August 2011

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Employers Pushing Healthier Living

August 8, 2011 in Employee Benefits, Health Insurance | 3 comments

“This isn’t about big brother telling people what to do,” says John Rice, GE’s vice-chairman, “but helping them make better choices.”

The Economist reviews large employers efforts to improve employee health and thus decrease their own health care costs.  Some of these efforts include:

  • Prohibiting smoking on company premises
  • Handing our healthy recipes
  • Building on-site gym
  • Bonuses for healthier living

Take these examples from Fortune 500 companies:
“At IBM, employees receive a $150 bonus for exercising, eating nutritious meals and so on. One such bonus is designed not just for an employee but for his entire family. According to IBM’s own data, caring for a diabetic child is six times costlier than caring for a healthy one.”

Kevin Volpp, the director of the Centre for Health Incentives at the University of Pennsylvania, found that GE’s anti-smoking incentives prompted 9.4% of smokers to remain smoke-free after 18 months. Without incentives, only 3.6% of those who tried to quit succeeded. A review published in Health Affairs last year found that firms saved $3.27 for every dollar they spent on health programmes.”

Is this a good thing? Health insurance should account for random health risks. Health risks due to individual employee behavioral choices, however, should be internalized by the individual. Since the premium prices are basically the same (free) for most employees in large firms, they have a smaller incentive to maintain a healthy behavior than would be the case if employers used individual underwriting in pricing policies. Thus, efforts to give bonuses for healthier behavior by employees and their families is, in essence, an effort to increase net premiums for those who do not engage in healthy behaviors. With health care costs consuming a larger and larger portion of employer’s budgets, these efforts to control costs will be increasingly important over time.

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Friday’s Fun Links

August 5, 2011 in Current Events | 1 comment

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HWR Heat Wave

August 4, 2011 in Carnivals | No comments

The latest edition of the Health Wonk Review is up at Joe Paduda’s Managed Care Matters.

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Medicare Patient Safety Monitoring System (MPSMS)

August 4, 2011 in Public Health | No comments

The Medicare Patient Safety Monitoring System (MPSMS) is a national surveillance project aimed at identifying the rates of specific adverse events within the Medicare population.  It is administered by the Quality Improvement Group (QIG) in the Office of Clinical Standards and Quality (OCSQ).  The goal of the project is not to monitor physicians for best practices or determine physician errors.  Instead, the project is limited solely to detecting harm which comes to patients from the fault of the physician.

To identify patients who experience harm, the MPSMS system uses hospital records from over 40,000 hospital discharges.  Whereas AHRQ’s Patient Safety Indicators (PSI) relies exclusively on claims data to identify patient safety problems, the MPSMS sends medical records from these 40,000 discharges for review at one of two Clinical Data Abstraction Centers (CDAC). Using medical records has the advantage of being able to access more data than is available in the claim; using medical record data, however, is expensive, time-consuming, and relies on providers entering information into the patient’s chart in an honest fashion.

The safety measures cover these topics.  Any adverse medical event selected for monitoring must met the following criteria:

  • The adverse event can be found.
  • The adverse event is common
  • The adverse event is likely to be associated with exposure to a specific process of care
  • The adverse event is responsible for serious morbidity/mortality
  • The adverse event is preventable or repairable

Examples of the events monitored include adverse events associated with hip/knee replacement and post-operative pneumonia (the second most frequent postoperative complication after major surgery).  The most frequent postoperative complication after major surgery is wound infection, but it was not selected as a topic because the wound infection often appears during post-acute care, and thus many wound infections are missed in the data.

One drawback of the MPSMS program is that it is simply a monitoring program.  If MPSMS detects that a provider is harming a large number of patient, no action is taken since MPSMS’s mandate is simply to monitor trends in harm to patient.  Additionally, MPSMS is much more expensive to administer than a safety monitoring program relying on claims data.  Further, even if a harmful provider were identified, the delay caused by medical record review may mean that the provider has corrected his action or no longer practices.

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All-Payer Claims Data

August 3, 2011 in Data | 1 comment

One of the challenges of studying import issues in health economics is that the patients often come in and out of your data file.  For instance, beneficiaries often switch their private health insurance plan, or can become eligible for public insurance (e.g., Medicare or Medicaid) or the individual may lose their insurace coverage.  In each of these cases, it is difficult to track these patients over time.

One effort to solve this problem is AHRQ’s All-Payer Claims Databases (APCD).  AHRQ does not create the APCDs themselves but facilitates States efforts to create them.  According to a 2010 fact sheet:

Payers include insurance carriers, third party administrators (TPAs), pharmacy benefit managers (PBMs), dental benefit administrators,state Medicaid agencies, CMS (Medicare), Federal EmployeesHealth Benefit (FEHB) and TRICARE administrators.APCD systems collect data from existing claims transaction systemsused by health care providers (facility and practitioners) andpayers.

The information typically collected in an APCD includes patient demographics, provider demographics, clinical, financial,and utilization data. Because of the difficulties involved with thecollection of certain information, most states implementing APCD systems have typically excluded a number of data sources, such asdenied claims, workers compensation claims, and, because claimsdo not exist, services provided to the uninsured.

One concern with these data is that the APCD must maintain beneficiary confidentiality. On the one hand, one of the key benefits of APCD is that it allows researchers to examine patterns in the cost and quality of care for beneficiaries who change insurers.  The institution administering the APCD, however, must institute a strong institutional review board (IRB) or data use agreement (DUA) policy.

Also, the APCD must determine whether or not the claims files are updated.  Oftentimes, claims payment amounts can change or the claims can be later denied.  The APCD must determine a policy for updating the data files over time.

Although there are a number of challenges, some states are making progress.  ”Oregon and Tennessee willhave live systems in 2010. Hawaii and Colorado havecurrently submitted legislation for their 2010 session toauthorize development.”

Hopefully, the APCD will be a high-quality, useful data resource that can be used to answer a variety of research questions.

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MassHealth P4P: Did it work?

August 2, 2011 in Hospitals, Medicaid, P4P, Quality | 1 comment

Massachusetts’ Medicaid program instituted a pay-for-performance program in 2008.  Did it work?  According to this paper, the answer is no.

MassHealth P4P Background

The MassHealth pay-for-perfrmance P4P program was implemented in 2008.  At first the program was implmented using a P4P structure for pneumonia and pay-for-reporting for surgical infection prevention (SIP) and transitioning to P4P for both conditions in 2009. The program measures and incentivizes hospital quality for a subset of MassHealth [Massachusetts Medicaid program] patients who are enrolled in plans that directly bill MassHealth.

The Measures

For pneumonia:

  • oxygenation assessment,
  • blood culture performed in emergency department before first antibiotic received in hospital,
  • adult smoking cessation advice and counseling, initial antibiotic received within 6 hours of arrival, and
  • appropriate antibiotic selection in immunocompetent patients.

For Surgical Infection Prevention (SIP):

  • prophylactic antibiotic within 1 hour of surgical incision,
  • appropriate antibioticselection for surgical prophylaxis, and
  • prophylactic antibiotic discontinuedwithin 24 hours after surgery end time.

Evaluating Hospital Performance

The MassHealth P4P followed the Hospital VBP Report to Congress. Hospital performance on individual measures is aggregated to create a composite score; this composite score then is used to indicate the share of the bonus paymen that each hospital receives. More information on the Hospital VBP Report to Congress can be found here.

Identification Strategy

“We do not observe the quality of care provided to Medicaid patients in Massachusetts and other states, and instead we observe the quality provided to patients from all payers. Our identification strategy assumes that the financial incentives of the MassHealth program, which are based on quality performance
for only a subset of MassHealth patients, are reflected in the quality of care received by all patients.”

The authors control for:

  • Observed and unobserved hospital characteristics which remain fixed over time (i.e., fixed effects)
  • A secular trend in quality for each hospital (i.e., using a hospital-specific time trend)
  • Hospital case mix measured by a “difficulty index” to identify cases where hospitals choose patients selectively after P4P was implemented
  • In one sensitivity analysis, the authors use propensity scoring, nearest neighbor, one-to-one matching without replacement to create a sample of non-Massachusetts hospitals similar to those in Massachusetts. Hospitals were matched based on ownership, nuber of beds, urban/rural status, share of Medicare patients, and share of Medicaid patients.
  • The authors also test if hospitals with more Medicaid patients are more likely to have a larger increase in quality.

Evaluating Hospital Performance

The authors find that the MassHealth P4P has little effect on quality. “Estimates from our preferred specification, including hospital fixed effects, trends, and the control for measure completeness, indicate small and nonsignificant program effects for pneumonia (−0.67 percentage points, p>.10) and SIP (−0.12 percentage points, p>.10). ” The result could be due to the fact that P4P has, in actuality, no effect on quality. On the other hand, by using hospital-specific time trends, there may be little variation in quality over time to capture quality improvements after the P4P implementation.

Source

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Brazil’s Health Care System

August 1, 2011 in International Health Care Systems | 4 comments

Today, I will review Brazil’s health care system.

According to the Economist:

“Created in 1989 from the merger of two state systems, one for those in formal work and the other for everyone else, it is exceptional in Latin America, which by and large continues with the two-tier public system Brazil abandoned. The 1988 constitution declared health care to be the right of the citizen and its provision the duty of the state. ICESP enshrines that promise: according to Paulo Hoff, its clinical director, its patients, both poor and better-off, get care which compares well to that of his private patients at the nearby Sírio-Libanês Hospital.”

Brazil’s Programa Saúde da Família (PSF), launched in 1994, is one step towards interdisciplinary basic health care for most Brazilians.  The PSF implements a national policy for primary care settings with the aim of substituting part of the traditional model of primary care based on medical specialists. As its name says, its main focus is on families instead of individuals, and it is organized around multidisciplinary Family Health Teams, formed by a core of professionals such as physicians, nurses, dentists, psychologists and social workers, as well as community health agents, a kind of “barefoot doctor”. Brazil has currently (August 2009) approximately 30,000 of these teams, deployed in 5,241 of its 5,656 municipalities.  By 2005 over 80% of municipalities had been reached. However, since these consisted mostly of small rural municipalities, this covered 35% of the population.

But there is a gap between the aspirations of SUS and the reality. Funding is an inadequate hotch-potch, part-state, part-federal, and varies wildly from place to place. More than two-thirds of ICESP’s (Instituto do Câncer) budget of 350m reais ($225m) comes from São Paulo’s state government. Few other states are rich enough to provide such generous top-ups. SUS’s family doctors reach only one Brazilian in two. Another quarter have private-health insurance; the remainder, mostly poor people, live in remote rural areas or violent urban slums where the service is lacking. They must either pay out of pocket or take their chances in crowded hospital emergency rooms.”

Further, basic indicators are not as good as peer countries.  Life expectancy is lower than in Mexico, Argentina, Venezuela and Chile, and the infant mortality rate is the highest among these countries.

“A recent survey of Brazilian health care published in the Lancet, an international journal, argued that SUS gets poor value for the money it spends on drugs, because too much goes on complying with court orders granted to patients who use the constitution’s lofty promises to demand expensive treatments not automatically covered by the system. And too much of the budget still goes to hospitals rather than the Family Health Programme, says Michele Gragnolati of the World Bank.”

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