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1.  The Experience Of Massachusetts Shows That Consumers Will Need Help In Navigating Insurance Exchanges 
Health affairs (Project Hope)  2013;32(1):78-86.
In 2022 twenty-five million people are expected to purchase health insurance through exchanges to be established under the Affordable Care Act. Understanding how people seek information and make decisions about the insurance plans that are available to them may improve their ability to select a plan and their satisfaction with it. We conducted a survey in 2010 of enrollees in one plan offered through Massachusetts’s unsubsidized health insurance exchange to analyze how a sample of consumers selected their plans. More than 40 percent found plan information difficult to understand. Approximately one-third of respondents had help selecting plans—most commonly from friends or family members. However, one-fifth of respondents wished they had had help narrowing plan choices; these enrollees were more likely to report negative experiences related to plan understanding, satisfaction with affordability and coverage, and unexpected costs. Some may have been eligible for subsidized plans. Exchanges may need to provide more resources and decision-support tools to improve consumers’ experiences in selecting a health plan.
PMCID: PMC3950973  PMID: 23297274
2.  Cesarean Delivery Rates Vary 10-Fold Among US Hospitals; Reducing Variation May Address Quality, Cost Issues 
Health affairs (Project Hope)  2013;32(3):527-535.
Cesarean delivery is the most commonly performed surgical procedure in the United States, and cesarean rates are increasing. Working with 2009 data from 593 US hospitals nationwide, we found that cesarean rates varied tenfold across hospitals, from 7.1 percent to 69.9 percent. Even for women with lower-risk pregnancies, in which more limited variation might be expected, cesarean rates varied fifteen-fold, from 2.4 percent to 36.5 percent. Thus, vast differences in practice patterns are likely to be driving the costly overuse of cesarean delivery in many US hospitals. Because Medicaid pays for nearly half of US births, government efforts to decrease variation are warranted. We focus on four promising directions for reducing these variations, including better coordination of maternity care, more data collection and measurement, tying Medicaid payment to quality improvement, and enhancing patient-centered decision making through public reporting.
PMCID: PMC3615450  PMID: 23459732
3.  An Increase In The Number Of Nurses With Baccalaureate Degrees Is Linked To Lower Rates Of Postsurgery Mortality 
Health affairs (Project Hope)  2013;32(3):579-586.
An Institute of Medicine report has called for registered nurses to achieve higher levels of education, but health care policy makers and others have limited evidence to support a substantial increase in the number of nurses with baccalaureate degrees. Using Pennsylvania nurse survey and patient discharge data from 1999 and 2006, we found that a ten-point increase in the percentage of nurses holding a baccalaureate degree in nursing within a hospital was associated with an average reduction of 2.12 deaths for every 1,000 patients—and for a subset of patients with complications, an average reduction of 7.47 deaths per 1,000 patients. We estimate that if all 134 hospitals in our study had increased the percentage of their nurses with baccalaureates by ten points during our study’s time period, some 500 deaths among general, orthopedic, and vascular surgery patients might have been prevented. The findings provide support for efforts to increase the production and employment of baccalaureate nurses.
PMCID: PMC3711087  PMID: 23459738
4.  Measures Such As Interstate Cooperation Would Improve The Efficacy Of Programs To Track Controlled Drug Prescriptions 
Health affairs (Project Hope)  2013;32(3):10.1377/hlthaff.2012.0945.
In response to increasing abuse of prescription drugs, 44 states have implemented -- and five more states will soon adopt -- monitoring programs to track prescriptions of controlled medications. Although these programs are primarily designed to help law enforcement officials and regulatory agencies spot possible illegal activity, health care providers have begun to use data from them to help improve patient safety and quality of care. We reviewed government documents, expert white papers, articles from the peer reviewed medical literature, and reports of the experiences of local health officials. Although we found some evidence that prescription drug monitoring programs are a benefit to both law enforcement and health care delivery, the programs have strengths and weaknesses, and their overall impact on drug abuse and illegal activity remains unclear. We believe that improving the efficacy of prescription drug monitoring programs will require such changes as more standardization and interstate cooperation, better training of providers, more secure funding, and further evaluation.
PMCID: PMC3835343  PMID: 23406570
5.  Racial and Ethnic Disparities in Mental Health Care: Evidence and Policy Implications 
Health affairs (Project Hope)  2008;27(2):393-403.
In the mental health arena, unlike general health, health care disparities predominate over disparities in mental health per se. Strategies to improve health care in general, such as improving access to care and improving the quality of care, would do much to eliminate mental health care disparities. However, a diverse mental health workforce, as well as provider and patient education, are important to eliminating mental health care disparities.
PMCID: PMC3928067  PMID: 18332495
6.  How Cumulative Risks Warrant A Shift In Our Approach To Racial Health Disparities: The Case of Lead, Stress, and Hypertension 
Health affairs (Project Hope)  2011;30(10):1895-1901.
Blacks have persistently higher rates of high blood pressure, or hypertension, compared to whites, resulting in higher health costs and greater mortality. Recent research has shown that social and environmental factors – such as high levels of stress and exposure to lead – may explain racial disparities in hypertension. Based on these findings, we recommend a fundamental shift in approaches to health disparities to focus on these sorts of cumulative risks and health effects. Federal and state agencies and research institutions should develop strategic plans to learn more about these connections and apply the broader findings to policies to improve health disparities.
PMCID: PMC3915245  PMID: 21976332
7.  Direct-To-Consumer Internet Promotion Of Robotic Prostatectomy Exhibits Varying Quality Of Information 
Health affairs (Project Hope)  2012;31(4):760-769.
Robotic surgery to remove a cancerous prostate has become a popular treatment. Internet marketing of this surgery provides an intriguing case study of direct-to-consumer promotions of medical devices, which are more loosely regulated than pharmaceutical promotions. We investigated whether the claims made in online promotions of robotic prostatectomy were consistent with evidence from comparative effectiveness studies. After performing a search and crosssectional analysis of websites that mentioned the procedure, we found that many sites claimed benefits that were unsupported by evidence and that 42 percent of the sites failed to mention risks. Most sites were published by hospitals and physicians, which the public may regard as more objective than pages published by manufacturers. Unbalanced information may inappropriately raise patients’ expectations. Increasing enforcement and regulation of online promotions may be beyond the capabilities of federal authorities. Thus, the most feasible solution may be for the government and medical societies to promote the production of balanced educational material.
PMCID: PMC3897330  PMID: 22492893
8.  Growing internet use may help explain the rise in prescription drug abuse in the United States 
Health affairs (Project Hope)  2011;30(6):10.1377/hlthaff.2011.0155.
The rise in availability of commonly abused prescription drugs through the internet has raised public health concerns. We examined whether U.S. prescription drug abuse growth may be explained by growth in internet use. We find that for every 10 percent increase in high-speed internet use at the state level, associated admissions for prescription drug abuse rose by 1 percent. Non-prescription drug related admissions bore no association with internet use. The results suggest that better surveillance of online prescription drug use is warranted, and aggressive efforts to curb illegitimate online pharmacies may be necessary.
PMCID: PMC3884823  PMID: 21565838
9.  Medicaid Cost Control Measures Aimed at Second Generation Antipsychotics Led to Less Use of All Antipsychotics 
Health affairs (Project Hope)  2011;30(12):10.1377/hlthaff.2010.1296.
Atypical antipsychotics and other psychotherapeutics are increasingly subject to prior authorization and other restrictions in state Medicaid programs, begging the question of how these formulary restrictions affect the drug treatments being delivered. To find an answer we collected drug-level information on utilization management for 30 state Medicaid programs over the past 10 years and drug-level utilization data for state Medicaid programs. We find that prior authorization requirements on atypical antipsychotics and other psychotherapeutics greatly reduced the utilization of these drugs and this reduction is not offset by substitution to other drugs in the same drug classes—with the adverse consequence that fewer patients are receiving pharmacotherapy.
PMCID: PMC3883626  PMID: 22147863
10.  Diabetes Management for Low-Income Patients in Los Angeles: Two Strategies Improved Disease Control In The Short Term 
Health affairs (Project Hope)  2012;31(1):10.1377/hlthaff.2011.0930.
Health care providers serving vulnerable patients in Los Angeles have developed programs intended to increase diabetes control through more intensive patient education and engagement. We examined two programs, the first using a short-term intensive intervention by a care team including nurses and a specialist, and the second integrating case management and clinical pharmacy programs into primary care in a community clinic. We show evidence that both models improved short-term disease control, as measured by reductions in HbA1c (blood glucose) and low-density lipoprotein (sometimes referred to as ”bad” cholesterol). However, integrating case management and clinical pharmacy programs into a primary care setting was less labor intensive and potentially less expensive than the care team intervention. The challenge is to understand the essential aspects of these interventions; refining their design so that they are cost-effective and fiscally feasible; and identifying long-term health and cost effects.
PMCID: PMC3883628  PMID: 22232107
11.  Generational Differences In U.S. Public Spending, 1980–2000 
Health affairs (Project Hope)  2004;23(5):10.1377/hlthaff.23.5.131.
The balance between spending on children and spending on the elderly is important in evaluating the allocation of public welfare spending. We examine trends in public spending on social welfare programs for children and the elderly during 1980–2000. For both groups, social welfare spending as a percentage of gross domestic product changed little, even during the economic expansions of the 1990s. In constant dollars, the gap in per capita social welfare spending between children and the elderly grew 20 percent. Unlike spending for programs for the elderly, spending for children’s programs suffered during recessions. Public discussion about the current imbalance in public spending is needed.
PMCID: PMC3877927  PMID: 15371377
12.  Blacks And Hispanics Are Less Likely Than Whites To Complete Addiction Treatment, Largely Due To Socioeconomic Factors 
Health affairs (Project Hope)  2013;32(1):135-145.
More than one-third of the approximately two million people entering publicly funded substance abuse treatment in the United States do not complete treatment. Additionally, racial and ethnic minorities with addiction disorders, who constitute approximately 40 percent of the admissions in publicly funded substance abuse treatment programs, may be particularly at risk for poor outcomes. Using national data, we found that blacks and Hispanics were 3.5–8.1 percentage points less likely than whites to complete treatment for alcohol and drugs, and Native Americans were 4.7 percentage points less likely to complete alcohol treatment. Only Asian Americans fared better than whites for both types of treatment. Completion disparities for blacks and Hispanics were largely explained by differences in socioeconomic status and, in particular, greater unemployment and housing instability. However, the alcohol treatment disparity for Native Americans was not explained by socioeconomic or treatment variables, a finding that warrants further investigation. The Affordable Care Act could reduce financial barriers to treatment for minorities, but further steps, such as increased Medicaid funding for residential treatment and better cultural training for providers, would improve the likelihood of completing treatment and increase treatment providers’ cultural competence.
PMCID: PMC3570982  PMID: 23297281
13.  US Spending On Complementary And Alternative Medicine During 2002–08 Plateaued, Suggesting Role In Reformed Health System 
Health affairs (Project Hope)  2013;32(1):45-52.
Complementary and alternative medicine services in the United States are an approximately $9 billion market each year, equal to 3 percent of national ambulatory health care expenditures. Unlike conventional allopathic health care, complementary and alternative medicine is primarily paid for out of pocket, although some services are covered by most health insurance. Examining trends in demand for complementary and alternative medicine services in the United States reported in the Medical Expenditure Panel Survey during 2002–08, we found that use of and spending on these services, previously on the rise, have largely plateaued. The higher proportion of out-of-pocket responsibility for payment for services may explain the lack of growth. Our findings suggest that any attempt to reduce national health care spending by eliminating coverage for complementary and alternative medicine would have little impact at best. Should some forms of complementary and alternative medicine—for example, chiropractic care for back pain—be proven more efficient than allopathic and specialty medicine, the inclusion of complementary and alternative medicine providers in new delivery systems such as accountable care organizations could help slow growth in national health care spending.
PMCID: PMC3644505  PMID: 23297270
14.  Small Physician Practices In New York Needed Sustained Help To Realize Gains In Quality From Use Of Electronic Health Records 
Health affairs (Project Hope)  2013;32(1):10.1377/hlthaff.2012.0742.
While Regional Extension Centers and other national policy efforts to increase the adoption of electronic health records (EHR) have been implemented in the United States, the relationship between EHR adoption and quality of care remains poorly understood. We evaluated the early effects on quality of the Primary Care Information Project, which provides subsidized EHRs and technical assistance to primary care practices in underserved neighborhoods in New York City. We find that nine or more months of participation in the Primary Care Information Project is associated with improved quality, but only for certain quality measures and only for physicians receiving extensive technical assistance.
PMCID: PMC3864096  PMID: 23297271
15.  Discovering how environmental exposures alter genes and could lead to new treatments for chronic illnesses 
Health affairs (Project Hope)  2011;30(5):10.1377/hlthaff.2011.0078.
Facilitating translation of basic and clinical discoveries into improved population health has become a national priority. In this commentary, we emphasize the need to expand the “bench to bedside” model to include trans-disciplinary research that integrates knowledge of genomics and epigenetic regulation with information about diverse environmental exposures. Such integrated studies are needed to understand mechanisms underlying human health and disease, and develop novel interventions at the level of the epigenome that might curb the growing global burden of complex chronic illnesses. The completion of the human genome project, as we now know, is only a first step in understanding the etiology of complex disease. Remaining challenges include understanding the role of genetics in controlling susceptibility to environmental exposures and the role of the environment in regulating gene expression and function. Here we emphasize the importance of understanding the crosstalk between the genome, the epigenome, and the environment in coregulating gene expression as key to developing a population health model for the control of chronic diseases. However, this will require developing and integrating new data resources.
PMCID: PMC3877678  PMID: 21555469
16.  Acute Care For Elders Units Produced Shorter Hospital Stays At Lower Cost While Maintaining Patients’ Functional Status 
Health affairs (Project Hope)  2012;31(6):10.1377/hlthaff.2012.0142.
Acute Care for Elders Units offer enhanced care for older adults in specially designed hospital units. The care is delivered by interdisciplinary teams, which can include geriatricians, advanced practice nurses, social workers, pharmacists, and physical therapists. In a randomized controlled trial of 1,632 elderly patients, length-of-stay was significantly shorter—6.7 days per patient versus 7.3 days per patient—among those receiving care in the Acute Care for Elders Unit compared to usual care. This difference produced lower total inpatient costs—$9,477 per patient versus $10,451 per patient—while maintaining patients’ functional abilities and not increasing hospital readmission rates. The practices of Acute Care for Elders Units, and the principles they embody, can provide hospitals with effective strategies for lowering costs while preserving quality of care for hospitalized elders.
PMCID: PMC3870859  PMID: 22665834
17.  US Hospice Industry Experienced Considerable Turbulence From Changes In Ownership, Growth, And Shift To For-Profit Status 
Health affairs (Project Hope)  2012;31(6):10.1377/hlthaff.2011.1247.
The US hospice industry, which provides palliative and supportive care to patients with terminal illness, has undergone substantial changes during the last decade. The magnitude of these changes has not been fully captured in previous studies or reports. In this longitudinal study of hospices active in Medicare during 1999–2009, we analyzed Provider of Services files to understand key shifts in the industry. We found evidence of substantial turbulence. One-fifth of Medicare-certified hospices active in 1999 had closed or withdrawn from the program by 2009, and more than 40 percent had experienced one or more changes in ownership. The most prominent trend was the shift in ownership type from nonprofit to for-profit ownership. Four out of five Medicare-certified hospices that entered the marketplace between 2000 and 2009 were for-profit. Hospices also became larger, as the proportion with 100 or more full-time employees doubled to 5 percent from 1999 to 2009. Although each of the Census regions had more hospices in 2009 than in 1999, the geographic distribution of hospices in the country changed, with proportionally more in the South and West. The impact of all of these changes on cost and quality of hospice care, as well as patient access, remains a critical area for future research.
PMCID: PMC3866916  PMID: 22665841
18.  New Forecasting Methodology Indicates More Disease And Earlier Mortality Ahead For Today’s American Children 
Health affairs (Project Hope)  2011;30(8):10.1377/hlthaff.2011.0092.
Traditional methods of projecting population health statistics, such as calculating future death rates, can give inaccurate results and lead to inferior or even poor policy decisions. A new “three-dimensional” method of forecasting vital health statistics is more accurate because it takes into account the delayed effects of the health risks being accumulated by today’s younger generations. Applying this forecasting technique to the US obesity epidemic suggests that future death rates and health care expenditures could be far worse than currently anticipated. We suggest that public policy makers adopt this more robust forecasting tool and redouble efforts to develop and implement effective obesity-related prevention programs and interventions.
PMCID: PMC3862028  PMID: 21700600
19.  Partnering Urban Academic Medical Centers And Rural Primary Care Clinicians To Provide Complex Chronic Disease Care 
Health affairs (Project Hope)  2011;30(6):10.1377/hlthaff.2011.0278.
Many of the estimated thirty-two million Americans expected to gain coverage under the Affordable Care Act are likely to have high levels of unmet need for various chronic illnesses and to live in areas that are already underserved. In New Mexico an innovative new model of health care education and delivery known as Project ECHO (Extension for Community Healthcare Outcomes) provides high-quality primary and specialty care to a comparable population. Using state-of-the-art telehealth technology and case-based learning, Project ECHO enables specialists at the University of New Mexico Health Sciences Center to partner with primary care clinicians in underserved areas to deliver complex specialty care to patients with hepatitis C, asthma, diabetes, HIV/AIDS, pediatric obesity and mental illness. As of March 2011, 298 Project ECHO teams across New Mexico have delivered more than 10,000 specialty care consultations for hepatitis C and other chronic diseases.
PMCID: PMC3856208  PMID: 21596757
20.  Low-Cost Transitional Care With Nurse Managers Making Mostly Phone Contact With Patients Cut Rehospitalization At A VA Hospital 
Health affairs (Project Hope)  2012;31(12):2659-2668.
The Coordinated-Transitional Care (C-TraC) Program was designed to improve care coordination and outcomes among veterans with high-risk conditions discharged to community settings from the William S. Middleton Memorial Veterans Hospital, in Madison, Wisconsin. Under the program, patients work with nurse case managers on care and health issues, including medication reconciliation, before and after hospital discharge, with all contacts made by phone once the patient is at home. Patients who received the C-TraC protocol experienced one-third fewer rehospitalizations than those in a baseline comparison group, producing an estimated savings of $1,225 per patient net of programmatic costs. This model requires a relatively low amount of resources to operate and may represent a viable alternative for hospitals seeking to offer improved transitional care as encouraged by the Affordable Care Act. In particular, the model may be attractive for providers in rural areas or other care settings challenged by wide geographic dispersion of patients or by constrained resources.
PMCID: PMC3520606  PMID: 23213150
21.  Steps to reduce favorable risk selection in medicare advantage largely succeeded, boding well for health insurance exchanges 
Health affairs (Project Hope)  2012;31(12):2618-2628.
Managing competition among health plans that attract different risks has been a challenging policy problem. Within Medicare, the Medicare Advantage (MA) program historically attracted better risks than did Traditional Medicare (TM). This favorable selection resulted in Medicare’s paying more for persons enrolled in MA than if they had been enrolled in TM. We studied whether policies Medicare implemented in the past decade to reduce favorable selection in the MA program succeeded, in particular improved matching of reimbursement with a beneficiary’s expected cost and restricting when beneficiaries could switch from MA to TM. We found they did. Differences in predicted spending between those switching from TM to MA relative to those who remained in TM markedly narrowed, as did adjusted mortality rates. Because insurance exchanges will employ similar policies to combat selection, our results give reason for optimism about managing competition among health plans.
PMCID: PMC3535470  PMID: 23213145
22.  New Risk-Adjustment System Was Associated With Reduced Favorable Selection in Medicare Advantage 
Health affairs (Project Hope)  2012;31(12):2630-2640.
Health plans participating in the Medicare managed care program, now called Medicare Advantage, have historically attracted healthier enrollees than the traditional fee-for-service program. Medicare Advantage plans have gained financially from this favorable risk selection because until recently Medicare payments to plans were adjusted only minimally for the clinical characteristics of enrollees, such that payments systematically exceeded costs for healthier enrollees and were systematically lower than costs for sicker enrollees. To address favorable selection in Medicare Advantage, a new risk-adjustment system adjusting plan payments for clinical diagnoses was phased in from 2004 to 2007. Also, a lock-in provision was instituted in 2006 and strengthened in 2007 to limit midyear disenrollment by Medicare Advantage enrollees, particularly those experiencing health declines whose disenrollment could benefit plans financially. To determine if these reforms were associated with intended reductions in favorable selection in Medicare Advantage, we compared self-reported utilization and health for Medicare Advantage vs. traditional Medicare beneficiaries and for those who switched into or out of Medicare Advantage vs. non-switchers both before and after these reforms were implemented. In 2001-2003, differences in utilization and health between these groups suggested favorable selection in Medicare Advantage. By 2006-2007, however, most differences were substantially narrowed, indicating reduced selection. For example, Medicare Advantage enrollees reported 17.7% lower utilization than traditional Medicare enrollees in 2001-2003 but 8.1% lower in 2006-2007. Similar risk-adjustment methods may help may help mitigate incentives for Accountable Care Organizations participating in the Medicare Shared Savings Program and plans competing in health insurance exchanges to select patients with favorable clinical risks.
PMCID: PMC3538078  PMID: 23213147
23.  Utilization of Services in Medicare Advantage versus Traditional Medicare since the Passage of the Medicare Modernization Act 
Health affairs (Project Hope)  2012;31(12):2609-2617.
Enrollment in Medicare Advantage has grown rapidly from 2003 to today. For the years 2003–2009, we compared individual-level Healthcare Effectiveness Data and Information Set (HEDIS®) data collected from all plans on service utilization by patients enrolled in Medicare Advantage HMO plans with comparable claims-based measures for matched samples from traditional Medicare. Controlling for self-reported health, health plan enrollees had lower rates of ambulatory visits and hospitalizations initially that converged by 2008 and fewer emergency department visits and ambulatory procedures (~25–30%). Health plan enrollees received fewer hip or knee replacements (lower by ~10%) but more coronary bypass surgery. Our study suggests utilization of services may be more appropriate in Medicare Advantage.
PMCID: PMC3587962  PMID: 23213144
Medicare; managed care; utilization
24.  China’s Rapidly Aging Population Creates Policy Challenges In Shaping A Viable Long-Term Care System 
Health affairs (Project Hope)  2012;31(12):2764-2773.
In China, formal long-term care services for the large aging population have increased to meet escalating demands as demographic shifts and socioeconomic changes have eroded traditional elder care. We analyze China’s evolving long-term care landscape and trace major government policies and private-sector initiatives shaping it. Although home and community-based services remain spotty, institutional care is booming with little regulatory oversight. Chinese policy makers face mounting challenges overseeing the rapidly growing residential care sector, given the tension arising from policy inducements to further institutional growth, a weak regulatory framework, and the lack of enforcement capacity. We recommend addressing the following pressing policy issues: building a balanced system of services and avoiding an “institutional bias” that promotes rapid growth of elder care institutions over home or community-based care; strengthening regulatory oversight and quality assurance with information systems; and prioritizing education and training initiatives to grow a professionalized long-term care workforce.
PMCID: PMC3711106  PMID: 23213161
25.  Independent Review Of Social And Population Variation In Mental Health Could Improve Diagnosis In DSM Revisions 
Health affairs (Project Hope)  2013;32(5):10.1377/hlthaff.2011.0596.
At stake in the May 2013 publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), are billions of dollars in insurance payments and government resources, as well as the diagnoses and treatment of millions of patients. We argue that the most recent revision process has missed social determinants of mental health disorders and their diagnosis: environmental factors triggering biological responses that manifest themselves in behavior; differing cultural perceptions about what is normal and what is abnormal behavior; and institutional pressures related to such matters as insurance reimbursements, disability benefits, and pharmaceutical marketing. In addition, the experts charged with revising the DSM lack a systematic way to take population-level variations in diagnoses into account. To address these problems, we propose the creation of an independent research review body that would monitor variations in diagnostic patterns, inform future DSM revisions, identify needed changes in mental health policy and practice, and recommend new avenues of research. Drawing on the best available knowledge, the review body would make possible more precise and equitable psychiatric diagnoses and interventions.
PMCID: PMC3837624  PMID: 23614899

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