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1.  Redesigning Care For Patients At Increased Hospitalization Risk: The Comprehensive Care Physician Model 
Health affairs (Project Hope)  2014;33(5):770-777.
Patients who have been hospitalized often experience care coordination problems that worsen outcomes and increase costs. One reason is that hospital care and ambulatory care are often provided by different physicians. However, interventions to improve care coordination for hospitalized patients have not consistently improved outcomes and generally have not reduced costs. We describe the rationale for the Comprehensive Care Physician model, in which physicians focus their practice on patients at increased risk of hospitalization so that they can provide both inpatient and outpatient care to their patients. We also describe the design and implementation of a study supported by the Center for Medicare and Medicaid Innovation to assess the model’s effects on costs and outcomes. Evidence concerning the effectiveness of the program is expected by 2016. If the program is found to be effective, the next steps will be to assess the durability of its benefits and the model’s potential for dissemination; evidence to the contrary will provide insights into how to alter the program to address sources of failure.
doi:10.1377/hlthaff.2014.0072
PMCID: PMC4331340  PMID: 24799573
2.  Hospitals With Higher Nurse Staffing Had Lower Odds Of Readmissions Penalties Than Hospitals With Lower Staffing 
Health affairs (Project Hope)  2013;32(10):1740-1747.
The Affordable Care Act’s Hospital Readmissions Reduction Program (HRRP) penalizes hospitals based on excess readmission rates among Medicare beneficiaries. The aim of the program is to reduce readmissions while aligning hospitals’ financial incentives with payers’ and patients’ quality goals. Many evidence-based interventions that reduce readmissions, such as discharge preparation, care coordination, and patient education, are grounded in the fundamentals of basic nursing care. Yet inadequate staffing can hinder nurses’ efforts to carry out these processes of care. We estimated the effect that nurse staffing had on the likelihood that a hospital was penalized under the HRRP. Hospitals with higher nurse staffing had 25 percent lower odds of being penalized compared to otherwise similar hospitals with lower staffing. Investment in nursing is a potential system-level intervention to reduce readmissions that policy makers and hospital administrators should consider in the new regulatory environment as they examine the quality of care delivered to US hospital patients.
doi:10.1377/hlthaff.2013.0613
PMCID: PMC4315496  PMID: 24101063
3.  [No title available] 
PMCID: PMC3962263  PMID: 24493773
4.  Exhaustion of Food Budgets at Month's End and Hospital Admissions for Hypoglycemia 
Health affairs (Project Hope)  2014;33(1):116-123.
One in seven US households cannot reliably afford food. Food budgets are more frequently exhausted at the end of a month than at other points in time. We postulated that this monthly pattern influenced health outcomes, such as risk for hypoglycemia among people with diabetes. Using administrative data on inpatient admissions in California for 2000–08, we found that admissions for hypoglycemia were more common in the low-income than the high-income population (270 versus 210 admissions per 1,000,000). Risk for hypoglycemia admission increased 27 percent in the last week of the month compared to the first week in the low-income population, but we observed no similar temporal variation in the high-income population. These findings suggest that exhaustion of food budgets might be an important driver of health inequities. Policy solutions to improve stable access to nutrition in low-income populations and raise awareness of the health risks of food insecurity might be warranted.
doi:10.1377/hlthaff.2013.0096
PMCID: PMC4215698  PMID: 24395943
5.  Transforming emergency care for older adults 
Health affairs (Project Hope)  2013;32(12):2116-2121.
Already crowded and stressful, US emergency departments are facing the challenge of serving an aging population that requires complex and lengthy evaluations. Creative solutions are necessary to improve the value and ensure the quality of emergency care delivered to older adults while more fully addressing their complex underlying physical, social, cognitive, and situational needs. Developing models of geriatric emergency care, including some that are already in use at dedicated geriatric emergency departments, incorporate a variety of physical, procedural, and staffing changes. Among the options for “geriatricizing” emergency care are approaches that may eliminate the need for an emergency department visit, such as telemedicine; for initial hospitalization, such as patient observation units; and for rehospitalization, such as comprehensive discharge planning. By transforming its current safety-net role to becoming a partner in care coordination, emergency departments have the opportunity to better integrate into the broader health care system, improve patient health outcomes, contribute to optimizing the health care system, and reduce overall costs of care—keys to improving emergency care for patients of all ages.
doi:10.1377/hlthaff.2013.0670
PMCID: PMC4070367  PMID: 24301394
6.  Washington Cancer Patients Found To Be At Greater Risk For Bankruptcy Than People Without A Cancer Diagnosis 
Health affairs (Project Hope)  2013;32(6):1143-1152.
Much has been written about the relationship between a person’s high medical expenses and his or her likelihood of filing for bankruptcy, but the relationship between receiving a cancer diagnosis and filing for bankruptcy is less well understood. We estimated the incidence and relative risk of bankruptcy for people age twenty-one or older diagnosed with cancer compared to people the same age without cancer by conducting a retrospective cohort analysis that used a variety of medical, personal, legal, and bankruptcy sources covering the Western District of Washington State in US Bankruptcy Court for the period 1995–2009. We found that cancer patients were 2.65 times more likely to go bankrupt than people without cancer. Younger cancer patients had 2–5 times higher rates of bankruptcy compared to cancer patients age sixty-five or older, indicating that Medicare insurance and Social Security may mitigate bankruptcy risk for the older group. The findings suggest that employers and governments may have a policy role to play in creating programs and incentives that could help people cover expenses in the first year following a cancer diagnosis.
doi:10.1377/hlthaff.2012.1263
PMCID: PMC4240626  PMID: 23676531
7.  Access and Cost Barriers to Mental Health Care by Insurance Status, 1999 to 2010 
Health affairs (Project Hope)  2013;32(10):1723-1730.
The cost of mental health services has always been a great barrier to accessing care for people with mental health problems. This article documents changes in insurance coverage and cost for mental health services for people with public insurance, private insurance, and no coverage. Compared to 1999–2000, in 2009–10 people with mental health problems were more likely to have public insurance and less likely to have private insurance. Although access to specialty care remained relatively stable for people with mental illness, cost barriers to care increased among the uninsured and the privately insured who had serious mental illness. The rise in cost barriers among those with private insurance suggests that the current financing of care in the private insurance market is insufficient to alleviate cost burdens and has implications for reforms under the Affordable Care Act. People with mental health problems who are newly eligible to purchase private insurance under the act might still find high cost barriers to accessing care.
doi:10.1377/hlthaff.2013.0133
PMCID: PMC4236908  PMID: 24101061
8.  Attributing Patients To Accountable Care Organizations: Performance Year Approach Aligns Stakeholders’ Interests 
Health affairs (Project Hope)  2013;32(3):587-595.
The accountable care organization (ACO) model of health care delivery is rapidly being implemented under government and private-sector initiatives. The model requires that each ACO have a defined patient population for which the ACO will be held accountable for both total cost of care and quality performance. However, there is no empirical evidence about the best way to define how patients are assigned to these groups of doctors, hospitals, and other health care providers. We examined the two major methods of defining, or attributing, patient populations to ACOs: the prospective method and the performance year method. The prospective method uses data from one year to assign patients to an ACO for the following performance year. The performance year method assigns patients to an ACO at the end of the performance year based on the population served during the performance year. We used Medicare fee-for-service claims data from 2008 and 2009 to simulate a set of ACOs to compare the two methods. Although both methods have benefits and drawbacks, we found that attributing patients using the performance year method yielded greater overlap of attributed patients and patients treated during the performance year and resulted in a higher proportion of care concentrated within an accountable care organization. Together, these results suggest that performance year attribution may more fully and accurately reflect an ACO’s patient population and may better position an ACO to achieve shared savings.
doi:10.1377/hlthaff.2012.0489
PMCID: PMC4230294  PMID: 23459739
9.  The Geography of Graduate Medical Education: Imbalances Signal Need for New Distribution Policies 
Health affairs (Project Hope)  2013;32(11):1914-1921.
Graduate medical education (GME) defines the overall number, specialty make-up and geographic distribution of the U.S. physician workforce. Medicare GME payments represent the largest single public investment in health workforce development but it is an inflexible system that is drawing scrutiny for its rationale, effectiveness and balance. We analyzed Medicare hospital cost reports for teaching hospitals and found large state level differences in the number of Medicare sponsored residents per population, total Medicare GME payments, payments per person (ranging from $1.94 to $103.63 per person in Montana and New York, respectively), and average payments per trainee (ranging from $63,811 to $155,135 per trainee in Louisiana and Connecticut, respectively). Options to address these imbalances include ensuring those states that receive less Medicare GME are prioritized or protected in the case of increases or decreases in funding and the re-examination of the Medicare GME formulas. The state level variation highlights that the GME system badly needs flexibility and the capability to deliberate and make policy about public investments in graduate medical education.
doi:10.1377/hlthaff.2013.0545
PMCID: PMC3951373  PMID: 24191080
10.  Physician Assistants and Nurse Practitioners Perform Effective Roles on Teams Caring for Medicare Patients with Diabetes 
Health affairs (Project Hope)  2013;32(11):1942-1948.
Redesigning healthcare systems to deliver team-based care is considered important to improving care for chronically ill patients. Including physician assistants and/or nurse practitioners on primary care teams is one approach to the patient-centered medical home. However, understanding of the impact of team structure on outcomes is limited. Using Medicare claims and electronic health record data from a large physician group, we compared multiple patient outcomes for older patients with diabetes between patient panels receiving physician only care and panels where primary care physician assistants/nurse practitioners served in different roles. Specific roles were associated with different quality of diabetes care and health service utilization patterns and no role was best for all outcomes. Findings suggest multiple potential approaches to implementing roles on primary care teams exist; however, local factors, including the characteristics of the patients served and prioritization of goals may be important considerations when implementing roles.
doi:10.1377/hlthaff.2013.0506
PMCID: PMC3909681  PMID: 24191084
11.  New Neighborhood Grocery Store Increased Awareness Of Food Access But Did Not Alter Dietary Habits Or Obesity 
Health affairs (Project Hope)  2014;33(2):283-291.
Current national and local policies to improve diet in low-income US populations include increasing physical access to grocery stores and supermarkets in underserved neighbourhoods. Using a prospective controlled quasi-experimental design we evaluate the impact on Body Mass Index, fruit and vegetable intake and perceptions of food access, of increasing neighborhood supermarket provision in one community in Philadelphia. This increase in provision was one part of the wider public-private Pennsylvania Fresh Food Financing Initiative. The intervention moderately increased perceptions of food access, but did not lead to changes in fruit and vegetable intake or BMI. This suggests that a perception-action `gap' may exist. The effectiveness of interventions to improve physical access to food by encouraging supermarkets to locate in underserved areas therefore remains uncertain. Replication of findings in other settings is urgently required.
doi:10.1377/hlthaff.2013.0512
PMCID: PMC4201352  PMID: 24493772
12.  A Report On Eight Early-Stage State And Regional Projects Testing Value-Based Payment 
Health affairs (Project Hope)  2013;32(5):998-1006.
To help contain health care spending and improve the quality of care, practitioners and policy makers are trying to move away from fee-for-service toward value-based payment, which links providers’ reimbursement to the value, rather than the volume, of services delivered. With funding from the Robert Wood Johnson Foundation, eight grantees across the country are designing and implementing value-based payment reform projects. For example, in Salem, Oregon, the Physicians Choice Foundation is testing “Program Oriented Payments,” which include incentives for providers who follow a condition-specific program of care designed to meet goals set jointly by patient and provider. In this article we describe the funding rationale and the specific objectives, strategies, progress, and early stages of implementation of the eight projects. We also share some early lessons and identify prerequisites for success, such as ensuring that providers have broad and timely access to data so they can meet patients’ needs in cost-effective ways.
doi:10.1377/hlthaff.2012.1124
PMCID: PMC4188548  PMID: 23650332
13.  Substantial Health and Economic Returns From Delayed Aging May Warrant a New Focus for Medical Research 
Health affairs (Project Hope)  2013;32(10):1698-1705.
Recent scientific advances suggest that slowing the aging process (senescence) is now a realistic goal. Yet most medical research remains focused on combating individual diseases. Using the Future Elderly Model—a microsimulation of the future health and spending of older Americans in the United States—we compared optimistic “disease specific” scenarios with a hypothetical “delayed aging” scenario in terms of their impact on longevity, disability, and major entitlement program costs. Delayed aging could increase life expectancy by an additional 2.2 years, most of which would be spent in good health. The economic value of delayed aging is estimated to be $7.1 trillion over fifty years. In contrast, addressing heart disease and cancer separately would yield diminishing improvements in health and longevity by 2060—mainly due to competing risks. Delayed aging would substantially increase entitlement outlays, especially for Social Security, but these changes could be offset by increasing the Medicare eligibility age and the normal retirement age for Social Security. Overall, greater investment in research to delay aging appears to be a highly efficient way to forestall disease, extend healthy life, and improve public health.
doi:10.1377/hlthaff.2013.0052
PMCID: PMC3938188  PMID: 24101058
14.  Providing More Home-Delivered Meals Is One Way To Keep Older Adults With Low-Care Needs Out Of Nursing Homes 
Health affairs (Project Hope)  2013;32(10):1796-1802.
Programs that help older adults live independently in the community can also deliver net savings to states on the costs of long-term supports and services. We estimate that if all states had increased by 1 percent the number of adults age sixty-five or older who received home-delivered meals in 2009 under Title III of the Older Americans Act, total annual savings to states’ Medicaid programs could have exceeded $109 million. The projected savings primarily reflect decreased Medicaid spending for an estimated 1,722 older adults with low-care needs who would no longer require nursing home care— instead, they could remain at home, sustained by home-delivered meals. Twenty-six states could have realized net savings in 2009 from the expansion of their home-delivered meals programs, while twenty-two states would have incurred net costs. Programs such as home-delivered meals have the potential to provide substantial savings to some states’ Medicaid programs.
doi:10.1377/hlthaff.2013.0390
PMCID: PMC4001076  PMID: 24101071
15.  Increasing Care Intensity at Emergency Department Visits in California, 2002–2009 
Health affairs (Project Hope)  2013;32(10):1811-1819.
High-intensity emergency department (ED) care involving complex diagnostic testing and treatment is costly and contributes to ED crowding. We examined high-intensity ED visit rates by patients with a severe, potentially life-threatening illness in California from 2002 through 2009. While total annual ED visits increased by 25% from 2002 (9.0 million) to 2009 (11.3 million), high-intensity ED visits increased 87%, from 778,000 to 1.5 million per year. The proportion of visits with high-intensity ED care increased from 8.6% to 13%(relative increase of 51%). Additionally, the overall rate of ED admissions increased by 39%, with a much larger increase in the rate of high-intensity ED admissions that increased by 88%. Safety-net EDs, compared with non-safety-net EDs, experienced a disproportionate increase in high-intensity ED visits (+157% vs. +61%, respectively). These findings suggest a trend toward intensification of ED care, particularly at safety-net hospitals where access to care outside the ED may be limited.
doi:10.1377/hlthaff.2013.0397
PMCID: PMC4109394  PMID: 24101073
16.  More Americans Living Longer With Cardiovascular Disease Will Increase Costs While Lowering Quality Of Life 
Health affairs (Project Hope)  2013;32(10):1706-1714.
In the past several decades some risk factors for cardiovascular disease have improved, while others have worsened. For example, smoking rates have dropped and treatment rates for cardiovascular disease have increased--factors that have made the disease less fatal. At the same time, Americans’ average body mass index and incidence of diabetes have increased as the population continues to live longer--factors that have made cardiovascular disease more prevalent. To assess the aggregate impact of these opposing trends, we used the nine National Health and Nutrition Examination Survey waves from 1973 to 2010 to forecast total cardiovascular disease risk and prevalence from 2015 to 2030. We found that continued improvements in cardiovascular disease treatment and declining smoking rates will not outweigh the influence of increasing population age and obesity on cardiovascular disease risk. Given an aging population, an obesity epidemic, and declining mortality from the disease, the United States should expect to see a sharp rise in the health care costs, disability, and reductions in quality of life associated with increased prevalence of cardiovascular disease. Policies that target the treatment of high blood pressure and cholesterol and the reduction of obesity will be necessary to curb the imminent spike in cardiovascular disease prevalence.
doi:10.1377/hlthaff.2013.0449
PMCID: PMC3894660  PMID: 24101059
17.  Racial Differences In Hospital Use After Acute Myocardial Infarction: Does Residential Segregation Play A Role? 
Health affairs (Project Hope)  2009;28(2):w368-w378.
This study compares the likelihood of admission to high-mortality hospitals for black and white Medicare patients in 118 health care markets, and whether admission patterns vary if residential racial segregation is greater in the area. Risk of admission to high-mortality hospitals was 35 percent higher for blacks than for whites in markets with high residential segregation. Moreover, blacks were more likely than whites to be admitted to hospitals with high mortality, even in analyses limited to patients who lived closest to lower-mortality hospitals. Eliminating health care disparities may require policies that address social factors leading to segregation.
doi:10.1377/hlthaff.28.2.w368
PMCID: PMC4182438  PMID: 19258343
18.  Publicly reported quality-of-care measures influenced Wisconsin physician groups to improve performance 
Health affairs (Project Hope)  2013;32(3):536-543.
Public reporting of performance on quality measures is increasingly common but little is known about the impact, especially among physician groups. The Wisconsin Collaborative for Healthcare Quality (Collaborative) is a voluntary consortium of physician groups which has publicly reported quality measures since 2004, providing an opportunity to study the effect of this effort on participating groups. Analyses included member performance on 14 ambulatory measures from 2004–2009, a survey regarding reporting and its relationship to improvement efforts, and use of Medicare billing data to independently compare Collaborative members to the rest of Wisconsin, neighboring states and the rest of the United States. Faced with limited resources, groups prioritized their efforts based on the nature of the measure and their performance compared to others. The outcomes demonstrated that public reporting was associated with improvement in health quality and that large physician group practices will engage in improvement efforts in response.
doi:10.1377/hlthaff.2012.1275
PMCID: PMC4137398  PMID: 23459733
19.  Peer Support For Self-Management Of Diabetes Improved Outcomes In International Settings 
Health affairs (Project Hope)  2012;31(1):130-139.
Self-management of diabetes is essential to reducing the risks of associated disabilities. But effective self-management is often short-lived. Peers can provide the kind of ongoing support that is needed for sustained self-management of diabetes. In this context, peers are nonprofessionals who have diabetes or close familiarity with its management. Key functions of effective peer support include assistance in daily management, social and emotional support, linkage to clinical care, and ongoing availability of support. Using these four functions as a template of peer support, project teams in Cameroon, South Africa, Thailand, and Uganda developed and then evaluated peer support interventions for adults with diabetes. Our initial assessment found improvements in symptom management, diet, blood pressure, body mass index, and blood sugar levels for many of those taking part in the programs. For policy makers, the broader message is that by emphasizing the four key peer support functions, diabetes management programs can be successfully introduced across varied cultural settings and within diverse health systems.
doi:10.1377/hlthaff.2011.0914
PMCID: PMC4128379  PMID: 22232103
20.  Satisfaction With Massachusetts Nursing Home Care Was Generally High during 2005-09, With Some Variability Across Facilities 
Health affairs (Project Hope)  2013;32(8):1416-1425.
Since 2005 Massachusetts has publicly reported results from biennial surveys of satisfaction with nursing homes, completed by responsible parties for residents, to promote consumer-centered care. Our analysis of the results from 2005, 2007, and 2009 revealed generally high satisfaction with care, which remained stable over time. On a scale of 1 to 5 (from very dissatisfied to very satisfied), average satisfaction with overall care was 4.22–4.31 and satisfaction that overall residents’ needs were met was 4.09–4.16; 89.9–90.1 percent of respondents would recommend the facility. Satisfaction ratings varied considerably across facilities, with higher scores associated with higher nursing staffing levels, fewer deficiency citations, and nonprofit or government ownership. Scores for six domains of care were, in general, closely associated with satisfaction scores. However, family members seemed less satisfied with the physical and social activities available to residents and with the food and meals served than with such attributes as the physical environment. Our findings suggest that including the consumer's perspective would improve the Centers for Medicare and Medicaid Services’ current nursing home reporting efforts, but that refinements may be necessary to detect the impact of consumer reporting on the quality of patient-centered care.
doi:10.1377/hlthaff.2012.1416
PMCID: PMC3784993  PMID: 23918486
21.  Electronic communication improves access, but barriers to its widespread adoption remain 
Health affairs (Project Hope)  2013;32(8):10.1377/hlthaff.2012.1151.
Principles of patient-centered care imply that physicians should use electronic communication with patients more extensively, including as a substitute for office visits when clinically appropriate. We interviewed leaders of 21 medical groups that use electronic communication with patients extensively and also interviewed staff in six of these groups. Electronic communication was widely perceived to be a safe, effective and efficient means of communication that improves patient satisfaction and saves patients time, but increases the volume of physician work unless office visits are reduced. Practice redesign and new payment methods are likely necessary for electronic communication to be used more extensively.
doi:10.1377/hlthaff.2012.1151
PMCID: PMC3817043  PMID: 23918479
22.  Root Cause Analysis Reports Help Identify Common Factors In Delayed Diagnosis And Treatment Of Outpatients 
Health affairs (Project Hope)  2013;32(8):10.1377/hlthaff.2013.0130.
Delays in diagnosis and treatment are widely considered to be threats to outpatient safety. However, few studies have identified and described what factors contribute to delays that might result in patient harm in the outpatient setting. We analyzed 111 root cause analysis reports that investigated such delays and were submitted to the Veterans Affairs National Center for Patient Safety in the period 2005–12. The most common contributing factors noted in the reports included coordination problems resulting from inadequate follow-up planning, delayed scheduling for unspecified reasons, inadequate tracking of test results, and the absence of a system to track patients in need of short-term follow-up. Other contributing factors were team-level decision making problems resulting from miscommunication of urgency between providers and providers' lack of awareness of or knowledge about a patient's situation; and communication failures among providers, patients, and other health care team members. Our findings suggest that to support care goals in the Affordable Care Act and the National Quality Strategy, even relatively sophisticated electronic health record systems will require enhancements. At the same time, policy initiatives should support programs to implement, and perhaps reward the use of, more rigorous interprofessional teamwork principles to improve outpatient communication and coordination.
doi:10.1377/hlthaff.2013.0130
PMCID: PMC3822525  PMID: 23918480
23.  Multiple Drug Cost Containment Policies in Michigan’s Medicaid Program Saved Money Overall, Although Some Increased Costs 
Health affairs (Project Hope)  2012;31(4):816-826.
Michigan’s Medicaid program implemented four policies (preferred lists, joint and multi-state purchasing arrangements, and maximum allowable cost) in 2002–2004 for its dual-eligible Medicaid and Medicare beneficiaries, taking antihypertensives and antihyperlipidemics prescriptions. We used interrupted time series analysis to evaluate the impact of each individual policy while holding the effect of all other policies constant. Preferred lists increased preferred and generic market share, and reduced daily cost. In contrast, maximum allowable cost increased daily cost, and is the only policy that did not generate cost savings. The joint and multi-state arrangements did not impact daily cost. Despite policy tradeoffs, the cumulative effect was a 10% decrease in daily cost and an annualized cost savings of $46,195.
doi:10.1377/hlthaff.2011.0246
PMCID: PMC4118749  PMID: 22492899
24.  “Will Employers Drop Health Insurance Coverage because of the Affordable Care Act?” Health Affairs 32(9): 1522–1530 
Health affairs (Project Hope)  2013;32(9):1522-1530.
Since the passage of the Affordable Care Act, there has been considerable speculation about how many employers will stop offering health insurance once the major coverage provisions of the Act take effect. While some observers predict little aggregate effect, others believe that 2014 marks the beginning of the end for our current system of employer- sponsored insurance. We address the question “how will employer health insurance offering respond to health reform?” using theoretical and empirical evidence. First, we describe economic models of why employers offer insurance. Second, we recap the relevant provisions of health reform and use our economic framework to consider how they may affect employer offers. Third, we review the various predictions that have been made on this subject. Finally, we offer some observations on interpreting early data from 2014.
doi:10.1377/hlthaff.2013.0526
PMCID: PMC4116668  PMID: 24019355
25.  Transitioning to Medicare before Age 65 
Health affairs (Project Hope)  2008;27(3):w175-w184.
Disabled workers who start receiving Social Security Disability Income (SSDI) must wait 24 months to qualify for Medicare. Legislation introduced in Congress would eliminate this waiting period, to guarantee that people with disabilities severe enough to qualify for SSDI will not be uninsured. We provide a longitudinal view of Medicare enrollment before age 65 by following a national sample from ages 55 to 64. One person in six was covered by Medicare before turning 65. A quarter of new enrollees were uninsured during the waiting period. There were great disparities in reliance on Medicare and coverage in the waiting period.
doi:10.1377/hlthaff.27.3.w175
PMCID: PMC4111896  PMID: 18364367

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