagues estimated the effect of the "coverage gap" during which US Medicare beneficiaries are fully responsible for drug costs and found that the gap was associated with a doubling in discontinuing essential medications.
Nations are struggling to expand access to essential medications while curbing rising health and drug spending. While the US government's Medicare Part D drug insurance benefit expanded elderly citizens' access to drugs, it also includes a controversial period called the “coverage gap” during which beneficiaries are fully responsible for drug costs. We examined the impact of entering the coverage gap on drug discontinuation, switching to another drug for the same indication, and drug adherence. While increased discontinuation of and adherence to essential medications is a regrettable response, increased switching to less expensive but therapeutically interchangeable medications is a positive response to minimize costs.
Methods and Findings
We followed 663,850 Medicare beneficiaries enrolled in Part D or retiree drug plans with prescription and health claims in 2006 and/or 2007 to determine who reached the gap spending threshold, n = 217,131 (33%). In multivariate Cox proportional hazards models, we compared drug discontinuation and switching rates in selected drug classes after reaching the threshold between all 1,993 who had no financial assistance during the coverage gap (exposed) versus 9,965 multivariate propensity score-matched comparators with financial assistance (unexposed). Multivariate logistic regressions compared drug adherence (≤80% versus >80% of days covered). Beneficiaries reached the gap spending threshold on average 222 d ±79. At the drug level, exposed beneficiaries were twice as likely to discontinue (hazard ratio [HR]  = 2.00, 95% confidence interval [CI] 1.64–2.43) but less likely to switch a drug (HR  = 0.60, 0.46–0.78) after reaching the threshold. Gap-exposed beneficiaries were slightly more likely to have reduced adherence (OR  = 1.07, 0.98–1.18).
A lack of financial assistance after reaching the gap spending threshold was associated with a doubling in discontinuing essential medications but not switching drugs in 2006 and 2007. Blunt cost-containment features such as the coverage gap have an adverse impact on drug utilization that may conceivably affect health outcomes.
Please see later in the article for the Editors' Summary
Editors' Summary
Every year, more effective drugs for more diseases become available. But the availability of so many drugs poses a problem. How can governments provide their citizens with access to essential medications but control drug costs? Many different approaches have been tried, among them the “coverage gap” or “donut hole” approach that the US government has incorporated into its Medicare program. Medicare is the US government's health insurance program for people aged 65 or older and for younger people with specific conditions. Nearly 50 million US citizens are enrolled in Medicare. In 2006, the government introduced a prescription drug insurance benefit called Medicare Part D to help patients pay for their drugs. Until recently, beneficiaries of this scheme had to pay all their drug costs after their drug spending reached an initial threshold in any calendar year ($2,830 in 2010). Beneficiaries remained in this coverage gap (although people on low incomes received subsidies to help them pay for their drugs) until their out-of-pocket spending reached a catastrophic coverage spending threshold ($4,550 in 2010) or a new year started, after which the Part D benefit paid for most drug costs. Importantly, the 2010 US health reforms have mandated a gradual reduction in the amount that Medicare Part D enrollees have to pay for their prescriptions when they reach the coverage gap.
Why Was This Study Done?
Three to four million Medicare Part D beneficiaries reach the coverage gap every year (nearly 15% of all Part D beneficiaries). Supporters of the coverage gap concept argue that withdrawal of benefits increases beneficiaries' awareness of medication costs and encourages switching to cost-effective therapeutic options. However, critics argue that the coverage gap is likely to lead to decreased drug utilization, increased use of health services, and adverse outcomes. In this study, the researchers examine the impact of entering the coverage gap on drug discontinuation, switching to another drug for the same indication, and drug adherence (whether patients take their prescribed drugs regularly).
What Did the Researchers Do and Find?
The researchers studied 663,850 Medicare beneficiaries enrolled in Part D or in retiree drug plans (which provide coverage under a employer's group health plan after retirement; the retiree drug plans included in this study did not have coverage gaps) who made prescription claims in 2006 and/or 2007. A third of these individuals reached the gap spending threshold. The researchers used detailed statistical analyses to compare the drug discontinuation, switching, and adherence rates of 1,993 beneficiaries who had no financial assistance during the coverage gap (exposed beneficiaries) with those of 9,965 matched beneficiaries who had financial assistance during the coverage gap (unexposed). On average, beneficiaries reached the gap spending threshold 222 days into the year (mid August). In a drug-level analysis, exposed beneficiaries were twice as likely to discontinue a drug and slightly more likely to have reduced drug adherence than unexposed beneficiaries but 40% less likely to switch a drug after reaching the threshold. Similar results were obtained in a beneficiary-level analysis in which discontinuation, switching, and adherence rates were considered in terms of the complete drug regimen of individual beneficiaries.
What Do These Findings Mean?
These findings show that, among the Medicare beneficiaries investigated, a lack of financial assistance to pay for drugs after reaching the coverage gap spending threshold led to a doubling in the rate of drug discontinuation and a slight reduction in drug adherence. Surprisingly, lack of financial assistance resulted in a decrease in drug switching even though the Centers for Medicare and Medicaid Services advise patients to consider switching to generic or low-cost drugs. Importantly, the researchers estimate that, for the whole Medicare population, the lack of financial assistance to pay for drugs could result in an additional 18,000 patients discontinuing one or more prescription drug per year. Although this study did not directly investigate the effect of the coverage gap on patient outcomes, these findings suggest that this and other blunt cost-containment approaches could adversely affect health outcomes through their effects on drug utilization. Thus, insurance strategies that specifically promote the use of drugs with high benefit but low cost might be a better approach for governments seeking to improve the health of their citizens while reining in drug costs.
Additional Information
Please access these websites via the online version of this summary at
The US Department of Health and Human Services Centers for Medicare and Medicaid provides information on all aspects of Medicare, including general advice on bridging the coverage gap and an information sheet on bridging the coverage gap in 2011, the official US government website for Medicare, provides information on all aspects of Medicare (in English and Spanish), including a description of Part D prescription drug coverage
An information sheet from the Kaiser Family Foundation explains the key changes to the Medicare Part D drug benefit coverage gap that were introduced in the 2010 health care reforms
MedlinePlus provides links to further information about Medicare (in English and Spanish)
PMCID: PMC3156689  PMID: 21857811
14.  Effect of maternal coffee, smoking and drinking behavior on adult son's semen quality: prospective evidence from the Child Health and Development Studies 
Fetal exposure to caffeine is associated with adverse pregnancy outcomes. Animal and human studies suggest that caffeine may have effects on the developing reproductive system. Here we report on mothers' smoking, coffee and alcohol use, recorded during pregnancy, and semen quality in sons in the age group of 38–47 years. Subjects were a subset of the Child Health and Development Studies, a pregnancy cohort enrolled between 1959 and 1967 in the Kaiser Foundation Health Plan near Oakland, California. In 2005, adult sons participated in a follow-up study (n = 338) and semen samples were donated by 196 participants. Samples were analyzed for sperm concentration, motility and morphology according to the National Cooperative Reproductive Medicine Network (Fertile Male Study) Protocol. Mean sperm concentration was reduced by approximately 16 million sperms for sons with high prenatal exposure (5 cups of maternal coffee use per day) compared with unexposed sons (P-value for decreasing trend = 0.09), which translates to a proportionate reduction of 25%. Mean percent motile sperm decreased by approximately 7 points (P-value = 0.04), a proportionate decline of 13%, and mean percent sperm with normal morphology decreased by approximately 2 points (P-value = 0.01), a proportionate decline of 25%. Maternal cigarette and alcohol use were not associated with son's semen quality. Adjusting for son's contemporary coffee, alcohol and cigarette use did not explain the maternal associations. Findings for son's coffee intake and father's prenatal coffee, cigarette and alcohol use were non-significant and inconclusive. These results contribute to the evidence that maternal coffee use during pregnancy may impair the reproductive development of the male fetus.
PMCID: PMC4181836  PMID: 25140488
coffee; prenatal exposure; sperm concentration; sperm motility; sperm morphology
15.  An Overview: Eliminating Racial, Ethnic, and SES Disparities in Health Care 
The papers featured in this issue of the Health Care Financing Review were presented at “Eliminating Racial, Ethnic, and SES Disparities in Health Care: A Research Agenda for the New Millennium.” This conference was held on October 15, 1999, in the Washington, DC., area and was co-sponsored by the Health Care Financing Administration (HCFA), the Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Health Care Policy and Research), and the Henry J. Kaiser Family Foundation. The conference was undertaken in response to the challenge posed by President Clinton's national goal of eliminating racial and ethnic disparities in six health domains by the year 2010.
PMCID: PMC4194633  PMID: 11481738
16.  How Might Immunization Rates Change if Cost Sharing Is Eliminated? 
Public Health Reports  2014;129(1):39-46.
There is a debate regarding the effect of cost sharing on immunization, particularly as the Affordable Care Act will eliminate cost sharing for recommended vaccines. This study estimates changes in immunization rates and spending associated with extending first-dollar coverage to privately insured children for four childhood vaccines.
We used the 2008 National Immunization Survey and peer-reviewed literature to generate estimates of immunization status for each vaccine by age group and insurance type. We used the Truven Health Analytics 2006 MarketScan Commercial Claims and Encounters Database of line-item medical claims to estimate changes in immunization rates that would result from eliminating cost sharing, and we used the Kaiser Family Foundation/Health Research and Educational Trust Employer Health Benefits Survey to determine the prevalence of coverage for patients with first-dollar coverage, patients who face office visit cost sharing, and patients who face cost sharing for all vaccine cost components. We assumed that once cost sharing is removed, coverage rates in plans that impose cost sharing will rise to the level of plans that do not.
We estimate that immunization rates would increase modestly and result in additional direct spending of $26.0 million to insurers/employers. Further, these payers would have an additional $11.0 million in spending associated with eliminating cost sharing for children already receiving immunizations.
The effects of eliminating cost sharing for vaccines vary by vaccine. Overall, immunization rates will rise modestly given high insurance coverage for vaccinations, and these increases would be more substantial for those currently facing cost sharing. However, in addition to the removal of cost sharing for immunizations, these findings suggest other strategies to consider to further increase immunization rates.
PMCID: PMC3863002  PMID: 24381358
17.  A National study of burdensome health care costs among non-elderly Americans 
Rising health care costs and increased cost sharing have resulted in significant medical expenses for many Americans. The goal of this study was to describe the prevalence of and risk factors for burdensome health care costs among non-elderly Americans.
This was a cross sectional study of a nationally representative sample of non-elderly Americans. We used survey data previously collected by the Kaiser Family Foundation. We used logistic regression to identify key risk factors for burdensome health care costs and to assess whether risk factors differ according to age within our study population. For analyses comparing younger and middle-aged adults, we compared participants ages 18–39 (younger Americans) to those ages 40–64 (middle-aged Americans).
Our study population included 5,493 participants. Twenty seven percent of participants reported difficulty paying medical bills, a prevalence that did not differ by age. Low income, lack of health insurance, and poor health were independently associated with difficulty paying medical bills after controlling for demographic covariates. Both younger and middle-aged adults were likely to experience burdensome health care costs at low incomes. At moderate incomes, risk fell for middle-aged adults, but remained high for younger adults (ORmiddle-age 1.40, 95% CI 1.12-1.75, ORyounger 2.48, 95% CI 1.73-3.57, p value for interaction 0.004). Younger adults without insurance were at risk for accruing burdensome costs compared to their insured counterparts (OR 2.61, 95% CI 1.96-3.47). Middle-aged adults without insurance, though, had an even higher risk (OR 3.82, 95% CI 2.93-4.97, p value for interaction 0.037).
Both younger and middle-aged adults commonly report difficulty paying medical bills. Younger adults remain vulnerable to burdensome medical costs even when earning moderate incomes. Middle-aged adults, however, are more likely to encounter burdensome costs when uninsured. These findings suggest that younger and middle-aged adults experience distinct vulnerabilities and may benefit differentially from health reform efforts intended to expand coverage and limit out-of-pocket expenses.
PMCID: PMC4261537  PMID: 25252706
Health care costs; Health insurance; Health economics
18.  Implantable Defibrillators for Secondary Prevention of Sudden Cardiac Death in Cardiac Surgery Patients With Perioperative Ventricular Arrhythmias 
Randomized studies of implantable cardioverter defibrillators (ICD) have excluded sudden cardiac death survivors who had revascularization before or after an arrhythmic event. To evaluate the role of ICD and the effects of clinical variables including degree of revascularization, we studied cardiac surgery patients who had an ICD implanted for sustained perioperative ventricular arrhythmias.
Methods and Results
The electronic database for Southern California Kaiser Foundation hospitals was searched for patients who had cardiac surgery between 1999 and 2005 and an ICD implanted within 3 months of surgery. One hundred sixty‐four patients were identified; 93/164 had an ICD for sustained pre‐ or postoperative ventricular tachycardia or fibrillation requiring resuscitation. Records were reviewed for the following: presenting arrhythmia, ejection fraction, and degree of revascularization. The primary end point was total mortality (TM) and/or appropriate ICD therapy (ICD‐T), and secondary end points are TM and ICD‐T. During the mean follow up of 49 months, the primary endpoint of TM+ICD‐T and individual end points of TM and ICD‐T were observed in 52 (56%), 35 (38%), and 28 (30%) patients, respectively, with 55% of TM, and 23% of ICD‐T occurring within 2 years of implant. In multivariate risk analysis, none of the following was associated with any of the end points: incomplete revascularization, presenting ventricular arrhythmia, and timing of arrhythmias.
Our data supports the recent guidelines for ICD in this cohort of patients, as the presence of irreversible substrate and triggers of ventricular arrhythmias, cannot be reliably excluded even with complete revascularization. Further studies are needed to understand this complex group of patients.
PMCID: PMC4310357  PMID: 25146702
implantable defibrillator; perioperative ventricular arrhythmias; revascularization
19.  Intestinal Protozoan Infections: Prevalence in the San Francisco Bay Area 
Western Journal of Medicine  1981;135(3):188-190.
A sample of 415 members of the Kaiser Foundation Health Plan (KFHP) were tested for intestinal protozoa. This parasite survey group was found to be comparable in age distribution, sex and ethnic background with the membership at large. Gastrointestinal complaints were no more numerous in this group than in a large series of KFHP members taking multiphasic examinations. Because KFPH membership included, at the time of the survey, approximately 27 percent of all residents of the San Francisco Bay Area, the membership may be considered approximately representative of the entire area. Fourteen percent of persons were found to be infected with one or more intestinal protozoan parasites, while 5.5 percent harbored potentially pathogenic sorts. Entamoeba histolytica was found in 0.7 percent of those surveyed, Giardia lamblia in 1.7 percent and Dientamoeba fragilis in 3.1 percent.
PMCID: PMC1273112  PMID: 7340117
20.  Lessons From the Frozen North 
Western Journal of Medicine  1989;151(2):217-219.
Presented in part as the Kaiser Foundation Distinguished Lecture at the annual meeting of the Western Association of Physicians, February 7, 1989.
PMCID: PMC1026936  PMID: 2773481
21.  A Conversation About Health Care Reform 
Western Journal of Medicine  1994;161(1):83-86.
Professor Victor R. Fuchs is the Henry J. Kaiser Jr Professor at Stanford (California) University, where he applies economic analysis to social problems of national concern, with special emphasis on health and medical care. He holds joint appointments in the Economics Department and the School of Medicine's Department of Health Research and Policy. Professor Fuchs is a Distinguished Fellow of the American Economic Association and a member of the American Philosophical Society, the American Academy of Arts and Sciences, and the Institute of Medicine of the National Academy of Sciences. He was the first economist to receive the Distinguished Investigator Award of the Association for Health Services Research and has also received the Baxter Foundation Health Services Research Prize. Professor Fuchs is president-elect of the American Economic Association. His latest book, The Future of Health Policy, was published by Harvard University Press in 1993.
The following edited conversation between Professor Fuchs and Linda Hawes Clever, MD, Editor of the journal, took place on April 8, 1994.
PMCID: PMC1011385  PMID: 7941523
22.  Relationship between socioeconomic status, health status, and lifestyle practices of American Indians: evidence from a Plains reservation population. 
Public Health Reports  1994;109(3):405-413.
This paper presents information on the prevalence of a variety of health behaviors and health conditions on an American Indian reservation in the Plains region of the western United States. In addition, data from two non-Indian comparison groups were used to examine the extent to which differences in health status and health behaviors between Indians and non-Indians could be explained by differences in socioeconomic status. The American Indian data were from a survey conducted in 1988 during an evaluation of a local community-based health promotion program, part of the Kaiser Family Foundation's Community Health Promotion Grants Program. The comparison groups were 12 communities in California surveyed in evaluating the Community Health Promotion Grants Program and three Plains States participating in the Behavioral Risk Factor Surveillance Survey. The results show that the higher prevalences of risk-taking behavior among Indians and their poorer self-reported health status remained after adjustment for socioeconomic status. Also, among Indians, higher levels of income and education were not associated with improved self-reported health status and lower prevalence of tobacco use, as was the case with the comparison groups. The higher prevalences of risk-taking behaviors and ill health among American Indians residing on one reservation, even among those with higher socioeconomic status, suggests a need for the investigation of other social and environmental influences.
PMCID: PMC1403505  PMID: 8190864
23.  A community-based approach to preventing alcohol use among adolescents on an American Indian reservation. 
Public Health Reports  1995;110(4):439-447.
This paper examines the effectiveness of a 5-year community-based health promotion program to reduce the rate of substance use, particularly alcohol, by adolescents on a Plains State American Indian reservation. The program was part of the Kaiser Family Foundation Community Health Promotion Grants Program. Since a reservation control group was not available, adolescents serving as control groups for other Community Health Promotion Grants Program communities, including a small sample of rural American Indians, were used as a basis for comparison. School-based surveys of 9th and 12th graders were carried out on the reservation and in five relevant California control communities--two suburban, three rural--in 1988, 1990, and 1992. The results showed that the use of both alcohol and marijuana declined substantially among American Indian adolescents living on the reservation. Binge drinking (five or more drinks on an occasion) declined from 46 percent to 30 percent, and marijuana use (in the past month) declined from 46 percent to 29 percent over the 4-year period. However, there were similar, if smaller, declines in alcohol use in the comparison groups. Since there was no evidence of a relative increase in exposure to alcohol and drug programs on the reservation, the authors are cautious in attributing the significant and heartening declines in substance use among adolescents on the reservation to the community-based program.
PMCID: PMC1382153  PMID: 7638331
24.  Health Benefits Offer Rates: Is There a Nonresponse Bias? 
Health Services Research  2005;40(2):401-412.
To determine whether a nonresponse bias exists in the offer rate for health benefits in firms with fewer than 50 workers and to present a simple adjustment to correct for observed bias.
Data Sources
The 2003 Employer Health Benefits Survey (EHBS) conducted by the Kaiser Family Foundation and Health Research and Educational Trust, and a follow-up survey of nonrespondents to the 2003 EHBS.
Study Design
We conducted a follow-up survey to the 2003 EHBS to collect health benefits offering data from firms with fewer than 50 workers. We used McNemar's test to verify that the follow-up survey provided results comparable to the EHBS, and t-tests were used to determine nonresponse bias. We applied a simple weighting adjustment to the EHBS.
Data Collection
The data for both the EHBS and the follow-up survey were collected by the same survey research firm. The EHBS interviews the person most knowledgeable about the firm's health benefits, while the follow-up survey interviews the first person who answers the telephone whether they are the most knowledgeable or not.
Principal Findings
Firms with 3–9 workers were more likely to exhibit a bias than were firms with 10–24 workers and 25–49 workers. Although the calculated bias for each size category was not significant, there is sufficient evidence to warrant caution when reporting offer rates.
Survey nonresponse in the EHBS produces an upward bias on estimates for the offer rates of small firms. Although not significant, this upward bias is because of nonresponse by small firms that do not offer health benefits. Our research is limited in that we only control for differences in the size of the firm.
PMCID: PMC1361148  PMID: 15762899
Bias; nonresponse analysis; health benefits offer rate
25.  The Kaiser Family Foundation Community Health Promotion Grants Program: findings from an outcome evaluation. 
Health Services Research  2000;35(3):561-589.
OBJECTIVES: To present results from an outcome evaluation of the Henry J. Kaiser Family Foundation's Community Health Promotion Grants Program (CHPGP) in the West, which represented a major community-based initiative designed to promote improved health by changing community norms, environmental conditions, and individual behavior in 11 western communities. METHODS: The evaluation design: 14 randomly assigned intervention and control communities, 4 intervention communities selected on special merit, and 4 matched controls. Data for the outcome evaluation were obtained from surveys, administered every two years at three points in time, of community leaders and representative adults and adolescents, and from specially designed surveys of grocery stores. Outcomes for each of the 11 intervention communities were compared with outcomes in control communities. RESULTS: With the exception of two intervention communities-a largely Hispanic community and a Native American reservation-we found little evidence of positive changes in the outcomes targeted by the 11 intervention communities. The programs that demonstrated positive outcomes targeted dietary behavior and adolescent substance abuse. CONCLUSIONS: Improvement of health through community-based interventions remains a critical public health challenge. The CHPGP, like other prominent community-based initiatives, generally failed to produce measurable changes in the targeted health outcomes. Efforts should focus on developing theories and methods that can improve the design and evaluation of community-based interventions.
PMCID: PMC1089138  PMID: 10966086

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