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Objective: This review evaluates costs and benefits associated with acquiring, implementing, and operating clinical decision support systems (CDSSs) to prevent cardiovascular disease (CVD). Materials and Methods: Methods developed for the Community Guide were used to review CDSS literature covering the period from January 1976 to October 2015. Twenty-one studies were identified for inclusion. Results: It was difficult to draw a meaningful estimate for the cost of acquiring and operating CDSSs to prevent CVD from the available studies (n = 12) due to considerable heterogeneity. Several studies (n = 11) indicated that health care costs were averted by using CDSSs but many were partial assessments that did not consider all components of health care. Four cost-benefit studies reached conflicting conclusions about the net benefit of CDSSs based on incomplete assessments of costs and benefits. Three cost-utility studies indicated inconsistent conclusions regarding cost-effectiveness based on a conservative $50,000 threshold. Discussion: Intervention costs were not negligible, but specific estimates were not derived because of the heterogeneity of implementation and reporting metrics. Expected economic benefits from averted health care cost could not be determined with confidence because many studies did not fully account for all components of health care. Conclusion: We were unable to conclude whether CDSSs for CVD prevention is either cost-beneficial or cost-effective. Several evidence gaps are identified, most prominently a lack of information about major drivers of cost and benefit, a lack of standard metrics for the cost of CDSSs, and not allowing for useful life of a CDSS that generally extends beyond one accounting period.

Many observers have been concerned about a mismatch between the knowledge, skills, and professional values of newly trained physicians and the requirements of current and future medical practice. We surveyed and interviewed Kaiser Permanente's clinical department chiefs for internal medicine, pediatrics, general surgery, and obstetrics/gynecology to ascertain their views of the perceived gaps in the readiness of newly trained physicians. Nearly half of those surveyed reported deficiencies among new physicians in managing routine conditions or performing simple procedures often encountered in office-based practice. A third of the chiefs noted deficiencies in coordinating care for patients. Filling these and other training gaps will require changes at many levels-from residency programs to Medicare reimbursement policies-to better prepare new physicians for the challenges of working in a health care system evolving to emphasize accountability, quality outcomes, cost control, and information technology.

Analyses of consumer-directed health plans often focus on how use of services under such a plan compares with what use would have been under a more comprehensive benefit design. That's a ...

Background As many other European healthcare systems the Danish healthcare system (DHS) has targeted chronic condition care in its reform efforts. Benchmarking is a valuable tool to identify areas for improvement. Prior work indicates that chronic care coordination is poor in the DHS, especially in comparison with care in Kaiser Permanente (KP), an integrated delivery system based in the United States. We investigated population rates of hospitalisation and readmission rates for ambulatory care sensitive, chronic medical conditions in the two systems. Methods Using a historical cohort study design, age and gender adjusted population rates of hospitalisations for angina, heart failure, chronic obstructive pulmonary disease, and hypertension, plus rates of 30-day readmission and mortality were investigated for all individuals aged 65+ in the DHS and KP. Results DHS had substantially higher rates of hospitalisations, readmissions, and mean lengths of stay per hospitalisation, than KP had. For example, the adjusted angina hospitalisation rates in 2007 for the DHS and KP respectively were 1.01/100 persons (95%CI: 0.98-1.03) vs. 0.11/100 persons (95%CI: 0.10-0.13/100 persons); 21.6% vs. 9.9% readmission within 30 days (OR = 2.53; 95% CI: 1.84-3.47); and mean length of stay was 2.52 vs. 1.80 hospital days. Mortality up through 30 days post-discharge was not consistently different in the two systems. Conclusions There are substantial differences between the DHS and KP in the rates of preventable hospitalisations and subsequent readmissions associated with chronic conditions, which suggest much opportunity for improvement within the Danish healthcare system. Reductions in hospitalisations also could improve patient welfare and free considerable resources for use towards preventing disease exacerbations. These conclusions may also apply for similar public systems such as the US Medicare system, the NHS and other systems striving to improve the integration of care for persons with chronic conditions.

Every profession spawns a dialect, a language that facilitates efficient communication among insiders. In written communication, that dialect often becomes even more compact, as acronyms and code words are substituted for “plain text.” This tendency has received some attention in the government sector (where efforts to translate bureaucratic jargon into English periodically gain media attention) but much less so in health care. Yet we may well have reached the point in health care at which the dialects spoken by practitioners and health policy experts are not just confusing to outsiders, but actually prevent us insiders from achieving our goals. The findings presented here emerged from what began as a qualitative marketing study, but which revealed a tremendous gap between what health care professionals say and what health care consumers hear. That the unfettered use of our professional dialect may be counterproductive is highlighted as two recent health care trends collide: the ever-increasing complexity in the language of health care occurring at the same time that we are asking lay people—as patients, consumers, and voters—to take a more active role in their health and health care choices. The language of health care and health policy has grown more complex over time as new diseases and conditions have been identified, new treatments discovered, and new ways of reimbursing providers implemented. Physicians who once could do little about heart attacks now treat “acute myocardial infarctions” with “beta blockers, angiotensin-converting enzyme inhibitors, and drug-eluting stents.” The Medicare program that once paid whatever numbers physicians wrote on their bills, now bases payments on “resource-based relative values” that are multiplied by a “geographic practice cost index” and a “conversion factor” and whose growth over time is determined by a “sustainable growth rate mechanism.” Twenty, perhaps even ten years ago, the discrepancy between professional and lay dialects did not particularly matter. Just as one need not be an engineer to drive a car, patients did not need to understand medical jargon or health care policy. But that has changed. Increasingly, we want consumers to be “empowered” and to take an active role in maintaining their health, not to be passive recipients of medical care. Consumer “choice” forces health care organizations to differentiate themselves, which they try to do by packaging and selling their new and improved services. We want voters to understand policy alternatives and assess options for change. Perhaps most importantly, we want to enlist patients and consumers to advocate for change in the way that health care is delivered and force the system to improve quality and efficiency. American health care consumers do not speak our dialect, and they perceive and understand our health care system in a very different way. Patients have strong opinions about health care based on their individual health conditions and their experience with that part of the largely fragmented delivery system in which they receive care. The problem is that in trying to enlist these patients and consumers, the provider and policy communities have gone full speed ahead in developing new ideas without bothering to investigate whether those new ideas and the words used to describe them resonate with the audience. Professional journals, trade publications, and policy blogs are replete with terms such as evidence-based medicine, care coordination, health information technology, medical home, and comparative effectiveness. From an insider perspective, these terms all describe ideas intended to make our health care system better. But do they mean anything to consumers? Before true health care reform can take place, we must convince patients that their needs will be fulfilled through whatever changes are made: at the national level to heal the ailing health care system, and locally, in individual physicians' offices to heal ailing patients themselves. But how do we convince them that any new model of health care delivery will benefit them? What words will work?

HEALTH INSURANCE EXCHANGE: This Issue Brief examines issues related to managed competition and the use of a health insurance exchange for the purpose of addressing cost, quality, and access to health care services. It discusses issues that must be addressed when designing an exchange in order to reform the health insurance market and also examines state efforts at health reform that use an exchange. RISK VS. PRICE COMPETITION: The basic component of managed competition is the creation an organized marketplace that brings together health insurers and consumers (either as individuals or through their employers). The sponsor of the exchange would set "rules of engagement" for participating insurers and offer consumers a menu of choices among different plans. Ultimately, the goal of a health insurance exchange is to shift the market from competition based on risk to competition based on price and quality. ADVERSE SELECTION AND AFFORDABILITY: Among the issues that need to be addressed if an exchange that uses managed competition has a realistic chance of reducing costs, improving quality, and expanding coverage: Everyone needs to be in the risk pool, with individuals required to purchase insurance or face significant financial consequences; effective risk adjustment is essential to eliminate risk selection as an insurance business model--forcing competition on costs and quality; the insurance benefit must be specific and clear--without standards governing cost sharing, covered services, and network coverage there is no way to assess whether a requirement to purchase or issue coverage has been met; and subsidies would be necessary for low-income individuals to purchase insurance. THE PUBLIC PLAN OPTION: The public plan option is shaping up to be one of the most contentious issues in the health reform debate. Proponents also believe of a public plan is necessary to drive private insurers toward true competition. Opponents view it as a step toward government-run health care and are wary of cost shifting from the public plan to private insurers. FUTURE OF EMPLOYMENT-BASED COVERAGE: The availability of a health insurance exchange may have implications for the future of the employment-based health benefits system and raises major questions for workers. Will employers provide a fixed contribution for the purchase of insurance through an exchange? Would that be large enough to purchase coverage? Would it be flat or vary by such factors as worker health status, age, and/or marital status or the presence of children? Would it be taxed? For both employers and workers, the implications are enormous.

To determine whether the offering of a consumer-directed health plan (CDHP) is likely to cause risk segmentation in an employer group. STUDY SETTING AND DATA SOURCE: The study population comprises the approximately 10,000 people (employees and dependents) enrolled as members of the employee health benefit program of Humana Inc. at its headquarters in Louisville, Kentucky, during the benefit years starting July 1, 2000, and July 1, 2001. This analysis is based on primary collection of claims, enrollment, and employment data for those employees and dependents.This is a case study of the experience of a single employer in offering two consumer-directed health plan options ("Coverage First 1" and "Coverage First 2") to its employees. We assessed the risk profile of those choosing the Coverage First plans and those remaining in more traditional health maintenance organization (HMO) and preferred provider organization (PPO) coverage. Risk was measured using prior claims (in dollars per member per month), prior utilization (admissions/1,000; average length of stay; prescriptions/1,000; physician office visit services/1,000), a pharmacy-based risk assessment tool (developed by Ingenix), and demographics.Complete claims and administrative data were provided by Humana Inc. for the two-year study period. Unique identifiers enabled us to track subscribers' individual enrollment and utilization over this period.Based on demographic data alone, there did not appear to be a difference in the risk profiles of those choosing versus not choosing Coverage First. However, based on prior claims and prior use data, it appeared that those who chose Coverage First were healthier than those electing to remain in more traditional coverage. For each of five services, prior-year usage by people who subsequently enrolled in Coverage First 1 (CF1) was below 60 percent of the average for the whole group. Hospital and maternity admissions per thousand were less than 30 percent of the overall average; length of stay per hospital admission, physician office services per thousand, and prescriptions per thousand were all between 50 and 60 percent of the overall average. Coverage First 2 (CF2) subscribers' prior use of services was somewhat higher than CF1 subscribers', but it was still below average in every category. As with prior use, prior claims data indicated that Coverage First subscribers were healthier than average, with prior total claims less than 50 percent of average.In this case, the offering of high-deductible or consumer-directed health plan options alongside more traditional options caused risk segmentation within an employer group. The extent to which these findings are applicable to other cases will depend on many factors, including the employer premium contribution policies and employees' perception of the value of the various plan options. Further research is needed to determine whether risk segmentation will worsen in future years for this employer and if so, whether it will cause premiums for more traditional health plans to increase.