Search

This article presents abstracts of several research papers published online on the Website of the journal "Health Affairs." A paper titled "Public Health Response to Urgent Case Reports," by David Dausey, Nicole Lurie, and Alexis Diamond, evaluates the ability of local public health agencies to meet a preparedness standard set by the U.S. Centers for Disease Control and Prevention. Another paper titled "What High-Deductible Plans Look Like: Findings From a National Survey of Employers, 2005," documents the availability, enrollment, premiums, and cost sharing for high-deductible health plans that are offered with a health reimbursement arrangement or are health savings account-qualified plans.

This paper presents selected components of the most recent (1999) Organization for Economic Cooperation and Development (OECD) Health Data. Previous trends in spending for health care, supply and use of health care resources, and health status are updated for the thirty industrialized countries in the OECD. In 1999 the United States spent 53 percent more on health care than any other OECD country spent. The paper reviews two possible reasons for the difference: economic development and population aging. It discusses spending, supply, and utilization for specific categories of health care services: pharmaceuticals, physicians, hospitals, and high-technology services. The paper concludes with a consideration of the strengths and weaknesses of using OECD data to compare health systems. [ABSTRACT FROM AUTHOR]

This paper focuses on the reforms to the British National Health Service (NHS) undertaken by the Labour government of Tony Blair. It is argued that these reforms do not seem to be delivering the improvements in services that might be expected, given the large increase in NHS resources that the government has also provided. The paper discusses some possible explanations for this, focusing on capacity constraints and on conflicting incentive structures for the key actors. [ABSTRACT FROM AUTHOR]

This article presents several abstracts related to public health. The first abstract is "New Signs of a Strengthening U.S. Nurse Labor Market," by Peter I. Buerhaus, Douglas O. Staiger and David I. Auerbach. This paper observes that wage increases, relatively high national unemployment and widespread private-sector initiatives aimed at increasing the number of people who become nurses has resulted in a second straight year of strong employment growth among registered nurses. Another abstract is "Means-Testing in Medicare," by Mark V. Pauly. This paper argues that additional means-testing could improve Medicare's financial picture.

Canada is, in many respects, culturally and economically similar to the United States, and until relatively recently, the two countries had similar health systems. However, since passage of the Canada Health Act in the 1970s, that nation's health statistics have become increasingly superior. Although the costs of Canada's health system are high by international standards, they are much lower than U.S. costs. This paper describes several factors likely to be responsible for Canada's better health at lower cost: universal financial coverage through a so-called single payer; features conducive to a strong primary care infrastructure; and provincial autonomy under general principles set by national law. [ABSTRACT FROM AUTHOR]

The concept of accountable care organizations (ACOs) has been set forth in recently enacted national health reform legislation as a strategy to address current shortcomings in the U.S. health care system. This paper focuses on implementation issues related to these organizations, building on some initial examples. We seek to clarify definitions and key principles, provide an update on implementation in the context of other reforms, and address emerging issues that will affect the organizations' success. Finally, building on the initial experience of several organizations that are implementing accountable care and complementary reforms, we propose a national strategy to identify and expand successful approaches to accountable care implementation. [ABSTRACT FROM AUTHOR]

Primary care is viewed both as the solution to better health care in the United States and as a threatened institution, beset by poor payment and difficult working conditions. Rhode Island has taken a direct approach to making primary care more effective for patients and more attractive for physicians. In 2009 the state's Office of the Health Insurance Commissioner developed "system affordability priorities" for Rhode Island's commercial insurers, including a directive to almost double the portion of their medical expenses devoted to primary care. Initial plans of those insurers to meet those expectations are now being implemented; this paper describes those plans. [ABSTRACT FROM AUTHOR]

The term primary care is widely used as if it were consistently defined or well understood. In fact, neither is the case. This paper offers a definition of primary care derived from historical perspectives-from both the United States and abroad. We discuss the evidence for primary care's important functions and international experiences with primary care. We also describe how and why the United States has deviated from this fuller realization of primary care, as well as the steps needed to achieve primary care and health outcomes on a par with those of other developed countries. These include doubling primary care financing to 10-12 percent of total health care spending-a step that would be likely to pay for itself via resulting reductions in overall health spending. [ABSTRACT FROM AUTHOR]

Compelling evidence suggests that the United States lags behind other developed nations in the health of its population and the performance of its health care system, partly as a result of a decades-long decline in primary care. This paper outlines the political, economic, policy, and institutional factors behind this decline. A large-scale, multifaceted effort-a new Charter for Primary Care-is required to overcome these forces. There are grounds for optimism for the success of this effort, which is essential to achieving health outcomes and health system performance comparable to those of other industrialized nations. [ABSTRACT FROM AUTHOR]

This paper analyzes the evolution of consumer-driven health care in terms of its original vision, its subsequent implementation, and the transformations it has endured as it moves into its second decade. The market is generating product designs that combine elements of consumerism with elements of managed care, but the trend is always toward a stronger role for consumer choice and a weaker role for management of those choices by physicians, insurers, employers, and regulators. [ABSTRACT FROM AUTHOR]

As the largest payer for health services in the United States, Medicare has the potential to use its payment policies to stimulate change in the organization of care to improve quality and mitigate cost growth. This paper proposes a framework in which Medicare would offer an array of new bundled payment options for physician group practices, hospitals, and delivery systems, with incentives to encourage greater integration in the organization of health care delivery and the provision of more coordinated care to beneficiaries. These changes could also serve as a model for other payers to improve quality and efficiency throughout the health system. [ABSTRACT FROM AUTHOR]

Health care reform has reemerged as a policy imperative. Congressional discussions regarding sizable federal investments in health information technology (IT) infrastructure have revitalized the vision of health IT as a critical component of accelerating improvements in the quality and value of health care for all Americans. Policymakers will be challenged to link investments in the health information infrastructure to the objectives of health care reform. The purpose of this paper is to articulate some near- and long-term steps that increase the likelihood of achieving high-value health care with the aid of health IT. [ABSTRACT FROM AUTHOR]

Health information technology (IT) has great potential to transform health care and inform population health goals in clinical research, quality measurement, and public safety. To fully realize the benefits of health IT for population health, we must focus on new models that maximize efficiency, encourage rapid learning, and protect patients' privacy. In this paper we explore the advantages of a networked model for analyzing population health information, providing several examples. Although broadening the use of networked models is challenging, the societal benefits of a networked model merit continued exploration and the development of workable solutions. [ABSTRACT FROM AUTHOR]

Personal health records (PHRs), centralized places for people to electronically store and organize their health information, can benefit both patients and doctors. This qualitative study of health insurers' PHRs for enrollees reveals potential benefits and challenges. Insurers' ability to put claims-based data into the PHR offers an advantage. However, consumers are concerned about sharing personal health information with insurers and about Internet security. Physicians question (1) the validity of claims data in making treatment decisions and (2) whether accessing these PHRs is worth the disruptions to their workflow. This paper offers possible solutions that may lead to more widespread adoption of insurer PHRs. [ABSTRACT FROM AUTHOR]

Medical imaging is a prime example of an innovation that has brought important advances to medical care while triggering concerns about potential overuse and excessive costs. Many hopes are riding on comparative effectiveness research to help guide better decision making to improve quality and value. But the dynamic nature of medical imaging poses challenges for the traditional paradigms of evidentiary review and analysis at the heart of comparative effectiveness. This paper discusses these challenges and presents policy lessons for manufacturers, evidence reviewers, and decisionmakers, illustrated by an assessment of a prominent emerging imaging technique: computed tomography (CT) colonography. [ABSTRACT FROM AUTHOR]

This paper assesses the evolving "facilitated consumerism" model of health care at the community level using data from the Community Tracking Study (CTS). We find that in a relatively short time, large employers and health plans have made notable progress in putting the building blocks in place to support their vision of consumerism. However, developments in the CTS communities suggest that the consumerism strategy evolving in local markets is more nuanced than implied by some descriptions of health care consumerism. [ABSTRACT FROM AUTHOR]

Disruptive innovation has brought affordability and convenience to customers in a variety of industries. However, health care remains expensive and inaccessible to many because of the lack of business-model innovation. This paper explains the theory of disruptive innovation and describes how disruptive technologies must be matched with innovative business models. The authors present a framework for categorizing and developing business models in health care, followed by a discussion of some of the reasons why disruptive innovation in health care delivery has been slow. [ABSTRACT FROM AUTHOR]

To achieve the diverse health care goals of the United States, health care value must increase. The capacity to create value through innovation is facilitated by an integrated delivery system focused on creating value, measuring innovation returns, and receiving market rewards. This paper describes the Geisinger Health System's innovation strategy for care model redesign. Geisinger's clinical leadership, dedicated innovation team, electronic health information systems, and financial incentive alignment each contribute to its innovation record. Although Geisinger's characteristics raise serious questions about broad applicability to nonintegrated health care organizations, its experience can provide useful insights for health system reform. [ABSTRACT FROM AUTHOR]

The gap between the two worlds of researchers and policymakers renders the use of research in the policy-making process problematic. Policymakers have three primary needs in their use of research evidence: clear translation, accessible and easy-to-use information, and relevance to the policy context. These needs are sometimes at odds with the priorities of the research community. This paper describes the Robert Wood Johnson Foundation's Synthesis Project, which aims to strengthen links between research and policy making by synthesizing evidence on pressing health policy questions. [ABSTRACT FROM AUTHOR]

Using panel data from two surveys of employees at one large employer from 2004 and 2005, this paper examines consumer-directed health plans' (CDHPs') influence on the use of health-related information and health services. We compare enrollees in a high-deductible CDHP, a lower-deductible CDHP, and a preferred provider organization (PPO). Enrollees in the lower-deductible CDHP were more likely than enrollees in the other plans to start using information. Enrollees in the high-deductible CDHP were more likely than those in the PPO to start forgoing medical care to save money. [ABSTRACT FROM AUTHOR]

This paper examines delivery of public health care services in India, in the broader context of decentralization. It provides an overview of the basic features and recent developments in intergovernmental fiscal relations and accountability mechanisms, and it examines the implications of these institutions for the quality of public service delivery. It then addresses recent policy proposals on the public provision of health care, in the context of decentralization. Finally, it makes suggestions for reform priorities to improve public health care delivery. [ABSTRACT FROM AUTHOR]

Health care markets in China and India have expanded rapidly. The regulatory response has lagged behind in both countries and has followed a different pathway in each. Using the examples of front-line health providers and health insurance, this paper discusses how their different approaches have emerged from their own historical and political contexts and have led to different ways to address the main regulatory questions concerning quality of care, value for money, social agreement, and accountability. In both countries, the challenge is to build trust-based institutions that rely less on state-dominated approaches to regulation and involve other key actors. [ABSTRACT FROM AUTHOR]

No other country has undergone health care reforms as dramatic as China's. Starting in 1978, China reformed its health system from a governmental, centrally planned, and universal system to a heavily market-based one. Now, three decades later, the Chinese government openly acknowledges that the reforms failed and seeks new directions. This paper adds to the literature by examining China's health care from a system perspective, describing its health services delivery, access, outcomes, and population health in the post-reform era. It also identifies the main issues in the current system and highlights the key lessons learned from China's reform process. [ABSTRACT FROM AUTHOR]

In this paper the problems of health services in China and India are related to some structural features of the two economies. Some similarities and differences exist across these two countries in terms of political economy, with differential results. Both countries have experienced remarkable economic growth during the past quarter-century, but this has not always translated into improvements in health for the poor. Although China used to have an egalitarian basic public health service, the system has become quite inegalitarian during the past quarter-century, with the disintegration of the communes and adoption of fee-based services under a system of decentralized public finance. India's health system has remained inegalitarian throughout. [ABSTRACT FROM AUTHOR]

Both China and India have recently committed to injecting new public funds into health care. Both countries are now deciding how best to channel the additional funds to produce benefits for their populations. In this paper we analyze how well the health care systems of China and India have performed and what determines their performance. Based on the analysis, we suggest that money alone, channeled through insurance and infrastructure strengthening, is inadequate to address the current problems of unaffordable health care and heavy financial risk, and the future challenges posed by aging populations that are increasingly affected by noncommunicable diseases. [ABSTRACT FROM AUTHOR]

This paper examines the introduction of a prioritized list of fifty-six health conditions in Chile, for which access to treatment is guaranteed. This is an important health reform issue, and the discussion of Chile's rich and complex approach may benefit other countries. Conditions on the list were selected using multiple criteria: burden of disease, inequality, high costs, social preferences, rule of rescue, and cost-effectiveness. The dominant criteria were high burden of disease and social preferences. Cost-effectiveness was introduced after the fact to identify effective treatments at a cost that the country could afford. [ABSTRACT FROM AUTHOR]

Expectations for state leadership in health reform have never been higher. States are thought to function as laboratories of democracy," but they do not fulfill this role effectively because insufficient attention is paid to experimentation and knowledge translation. Congressional proposals to encourage state action cover too narrow a span of state health policy, do not provide states with sufficient authority to tackle major health policy challenges, and supply insufficient funding. This paper concludes with a description of a more robust state-federal partnership that would be more likely to yield substantial health reform. [ABSTRACT FROM AUTHOR]

The Oregon Health Plan (OHP) has received national and international attention for rationing medical care based on explicit priorities. However, in recent years OHP has lost substantial enrollment and struggled to live up to its core principles. This paper explores what went wrong in OHP and the implications of Oregon's experience for state-led health reform. [Health Affairs 26, no. 1(2007): w96-w105 (published online 19 December 2006; 10.1377/hlthaff.26.1.w96)] [ABSTRACT FROM AUTHOR]

This paper represents initial analyses of data on self-perceived health conditions and satisfaction with personal health from a representative survey of citizens in 130 countries. The analysis examines the effects of income and age on health perceptions along with the combined effect of cultural norms and income. Three important conclusions can be drawn. First, individual perceptions regarding personal health status are remarkably consistent around the world. Second, the incidence of satisfaction with personal health in the United States is comparable to that in most countries. Third, perceptions of personal health correlate strongly with respondents' income level, both globally and regionally. [ABSTRACT FROM AUTHOR]

Pay-for-performance (P4P) and public quality-reporting programs can increase the quality of health care for the services being measured. However, unless carefully designed, these programs may have the unintended consequence of increasing racial and ethnic disparities. This paper describes ways in which P4P and public reporting programs may increase disparities and suggests ways in which programs might be designed that will make them likely to reduce, or at least not increase, disparities. [Health Affairs 26, no. 3 (2007): w405-w414 (published online 10 April 2007; 10.1377/hlthaff.26.3.w405)] [ABSTRACT FROM AUTHOR]

In this paper we argue that there is a real need for Medicaid reform primarily because of the large differences among states in coverage and benefits and because of the program's high and rising costs. We describe and develop several options for Medicaid reform that would expand coverage, provide fiscal relief to states, shift responsibility for some or all of the care of dual eligibles to the federal government, and eliminate or restructure disproportionate-share hospital (DSH) payments. We conclude with a discussion on a number of other issues, particularly Medicaid cost containment and the federal matching payment structure. [Health Affairs 26, no. 2 (2007): w254-w270 (published online 23 February 2007; 10.1377/hlthaff.26.2.w254)] [ABSTRACT FROM AUTHOR]

When everyone is required to pay the same out-of-pocket amount for health care services whose benefits depend on patient characteristics, there is enormous potential for both under- and overuse. Unlike most current health plan designs, Value-Based Insurance Design (VBID) explicitly acknowledges and responds to patient heterogeneity. It encourages the use of services when the clinical benefits exceed the cost and likewise discourages the use of services when the benefits do not justify the cost. This paper makes the case for VBID and outlines current VBID initiatives in the private sector as well as barriers to further adoption. [Health Affairs 26, no. 2 (2007): w195-w203 (published online 30 January 2007; 10.1377/hlthaff.26.2.w195)] [ABSTRACT FROM AUTHOR]

Seeking to redress health disparities across income and race, many policymakers mandate health insurance benefits, presuming that equalized benefits will help equalize use of beneficial health services. This paper tests that presumption by measuring health care use by a diverse population with comprehensive health insurance. Focusing on use of mental health care and pharmaceuticals, it finds that even when insurance benefits and access are constant, whites and those with high incomes consume more of these benefits than other people do. This suggests that privileged classes extract more health care services even when everyone pays equal premiums for equal insurance coverage. [ABSTRACT FROM AUTHOR]

Foundations have sought to influence health policy in the public, private, and nonprofit sectors for more than a century. Their effectiveness in this has been a result of reliability and relevance in seeking and disseminating information, responsiveness to policy-makers' priorities and operating styles, circumspection in communicating with policy-makers and the media, and ability to maintain continuity in the issues of policy that funders address. This paper draws evidence to support these points from the history of foundations and health policy and, in particular, the Milbank Memorial Fund. [ABSTRACT FROM AUTHOR]

State public employee health plans (PEHPs) provide health benefits for millions of state and local workers, retirees, and their dependents nationwide. This paper explores major issues and challenges that PEHP leaders and state policymakers are addressing. These include the perennial challenge of funding benefits for a diverse and aging workforce; new accounting standards affecting public employers; and the changing relationship between states, retired public employees, and the Medicare program. Interviews with PEHP executives explored whether these are incremental challenges to which states can effectively adapt, or whether these challenges will catalyze broader and lasting change in the public employee and retiree health benefits arena. [ABSTRACT FROM AUTHOR]

High-deductible health plans—with and without spending accounts—are gaining ground. Will these evolving benefit designs complement or undermine the coordination of care for patients with chronic illnesses? Based on an October 2005 roundtable sponsored by the California HealthCare Foundation and Health Affairs, this paper discusses the implications of a changing health insurance market for the chronically ill, capitation payment for medical groups, and consumers navigating the system. [ABSTRACT FROM AUTHOR]

During the past few years, health plans have focused product development on consumer-driven health plans. This paper examines how these products are faring in twelve Community Tracking Study (CTS) communities. Although there has been a proliferation in the number and variety of consumer-directed plan options available, employers have taken a cautious approach. Given the increased financial stake and decision-making responsibility consumers hold when enrolled in these plans, respondents expressed frustration that the availability of information support has lagged behind the demands placed on consumers. [ABSTRACT FROM AUTHOR]

Fairness in finance is an intrinsic and challenging goal of health systems. Mexico recently devised a structural reform that responds to this challenge. Through a new system of social protection in health that will offer public insurance to all citizens, the reform is expected to reduce catastrophic and out-of-pocket spending while promoting efficiency, more equitable resource distribution, and better-quality care. This paper analyzes the reform, focusing on financial features, expected benefits, and future challenges. It also highlights aspects of relevance for other countries that are striving to formulate and implement health policies to promote universal social protection and fair financing. [ABSTRACT FROM AUTHOR]

This paper reports findings on the state of job-based health insurance in spring 2005 and how it has changed during recent years. Premiums rose 9.2 percent, the first year of single-digit increases since 2000. The percentage of firms offering health benefits has fallen from 69 percent in 2000 to 60 percent in 2005. Cost sharing did not grow appreciably in the past year. Enrollment in preferred provider organizations (PROs) grew from 55 percent in 2004 to 61 percent in 2005, while enrollment in health maintenance organizations (HMOs) fell from 25 percent to 21 percent of the total. [ABSTRACT FROM AUTHOR]

Recent forces have created new financial stress for hospitals but also some relief. This paper explores hospitals' changing involvement in the safety net between 1996 and 2002. We replicate approaches used in a study of 1990-1997 and thus provide a needed update on the U.S. hospital safety net. Overall, some groups of safety-net hospitals increased uncompensated care, but others did not Non-safety-net hospitals trimmed certain services commonly used by the indigent; this may point to future reductions in access. We examine the implications of these findings for the future of the safety net. [ABSTRACT FROM AUTHOR]

The quality of communication between patients and clinicians can have a major impact on health outcomes, and limited English proficiency can interfere with effective communication. More than ten million U.S. residents speak English poorly or not at all, constituting a language chasm in the health care system. This paper reviews the evidence on the link between linguistic competence and health care quality and the impact of particular language-assistance strategies. Drawing on the experiences of fourteen health plans that have been at the forefront of linguistic competence efforts, we identify lessons for plans, purchasers, policymakers, and researchers on ways to improve the availability and quality of interpreter services. [ABSTRACT FROM AUTHOR]

Despite strong interest in improving care for high-risk elders, demonstration projects typically show negative results. This paper examines one large foundation-sponsored initiative to gain insight on why success often is so elusive. The findings indicate that specific flaws in concept, design, and implementation each make it more challenging for demonstrations to achieve their intended goals, especially those involving cost and utilization reductions. We speculate that part of the reason for this is that organizational and political processes lead to fundamentally conservative demonstrations that assume that small amounts of resources directed at incremental change can be effective in generating substantial change in organizations and can do so rapidly. [ABSTRACT FROM AUTHOR]

In this paper we assess the value of electronic health care information exchange and interoperability (HIEI) between providers (hospitals and medical group practices) and independent laboratories, radiology centers, pharmacies, payers, public health departments, and other providers. We have created an HIEI taxonomy and combined published evidence with expert opinion in a cost-benefit model. Fully standardized HIEI could yield a net value of $77.8 billion per year once fully implemented. Nonstandardized HIEI offers smaller positive financial returns. The clinical impact of HIEI for which quantitative estimates cannot yet be made would likely add further value. A compelling business case exists for national implementation of fully standardized HIEI. [ABSTRACT FROM AUTHOR]

Behind the wide acceptance of the idea of "evidence-based medicine" are two curious facts: There are two very different approaches to applying evidence to medicine, and the most commonly cited definition applies to only one of them. This paper describes the problem that we are asking "evidence" to solve and the different methods by which evidence can be used to help solve that problem, and recommends a unified approach. [ABSTRACT FROM AUTHOR]

Medical practices, clinical practice guidelines, clinical performance measures and measurements, and a variety of health care-related administrative decisions, such as insurance coverage decisions, are claiming to be "evidence based" with increasing frequency. In this paper we examine the "evidence based" label; discuss how evidence ought to have been assembled, evaluated, and synthesized; and when evidence is sufficient for the "evidence-based" moniker to rightfully apply. We also highlight several considerations other than the strength of evidence that are relevant to several common types of health care-related administrative decisions and that influence the extent to which the resulting decisions are truly evidence based. [ABSTRACT FROM AUTHOR]

The individual market is the only source of health insurance for the more than 20 percent of Americans not eligible for group or public health insurance, yet participation rates are low and shrinking. This paper examines this market's structural features and assesses the likelihood that it will play an expanded role in the future. We describe how pressures such as cost growth, new technologies, and changes in the nature of the workplace are shaping the individual market We conclude that the future of the market will depend largely on whether there are policy interventions that balance the problems of affordability, risk sharing, and adverse selection. [ABSTRACT FROM AUTHOR]

The Bush administration has proposed expanding insurance coverage as well as community health centers (CHCs) to increase access to care for uninsured people. This paper examines the relative effects of insurance coverage and CHC capacity on access to care. Communities that have both high insurance coverage and extensive CHC capacity tend to have the best access, although the former appears more important. Funding of insurance coverage expansions is likely to produce greater gains in access than if an equivalent level of funding were invested in CHCs. Policymakers should consider CHC expansions as complementary to insurance coverage expansions rather than as a substitute. [ABSTRACT FROM AUTHOR]

Since the early 1990s almost all states have moved some or all of their Medicaid beneficiaries to Medicaid managed care (MMC). Critics have worried about quality since MMC'S inception. Proponents argued that state Medicaid agencies, as large-scale purchasers of care, would pursue "value-based purchasing" and other strategies to stimulate quality improvements. In this paper we extend and update previous evaluations of the use of managed care for the Medicaid population, the extent to which beneficiaries receive care from Medicaid only and from commercial health plans, and the quality management programs that state Medicaid agencies supported during 2001. [ABSTRACT FROM AUTHOR]

The expansive vision of modern public health, "healthy people in healthy communities," is politically charged. This paper offers a justification for this broad vision and offers concrete proposals. By pointing to the poor condition of public health agencies; urging a transition to an intersectoral public health system; promoting the adoption of bold changes in U.S. physical, social, and economic conditions; and endorsing a values shift to a commitment to collective interest in healthier communities, we hope to take a dramatic step toward achieving these aspirations for "healthy people in healthy communities." [ABSTRACT FROM AUTHOR]

In 2002 Pennsylvania became the first state to impose on hospitals a statutory duty to notify patients in writing of a serious event. If the disclosure conversations are carefully planned, properly executed, and responsive to patients' needs, this new requirement creates possible benefits for both patient safety and litigation risk management. This paper describes a model for accomplishing these goals that encourages health care providers to communicate more effectively with patients following an adverse event or medical error, learn from mistakes, respond to the concerns of patients and families after an adverse event, and arrive at a fair and cost-effective resolution of valid claims. [ABSTRACT FROM AUTHOR]