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Context: Continuing changes in the health care delivery system make it essential to monitor underuse of needed care, even for relatively well-insured populations. Traditional approaches to measuring underuse have relied on patient surveys and chart reviews, which are expensive, or simple single-condition claims-based indicators, which are not clinically convincing.Objective: To develop a comprehensive, low-cost system for measuring underuse of necessary care among elderly patients using inpatient and outpatient Medicare claims.Design: A 7-member, multispecialty expert physician panel was assembled and used a modified Delphi method to develop clinically detailed underuse indicators likely to be associated with avoidable poor outcomes for 15 common acute and chronic medical and surgical conditions. An automated system was developed to calculate the indicators using administrative data.Setting and Subjects: A total of 345,253 randomly selected elderly US Medicare beneficiaries in 1994-1996.Main Outcome Measures: Proportion of beneficiaries receiving care, stratified by indicators of necessary care (n = 40, including 3 for preventive care), and avoidable outcomes (n = 6).Results: For 16 of 40 necessary care indicators (including preventive care indicators), beneficiaries received the indicated care less than two thirds of the time. Of all indicators, African Americans scored significantly worse than whites on 16 and better on 2; residents of poverty areas scored significantly lower than nonresidents on 17 and higher on 1; residents of federally defined Health Professional Shortage Areas scored significantly lower than nonresidents on 16 and higher on none (P<.05 for all).Conclusions: This claims-based method detected substantial underuse problems likely to result in negative outcomes in elderly populations. Significantly more underuse problems were detected in populations known to receive less-than-average medical care. The method can serve as a reliable, valid tool for monitoring trends in underuse of needed care for older patients and for comparing care across health care plans and geographic areas based on claims data. JAMA. 2000;284:2325-2333. [ABSTRACT FROM AUTHOR]

In a previous comparison of persons between 14 and 62 years of age randomly assigned to receive care through a fee-for-service system (n = 784) or through a health maintenance organization (HMO) (n = 738) in Seattle, Washington, persons in the HMO had much lower hospital expenditures and admissions, more bed days, a higher prevalence of serious symptoms, and less satisfaction with care. We report an examination of 20 additional health status measures. Our results are consistent with a hypothesis of no differences in health status measures between the two systems. In addition, a comparison of nine health practices between the systems also indicated no overall differences. Most physiologic measures and health practices for a typical person were not affected by care received through the fee-for-service system or the HMO. However, we are less certain of this result in specific subgroups, such as persons of lower income initially at elevated risk, because confidence intervals are necessarily wider. We conclude that the cost savings achieved by this HMO through lower hospitalization rates were not reflected in lower levels of health status. [ABSTRACT FROM AUTHOR]

We estimate the lifetime, discounted costs that smokers and drinkers impose on others through collectively financed health insurance, pensions, disability insurance, group life insurance, fires, motor-vehicle accidents, and the criminal justice system. Although nonsmokers subsidize smokers' medical care and group life insurance, smokers subsidize nonsmokers' pensions and nursing home payments. On balance, smokers probably pay their way at the current level of excise taxes on cigarettes; but one may, nonetheless, wish to raise those taxes to reduce the number of adolescent smokers. In contrast, drinkers do not pay their way: current excise taxes on alcohol cover only about half the costs imposed on others. [ABSTRACT FROM AUTHOR]

This article cites a study conducted by researcher N.S. Wenger and colleagues, published in the November 4, 2003 issue of the medical journal "Annals of Internal Medicine," which evaluated the quality of care provided to older patients who are at risk for functional decline. Quality of care varied substantially by condition, being worst for end-of-life care and best for stroke. Care aimed at treating an illness was more likely to meet quality indicator standards than care aimed at follow-up, diagnosis, or prevention. Quality of care was better for general medical conditions than for common geriatric conditions.

Objectives: To develop a simple method for identifying community-dwelling vulnerable older people, defined as persons age 65 and older at increased risk of death or functional decline. To assess whether self-reported diagnoses and conditions add predictive ability to a function-based survey., Design: Analysis of longitudinal survey data., Setting: A nationally representative community-based survey., Participants: Six thousand two hundred five Medicare beneficiaries age 65 and older., Measurements: Bivariate and multivariate analyses of the Medicare Current Beneficiary Survey; development and comparison of scoring systems that use age, function, and self-reported diagnoses to predict future death and functional decline., Results: A multivariate model using function, self-rated health, and age to predict death or functional decline was only slightly improved when self-reported diagnoses and conditions were included as predictors and was significantly better than a model using age plus self-reported diagnoses alone. These analyses provide the basis for a 13-item function-based scoring system that considers age, self-rated health, limitation in physical function, and functional disabilities. A score of >or=3 targeted 32% of this nationally representative sample as vulnerable. This targeted group had 4.2 times the risk of death or functional decline over a 2-year period compared with those with scores <3. The receiver operating characteristics curve had an area of.78. An alternative scoring system that included self-reported diagnoses did not substantially improve predictive ability when compared with a function-based scoring system., Conclusions: A function-based targeting system effectively and efficiently identifies older people at risk of functional decline and death. Self-reported diagnoses and conditions, when added to the system, do not enhance predictive ability. The function-based targeting system relies on self-report and is easily transported across care settings.

Objective: To examine the evaluation process for the CHAMPUS Reform Initiative (CRI) both to highlight issues that evaluators must consider when undertaking such projects and to provide policymakers with tools to better assess demonstration project evaluations., Data Sources: The CRI evaluation., Study Design: Case study., Data Collection: Review of CRI evaluation reports., Principal Findings: Although policymakers increasingly rely on the evaluations of demonstration projects to determine whether to extend the scope and funding of many public programs, the results of these evaluations are often difficult to assess. Despite its analytical sophistication, the CRI evaluation was no exception. The somewhat artificial time constraints imposed by policymakers made projection of the CRI's performance beyond the demonstration period particularly difficult., Conclusions: Much uncertainty generally remains even after well-planned and well-executed evaluations of demonstration projects.

Objective: To identify a set of geriatric conditions as optimal targets for quality improvement to be used in a quality measurement system for vulnerable older adults., Design: Discussion and two rounds of ranking of conditions by a panel of geriatric clinical experts informed by literature reviews., Methods: A list of 78 conditions common among vulnerable older people was reduced to 35 on the basis of their (1) prevalence, (2) impact on health and quality of life, (3) effectiveness of interventions in improving mortality and quality of life, (4) disparity in the quality of care across providers and geographic areas, and (5) feasibility of obtaining the data needed to test compliance with quality indicators. A panel of 12 experts in geriatric care discussed and then ranked the 35 conditions on the basis of the same five criteria. We then selected 21 conditions, based on panelists' iterative rankings. Using available national data, we compiled information about prevalence of the selected conditions for community-dwelling older people and older nursing home residents and estimated the proportion of inpatient and outpatient care attributable to the selected conditions., Results: The 21 conditions selected as targets for quality improvement among vulnerable older adults include (in rank order): pharmacologic management; depression; dementia; heart failure; stroke (and atrial fibrillation); hospitalization and surgery; falls and mobility disorders; diabetes mellitus; end-of-life care; ischemic heart disease; hypertension; pressure ulcers; osteoporosis; urinary incontinence; pain management; preventive services; hearing impairment; pneumonia and influenza; vision impairment; malnutrition; and osteoarthritis. The selected conditions had mean rank scores from 1.2 to 3.8, and those excluded from 4.6 to 6.9, on a scale from 1 (highest ranking) to 7 (lowest ranking). Prevalence of the selected conditions ranges from 10 to 50% among community-dwelling older adults and from 25 to 80% in nursing home residents for the six most common selected conditions. The 21 target conditions account for at least 43% of all acute hospital discharges and 33% of physician office visits among persons 65 years of age and older. Actual figures must be higher because several of the selected conditions (e.g., end-of-life care) are not recorded as diagnoses., Conclusions: Twenty-one conditions were selected as targets for quality improvement in vulnerable older people for use in a quality measurement system. The 21 geriatric conditions selected are highly prevalent in this group and likely account for more than half of the care provided to this group in hospital and ambulatory settings.

Recently, the Department of Defense replaced its traditional fee-for-service insurance plan for military health care beneficiaries with an HMO/PPO hybrid. Using survey and claims data, we compare changes in costs over two years at sites that implemented this initiative (CRI) with changes at matched control sites. The results indicate that CRI substantially raised per beneficiary government costs for providing benefits (as compared to predicted costs in the absence of CRI). We attribute this difference to the higher overhead of managed care and the increased expenditures by HMO participants.

Few capitation arrangements vary premiums by a child's health characteristics, yielding an incentive to discriminate against children with predictably high expenditures from chronic diseases. In this article, we explore risk adjusters for the 35 percent of the variance in annual out-patient expenditure we find to be potentially predictable. Demographic factors such as age and gender only explain 5 percent of such variance; health status measures explain 25 percent, prior use and health status measures together explain 65 to 70 percent. The profit from risk selection falls less than proportionately with improved ability to adjust for risk. Partial capitation rates may be necessary to mitigate skimming and dumping.

Although the prevalence of chronic bronchitis has been measured in several populations, its impact on quality of life has not been assessed. We report the prevalence and impact of chronic bronchitis (defined as having phlegm on most days for at least 3 months during the previous year) among 4,708 adults ages 20 to 69 representative of the nonaged U.S. population. Men reported chronic bronchitis more frequently than women (12 vs 8%); smokers, regardless of age and sex, reported chronic bronchitis more frequently than former or never smokers. Among both men and women 35 years of age or older, current smokers--as opposed to ex- or never smokers--with chronic bronchitis had the poorest forced expiratory volume in 1 sec (FEV1). The most commonly reported impact of chronic bronchitis was worry, followed by pain and restricted activity days, regardless of age, sex, or smoking habits. Of those current and ex-smokers who had seen a physician about their chronic bronchitis, 65% of men and 44% of women had decreased or stopped smoking. Among those current and ex-smokers with chronic bronchitis who did not consult a physician, the proportion of those who had decreased or stopped smoking was 29% for men and 37% for women. Finally, only 43% of male current smokers and 55% of female current smokers who had chronic bronchitis reported that a physician had advised them to decrease or stop smoking.

Several analysts have proposed adding adjusters based on health status and prior utilization to the adjusted average per capita cost formula. The authors estimate how well such adjusters predict annual medical expenditures among non-elderly adults. Both measures substantially improve on the variables currently used. If only health measures are added, 20-30 percent of the predictable variance is explained; if only prior use is added, more than 40 percent is explained; if both are added, about 60 percent is explained. The results support including some measure of use in the formula until better health measures are developed.

In a randomized trial of the effects of medical insurance on spending and the health status of the nonaged, we previously reported that patients with limited cost sharing had approximately one-third less use of medical services, similar general self-assessed health, and worse blood pressure, functional far vision, and dental health than those with free care. Of the 20 additional measures of physiological health studied here on 3,565 adults, people with cost sharing scored better on 12 measures and significantly worse only for functional near vision. People with cost sharing had less worry and pain from physiological conditions on 33 of 44 comparisons. There were no significant differences between plans in nine health practices, but those with cost sharing fared worse on three types of cancer screening and better on weight, exercise, and drinking. Overall, except for patients with hypertension or vision problems, the effects of cost sharing on health were minor.