Health Affairs recent issues

Hospital Governance And The Quality Of Care [Web Exclusives]

Jha, A. K., Epstein, A. M. — Fri, 06 Nov 2009 00:55:54 PST

Hospitals' boards may influence the quality of care that hospitals provide, but their engagement in quality-related issues is largely unknown. We surveyed a nationally representative sample of board chairs of 1,000 U.S. hospitals to understand their expertise, perspectives, and activities in clinical quality. We found that fewer than half of the boards rated quality of care as one of their two top priorities, and only a minority reported receiving training in quality. The large differences in board activities between high-performing and low-performing hospitals we found suggest that governing boards may be an important target for intervention for policymakers hoping to improve care in U.S. hospitals. [Health Aff (Millwood). 2010;29(1): published online 6 November 2009; 10.1377/hlthaff.2009.0297]

Understanding The Current Population Survey's Insurance Estimates And The Medicaid 'Undercount' [Web Exclusives]

Klerman, J. A., Davern, M., Call, K. T., Lynch, V., Ringel, J. D. — Mon, 02 Nov 2009 17:03:47 PST

The widely cited Census Bureau estimates of the number of uninsured people, based on the Current Population Survey, probably overstate the number of uninsured people. This is because of a Medicaid "undercount": Fewer people report to survey takers that they’re covered by Medicaid than program administrative data show are enrolled. Our study finds that the undercount can be explained by the inability of people to recall their insurance status accurately from the previous year. We suggest that other data sources, such as Census’s American Community Survey, should be studied to determine whether they would provide better estimates of the uninsured.

Job-Based Health Insurance: Costs Climb At A Moderate Pace [Web Exclusives]

Mon, 02 Nov 2009 17:03:47 PST

Each year the Kaiser/HRET Survey of Employer Health Benefits takes a snapshot of the state of employee benefits in the United States, based on interviews with public and private employers. Our findings for 2009 show that families continue to face higher premiums, up about 5 percent from last year, and that cost sharing in the form of deductibles and copayments for office visits is greater as well. Average annual premiums in 2009 were $4,824 for single coverage and $13,375 for family coverage. Enrollment in high-deductible health plans held steady. We offer new insights about health risk assessments and how firms responded to the economic downturn.

How A New 'Public Plan' Could Affect Hospitals' Finances And Private Insurance Premiums [Web Exclusives]

Dobson, A., DaVanzo, J. E., El-Gamil, A. M., Berger, G. — Mon, 02 Nov 2009 17:03:47 PST

Two key health reform bills in the House of Representatives and Senate include the option of a "public plan" as an additional source of health coverage. At least initially, the plan would primarily be structured to cover many of the uninsured and those who now have individual coverage. Because it is possible, and perhaps even likely, that this new public payer would pay less than private payers for the same services, such a plan could negatively affect hospital margins. Hospitals may attempt to recoup losses by shifting costs to private payers. We outline the financial pressures that hospitals and private payers could experience under various assumptions. High uninsured enrollment in a public plan would bolster hospital margins; however, this effect is reversed if the privately insured enter a public plan in large proportions, potentially stressing the hospital industry and increasing private insurance premiums.

Containing Costs And Improving Care For Children In Medicaid And CHIP [Web Exclusives]

Kenney, G. M., Ruhter, J., Selden, T. M. — Mon, 02 Nov 2009 17:03:47 PST

The current health reform debate is greatly concerned with "bending the curve" of cost growth and containing costs, particularly in public programs. Our research demonstrates that spending in Medicaid and the Children’s Health Insurance Program (CHIP) is highly concentrated, particularly among children with chronic health problems. Ten percent of enrollees (two-thirds of whom have a chronic condition) account for 72 percent of the spending; 30 percent of enrolled children receive little or no care. These results highlight the importance of cost containment strategies that reduce avoidable hospitalizations among children with chronic problems and policies that increase preventive care, particularly among African American children.

Portrait Of A Policy And Political Entrepreneur [Web Exclusives]

Blumenthal, D. — Mon, 02 Nov 2009 17:03:47 PST

Senator Edward M. Kennedy: The Master Legislative Craftsman [Web Exclusives]

Nexon, D. — Mon, 02 Nov 2009 17:03:47 PST

Senator Edward M. Kennedy: Making Common Cause With Adversaries While Committed To Health Reform [Web Exclusives]

Marmor, T. R. — Mon, 02 Nov 2009 17:03:47 PST

The Dangerous Shortage Of Domestic Violence Services [Web Exclusives]

Iyengar, R., Sabik, L. — Mon, 02 Nov 2009 17:03:47 PST

Domestic violence is a serious, preventable health problem affecting more than thirty million Americans annually, yet little is known about federally funded service provision. We used the National Census of Domestic Violence Services, an innovative victim-safety focused survey, to count services provided by more than 2,000 programs. During the twenty-four-hour survey period, 48,350 people used these services. The results show substantial unmet demand for services (10 percent of requests) because of resource constraints, particularly in rural, economically disadvantaged, and minority communities. Greater funding of domestic violence programs, particularly housing support, is likely to be a cost-effective public health investment.

Closing The Schools: Lessons From The 1918-19 U.S. Influenza Pandemic [Web Exclusives]

Stern, A. M., Cetron, M. S., Markel, H. — Mon, 02 Nov 2009 17:03:47 PST

When the novel strain of A/H1N1 influenza first appeared in spring 2009, closing schools was initially a common and often challenging strategy implemented in many communities. Arguments for and against closing schools are likely to arise anew if influenza spikes in the fall of 2009. Policymakers and community officials considering this and other nonpharmaceutical responses can learn from the experiences of ninety-one years ago, during the 1918–19 influenza pandemic that killed thousands of Americans. Analysis of the school closure policies of forty-three U.S. cities during that pandemic shows that smooth implementation was associated with clear lines of authority among agencies and with transparent communication between health officials and the public.

Massachusetts Health Reform: Employer Coverage From Employees' Perspective [Web Exclusives]

Long, S. K., Stockley, K. — Mon, 02 Nov 2009 17:03:47 PST

The national health reform debate continues to draw on Massachusetts’ 2006 reform initiative, with a focus on sustaining employer-sponsored insurance. This study provides an update on employers’ responses under health reform in fall 2008, using data from surveys of working-age adults. Results show that concerns about employers’ dropping coverage or scaling back benefits under health reform have not been realized. Access to employer coverage has increased, as has the scope and quality of their coverage as assessed by workers. However, premiums and out-of-pocket costs have become more of an issue for employees in small firms.

Zoning For Health? The Year-Old Ban On New Fast-Food Restaurants In South LA [Web Exclusives]

Sturm, R., Cohen, D. A. — Mon, 02 Nov 2009 17:03:47 PST

A regulation banning new fast-food establishments for one year in Los Angeles, California, was passed unanimously by the city council in July 2008. It was motivated by health concerns and excessive obesity rates in South Los Angeles. However, it might not have had the impact that was intended. This paper reviews the empirical evidence for the regulation and whether it is likely to target the primary levers of obesity. We argue that the premises for the ban were questionable. For example, the density of fast-food chain restaurants per capita is actually higher in other parts of Los Angeles than in South LA. Other changes, such as menu calorie labeling, are likely to have a bigger impact on overweight and obesity.

New York City's Fight Over Calorie Labeling [Web Exclusives]

Farley, T. A., Caffarelli, A., Bassett, M. T., Silver, L., Frieden, T. R. — Mon, 02 Nov 2009 17:03:48 PST

In 2006, New York City’s Health Department amended the city Health Code to require the posting of calorie counts by chain restaurants on menus, menu boards, and item tags. This was one element of the city’s response to rising obesity rates. Drafting the rule involved many decisions that affected its impact and its legal viability. The restaurant industry argued against the rule and twice sued to prevent its implementation. An initial version of the rule was found to be preempted by federal law, but a revised version was implemented in January 2008. The experience shows that state and local health departments can use their existing authority over restaurants to combat obesity and, indirectly, chronic diseases.

Calorie Labeling And Food Choices: A First Look At The Effects On Low-Income People In New York City [Web Exclusives]

Elbel, B., Kersh, R., Brescoll, V. L., Dixon, L. B. — Mon, 02 Nov 2009 17:03:48 PST

We examined the influence of menu calorie labels on fast food choices in the wake of New York City’s labeling mandate. Receipts and survey responses were collected from 1,156 adults at fast-food restaurants in low-income, minority New York communities. These were compared to a sample in Newark, New Jersey, a city that had not introduced menu labeling. We found that 27.7 percent who saw calorie labeling in New York said the information influenced their choices. However, we did not detect a change in calories purchased after the introduction of calorie labeling. We encourage more research on menu labeling and greater attention to evaluating and implementing other obesity-related policies.

Adoption And Spread Of New Imaging Technology: A Case Study [Web Exclusives]

Ladapo, J. A., Horwitz, J. R., Weinstein, M. C., Gazelle, G. S., Cutler, D. M. — Mon, 02 Nov 2009 17:03:48 PST

Technology is a major driver of health care costs. Hospitals are rapidly acquiring one new technology in particular: 64-slice computed tomography (CT), which can be used to image coronary arteries in search of blockages. We propose that it is more likely to be adopted by hospitals that treat cardiac patients, function in competitive markets, are reimbursed for the procedure, and have favorable operating margins. We find that early adoption is related to cardiac patient volume but also to operating margins. The paucity of evidence informing this technology’s role in cardiac care suggests that its adoption by cardiac-oriented hospitals is premature. Further, adoption motivated by operating margins reinforces concerns about haphazard technology acquisition.

Magnetic Resonance Imaging And Low Back Pain Care For Medicare Patients [Web Exclusives]

Baras, J. D., Baker, L. C. — Mon, 02 Nov 2009 17:03:48 PST

Magnetic resonance imaging (MRI) is a technology frequently used to evaluate low back pain, despite evidence that challenges the usefulness of routine MRI and the surgical interventions it may trigger. We analyze the relationship between MRI supply and care for fee-for-service Medicare patients with low back pain. We find that increases in MRI supply are related to higher use of both low back MRI and surgery. This is worrisome, and careful attention should be paid to assessing the outcomes for patients.

Uninsured Adults With Chronic Conditions Or Disabilities: Gaps In Public Insurance Programs [Web Exclusives]

Pizer, S. D., Frakt, A. B., Iezzoni, L. I. — Mon, 02 Nov 2009 17:03:48 PST

Among nonelderly U.S. adults (ages 25–61), uninsurance rates increased from 13.7 percent in 2000 to 16.0 percent in 2005. Despite the existence of public insurance programs, rates remained high for low-income people reporting serious health conditions (25 percent across years) or disabilities (15 percent). Residents of southern states had even higher rates (32 percent with health conditions, 22 percent with disabilities). Those who did not belong to a federally mandated Medicaid eligibility category were about twice as likely as others to be uninsured overall, and uninsurance among this group increased more rapidly over time. These regional and categorical differences reflect gaps in current policy that pose challenges for incremental health reform.

Hypertension, Diabetes, And Elevated Cholesterol Among Insured And Uninsured U.S. Adults [Web Exclusives]

Mon, 02 Nov 2009 17:03:48 PST

In this paper we explore whether uninsured Americans with three chronic conditions were less likely than the insured to be aware of their illness or to have it controlled. Among those with diabetes and elevated cholesterol, the uninsured were more often undiagnosed. Among hypertensives and people with elevated cholesterol, the uninsured more often had uncontrolled conditions. Undiagnosed and uncontrolled chronic illness, which is common among insured people, is even more frequent among the uninsured.

Evidence Of An Emerging Digital Divide Among Hospitals That Care For The Poor [Web Exclusives]

Mon, 02 Nov 2009 17:03:48 PST

Some hospitals that disproportionately care for poor patients are falling behind in adopting electronic health records (EHRs). Data from a national survey indicate early evidence of an emerging digital divide: U.S. hospitals that provide care to large numbers of poor patients also had minimal use of EHRs. These same hospitals lagged others in quality performance as well, but those with EHR systems seemed to have eliminated the quality gap. These findings suggest that adopting EHRs should be a major policy goal of health reform measures targeting hospitals that serve large populations of poor patients.

A Survey Of Primary Care Physicians In Eleven Countries, 2009: Perspectives On Care, Costs, And Experiences [Web Exclusives]

Schoen, C., Osborn, R., Doty, M. M., Squires, D., Peugh, J., Applebaum, S. — Mon, 02 Nov 2009 17:03:48 PST

This 2009 survey of primary care doctors in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States finds wide differences in practice systems, incentives, perceptions of access to care, use of health information technology (IT), and programs to improve quality. Response rates exceeded 40 percent except in four countries: Canada, France, the United Kingdom, and the United States. U.S. and Canadian physicians lag in the adoption of IT. U.S. doctors were the most likely to report that there are insurance restrictions on obtaining medication and treatment for their patients and that their patients often have difficulty with costs. We believe that opportunities exist for cross-national learning in disease management, use of teams, and performance feedback to improve primary care globally.

Stretching To Meet Global Health Needs [From the Editor]

Dentzer, S. — Mon, 02 Nov 2009 17:03:46 PST

The Difficult But Necessary Choices In Fighting HIV/AIDS [Fighting HIV/AIDS]

Mon, 02 Nov 2009 17:03:46 PST

The Evolving HIV/AIDS Response And The Urgent Tasks Ahead [Fighting HIV/AIDS]

Bertozzi, S. M., Martz, T. E., Piot, P. — Mon, 02 Nov 2009 17:03:46 PST

AIDS continues to outpace the science, financing, prevention, and treatment efforts of the past quarter-century. There have been different epochs along the evolutionary timeline of the global AIDS response, from the discovery of HIV to the threat posed by the current economic crisis. This timeline serves as a reference to how we have arrived where we are today, in the hope that understanding our past will help us set the course for a more efficient and effective future response.

Critical Choices In Financing The Response To The Global HIV/AIDS Pandemic [Fighting HIV/AIDS]

Mon, 02 Nov 2009 17:03:46 PST

The AIDS pandemic will enter its fiftieth year in 2031. Despite much progress, there are thirty-three million infected people worldwide, and 2.3 million adults were newly infected in 2007. Without a change in approach, a major pandemic will still be with us in 2031. Modeling carried out for the AIDS 2031 project suggests that funding required for developing countries to address the pandemic could reach $35 billion annually by 2031—three times the current level. Even then, more than a million people will still be newly infected each year. However, wise policy choices focusing on high-impact prevention and efficient treatment could cut costs by half. Investments in new prevention tools and major behavior-change efforts are needed to spur more rapid advances. Existing donors, middle-income countries with contained epidemics, philanthropists, and innovative financing could help bridge the likely funding gap.

Financing HIV/AIDS Programs In Sub-Saharan Africa [Fighting HIV/AIDS]

Haacker, M. — Mon, 02 Nov 2009 17:03:46 PST

This paper offers an analysis of the costs and the financing of HIV/AIDS programs for countries in sub-Saharan Africa. The rate of external financing varies with gross domestic product (GDP) per capita, but not much at all with HIV prevalence. In six of the thirty-four countries examined, the costs of HIV/AIDS programs will exceed 3 percent of GDP by 2015. Most of these are low-income countries. Considerable external support at current rates in these countries would help contain the fiscal costs to around 1 percent of GDP. But if that support dwindles, countries would have to borrow money or cut back on their own spending for HIV/AIDS.

Bridging The Resource Gap: Improving Value For Money In HIV/AIDS Treatment [Fighting HIV/AIDS]

Soni, A., Gupta, R. — Mon, 02 Nov 2009 17:03:46 PST

The world faces both near-term and potentially long-term shortfalls in funding for HIV/AIDS care and treatment. We review the current funding environment, then discuss a range of opportunities to optimize spending on HIV/AIDS. These include (but are not limited to) more use of specific technologies, such as fixed-dose combination drugs or new diagnostics, as well as investments that strengthen underlying health systems, such as expanding training enrollment of health care providers. We also examine the potential cost impact of these opportunities in a hypothetical country. Combined, these approaches can reduce the cost of treatment while preserving and in some cases improving quality.

Investing To Meet The Scientific Challenges Of HIV/AIDS [Fighting HIV/AIDS]

Fauci, A. S., Folkers, G. K. — Mon, 02 Nov 2009 17:03:46 PST

Despite extraordinary scientific advances over more than twenty-five years, the human immunodeficiency virus (HIV) continues to exact an enormous toll worldwide. Given the limitations of current HIV treatment and prevention interventions and the financial and logistical impediments to delivering them, new and potentially transforming interventions are needed if the HIV/AIDS pandemic is to be significantly slowed. Serious scientific challenges remain in the realm of developing potentially curative therapies and a safe and effective HIV vaccine, and in developing, assessing, and validating other new prevention modalities. Substantial funding of the research enterprise must be maintained.

Why We Don't Have An HIV Vaccine, And How We Can Develop One [Fighting HIV/AIDS]

Harris, J. E. — Mon, 02 Nov 2009 17:03:46 PST

Confronted with the recent high-profile failures of several clinical trials of promising candidate vaccines against HIV, many scientists have all but given up hope of producing a human-ready vaccine within the next decade. In this review I contend that although the scientific obstacles remain formidable, the economic challenges are just as real. The groundwork will be laid for a major scientific breakthrough in vaccine development only when there are new contractual structures that enhance private incentives for vaccine development; when we have clearly specified the rights to the profitable North American market; when we have established a system of liability protection for vaccine side effects; and when our clinical trials also test the behavioral consequences of vaccination.

Transforming Social Structures And Environments To Help In HIV Prevention [Fighting HIV/AIDS]

Auerbach, J. — Mon, 02 Nov 2009 17:03:46 PST

Interest in social and structural interventions for HIV prevention is growing. Such approaches modify social norms, institutions, laws, and policies to reduce vulnerability and create environments in which individuals can protect themselves against HIV infection. Examples include expanding access to sterile syringes for injecting drug users and subsidizing stable housing for low-income people. Evidence of the effectiveness of such interventions is emerging despite scientific and political obstacles to their development, implementation, and evaluation. The U.S. government can help build the evidence base for such interventions. It can also implement those with demonstrated or promising results as part of a cost-effective HIV prevention strategy domestically and globally.

Ethical Challenges In Long-Term Funding For HIV/AIDS [Fighting HIV/AIDS]

Brock, D. W., Wikler, D. — Mon, 02 Nov 2009 17:03:46 PST

The global response to the AIDS pandemic aims for universal access to treatment and for pursuing every possible avenue to prevention. Skeptics, doubting that the huge increases in current funding levels needed for universal treatment will ever happen, would scale back antiretroviral treatment in favor of more cost-effective preventive interventions. Economics, politics, and science figure in this debate. But there is also a question of ethical principle: Is there a moral imperative to emphasize treatment, even if emphasizing prevention would save more lives? The authors examine moral arguments that address this question, and come down on the side of saving the most lives via prevention.

Fighting HIV/AIDS In Washington, D.C. [Fighting HIV/AIDS]

Mon, 02 Nov 2009 17:03:46 PST

Washington, D.C., is the capital of the United States and is a major center for public health and health policy expertise. Yet the District of Columbia has an HIV prevalence rate among adults of 3 percent, on par with some sub-Saharan African countries. To date, the local public health response has not controlled the epidemic. The ways in which that response has been galvanized in recent years—through collaboration among the capital’s public health agencies, community and faith organizations, and research institutions—may be instructive to other jurisdictions combating HIV/AIDS.

Tropical Diseases: The Price Of Neglect [Neglected Diseases]

Mon, 02 Nov 2009 17:03:46 PST

Turning Neglected Tropical Diseases Into Forgotten Maladies [Neglected Diseases]

Musgrove, P., Hotez, P. J. — Mon, 02 Nov 2009 17:03:46 PST

Because they afflict mostly poor people in poor countries, killing relatively few compared to the many who suffer from severe chronic disabilities, a large cluster of infections deserve the label of neglected tropical diseases (NTDs). That is changing as these diseases’ enormous health, educational, and economic toll is better understood, including how they interact with HIV/AIDS, malaria, and other illnesses. Several NTDs could be controlled or even eliminated within a decade, using integrated, highly cost-effective mass drug administration programs together with nondrug interventions. Research is needed to provide additional means of control for these conditions and make elimination feasible for still others.

Controlling And Eliminating Neglected Diseases In Latin America And The Caribbean [Neglected Diseases]

Bitran, R., Martorell, B., Escobar, L., Munoz, R., Glassman, A. — Mon, 02 Nov 2009 17:03:46 PST

This paper analyzes the rationale for, and costs associated with, the control and elimination of neglected tropical diseases (NTDs) in Latin America and the Caribbean. It also estimates the magnitude of potential health gains. The results suggest that lymphatic filiariasis, onchocerciasis, and trachoma can be feasibly and affordably eliminated by 2020, at a total cost of US$128 million. Control of other NTDs could produce important reductions in prevalence and incidence, along with other social and economic benefits. In particular, controlling soil-transmitted helminths (roundworm and hookworm, for example) would produce total costs of $41 million between now and 2020.

Neglected Diseases Amid Wealth In The United States And Europe [Neglected Diseases]

Hotez, P. — Mon, 02 Nov 2009 17:03:46 PST

Neglected tropical diseases are not exclusive to low-income countries. In the United States, such infections account for a sizable but largely hidden disease burden among minority populations living in poverty and among people of African descent in particular. Similar infections also occur in Europe. As efforts to control neglected tropical diseases expand throughout Africa, parallel efforts should also target poor and forgotten people in wealthy nations.

Neglected Tropical Diseases: Moving Beyond Mass Drug Treatment To Understanding The Science [Neglected Diseases]

Mahmoud, A., Zerhouni, E. — Mon, 02 Nov 2009 17:03:46 PST

Neglected tropical diseases (NTDs) represent a major health burden in many developing countries. To date, global efforts to control thirteen parasitic and bacterial infections that affect more than 1.4 billion people have relied on mass drug administration. This singular approach should now be expanded to a more comprehensive suite of tools including coordinated community-based programs, vector control, local training, education, and environmental change. In addition, an intensive basic research agenda is urgently needed to develop effective diagnostic, preventive, and therapeutic interventions to stay one step ahead of the evolutionary adaptation tactics of disease-causing microbes and parasites.

How Four Once Common Diseases Were Eliminated From The American South [Neglected Diseases]

Humphreys, M. — Mon, 02 Nov 2009 17:03:47 PST

Four major diseases stigmatized the American South in the nineteenth and twentieth centuries: yellow fever, malaria, hookworm, and pellagra. Each disease contributed to the inhibition of economic growth in the South, and the latter three severely affected children’s development and adult workers’ productivity. However, all four had largely disappeared from the region by 1950. This paper analyzes the reasons for this disappearance. It describes the direct effects of public health interventions and the indirect effects of prosperity and other facets of economic development. It also offers insights into the invaluable benefits that could be gained if today’s neglected diseases were also eliminated.

Progress In Public-Private Partnerships To Fight Neglected Diseases [Perspective]

Gustavsen, K., Hanson, C. — Mon, 02 Nov 2009 17:03:47 PST

In the global fight against neglected tropical diseases (NTDs), public health partnerships involving donations of medicines by pharmaceutical companies are enabling access to treatment for millions of people worldwide. These partnerships collaborate with other disease programs and a range of key stakeholders to develop and improve programs to control and eliminate NTDs. Although progress is being made against NTDs, continued success depends on a policy environment that supports appropriate levels of engagement and collaboration from all participants.

Spurring New Research For Neglected Diseases [Neglected Diseases]

Anderson, G. F. — Mon, 02 Nov 2009 17:03:47 PST

A very small proportion of global spending for biomedical research is for neglected diseases. However, neglected diseases account for a sizable percentage of the global burden of disease, especially in low-income countries. For-profit pharmaceutical and biotech companies are unlikely to conduct significant additional research on neglected diseases without financial incentives. This paper examines the benefits of providing a tax credit to encourage companies to conduct preclinical research on neglected diseases in the laboratory or in animals. This strategy could lead to a new generation of treatment options for the people in low-income countries who are susceptible to neglected diseases.

A Business Plan To Help The 'Global South' In Its Fight Against Neglected Diseases [Neglected Diseases]

Frew, S. E., Liu, V. Y., Singer, P. A. — Mon, 02 Nov 2009 17:03:47 PST

Although neglected tropical diseases (NTDs) threaten the health of those living in the developing world, innovation directed toward addressing NTDs is comparatively meager. Health biotechnology firms in rapidly growing economies in the global South are developing and selling vaccines, diagnostics, and therapeutics for these diseases to local markets. In this paper we identify a pipeline of sixty-two NTD products from seventy-eight "Southern" companies. We also propose creation of a Global Health Accelerator—a new nonprofit organization whose mission would be to support and help grow this Southern source of affordable innovation for NTDs.

Expanding The Biopharmaceutical Industry's Involvement In Fighting Neglected Diseases [Perspective]

Geraghty, J. A. — Mon, 02 Nov 2009 17:03:47 PST

The increasingly recognized need for new products for so-called neglected diseases, which afflict large numbers of people but have received relatively little industry investment, presents a clear example of a "strategic" corporate responsibility. Addressing neglected diseases can be important to "health diplomacy" and other national interests as well. Because industrial capabilities are essential to the development of new drugs and vaccines for these diseases, specific policy initiatives to attract more companies to do such work should also be further developed.

How Private, Voluntary Health Insurance Can Work In Developing Countries [MarketWatch]

Pauly, M. V., Blavin, F. E., Meghan, S. — Mon, 02 Nov 2009 17:03:47 PST

Could voluntary insurance markets exist in developing countries? We used data from the World Health Survey for eleven countries to estimate, at different income levels, variation in total medical spending and spending for hospitals, physicians, and outpatient drugs. The goal was to generate estimates of risk premiums that consumers might pay for insurance coverage and to calculate likely insurance administrative costs. We conclude that insurance covering either hospital spending or total spending is feasible for much of the population, but not insurance for physician services or medicines. Spending varies by income, so insurance markets should be segmented by income.

Microinsurance: Innovations In Low-Cost Health Insurance [MarketWatch]

Mon, 02 Nov 2009 17:03:47 PST

Microinsurance—low-cost health insurance based on a community, cooperative, or mutual and self-help arrangements—can provide financial protection for poor households and improve access to health care. However, low benefit caps and a low share of premiums paid as benefits—both designed to keep these arrangements in business—perversely limited these schemes’ ability to extend coverage, offer financial protection, and retain members. We studied three schemes in India, two of which are member-operated and one a commercial scheme, using household surveys of insured and uninsured households and interviews with managers. All three enrolled poor households and raised their use of hospital services, as intended. Financial exposure was greatest, and protection was least, in the commercial scheme, which imposed the lowest caps on benefits and where income was the lowest.

Innovation In Namibia: Preserving Private Health Insurance And HIV/AIDS Treatment [MarketWatch]

Mon, 02 Nov 2009 17:03:47 PST

Namibia, a lower-middle-income country in sub-Saharan Africa, suffers from a huge HIV/AIDS burden. An influx of donor funding in 2004–2007 increased support for publicly provided HIV care and treatment. This raised concern that private funding would be "crowded out," thereby leading to a reduction in the overall resources used to treat patients. In 2006 the Namibian medical aid industry, with donor support, created a special fund to subsidize private health insurance, including HIV/AIDS services. The program allowed both low- and higher-income people to be covered. Crowding out valuable private resources was avoided and the quality of HIV/AIDS services improved.

Dying Of A Treatable Disease [Narrative Matters]

Keirns, C. C. — Mon, 02 Nov 2009 17:03:47 PST

Participation Of Academic Scientists In Relationships With Industry [DataWatch]

Mon, 02 Nov 2009 17:03:47 PST

Relationships between academic researchers and industry have received considerable attention in the past twenty years. However, current data on the prevalence, magnitude, and trends in such relationships are rare. In a mailed survey of 3,080 academic life science researchers conducted in 2007, we found that 52.8 percent have some form of relationship with industry. Life science faculty with industry research support were more productive than faculty without such support on virtually every measure. However, we also found a significant decrease in industry support of university research, which could have major consequences for the academic life science research sector.

Adverse Selection In The Medicare Prescription Drug Program [DataWatch]

Riley, G. F., Levy, J. M., Montgomery, M. A. — Mon, 02 Nov 2009 17:03:47 PST

The Medicare Part D drug benefit created choices for beneficiaries among many prescription drug plans with varying levels of coverage. As a result, Medicare enrollees with high prescription drug costs have strong incentives to enroll in Part D, especially in plans with more comprehensive coverage. To measure this potential problem of "adverse selection," which could threaten plans’ finances, we compared baseline characteristics among groups of beneficiaries with various drug coverage arrangements in 2006. We found some significant differences. For example, enrollees in stand-alone prescription drug plans, especially in plans offering benefits in the coverage gap, or "doughnut hole," had higher baseline drug costs and worse health than enrollees in Medicare Advantage prescription drug plans. Although risk-adjusted payments and other measures have been put in place to account for selection, these patterns could adversely affect future Medicare costs and should be watched carefully.

Cancer Screening And Age In The United States And Europe [DataWatch]

Howard, D. H., Richardson, L. C., Thorpe, K. E. — Mon, 02 Nov 2009 17:03:47 PST

We compare cancer screening rates between the United States and Europe. Many European countries have organized screening programs, whereas the U.S. approach is relatively decentralized. Many European countries, unlike the United States, also impose upper age limits on screening. Overall, European screening rates were 22–88 percent of the corresponding U.S. rates. U.S. residents are more likely to be screened at younger ages, when the expected benefit from early detection is the greatest, but also at older ages, when the expected benefit is declining.

GrantWatch: Outcomes [GrantWatch]

Mon, 02 Nov 2009 17:03:47 PST

Boundary Politics And AIDS Policy [Book Reviews]

Weinreb, A. — Mon, 02 Nov 2009 17:03:47 PST

Killing The Greatest Killer--Smallpox [Book Reviews]

Musgrove, P. — Mon, 02 Nov 2009 17:03:47 PST

Deconstructing Medical Hype [Book Reviews]

Goozner, M. — Mon, 02 Nov 2009 17:03:47 PST

Tele-ICU: Much-Needed Evidence [Letters]

Everett, W. — Mon, 02 Nov 2009 17:03:47 PST

Tele-ICU And Clinical Quality [Letters]

Miller, M. D. — Mon, 02 Nov 2009 17:03:47 PST

eICU: More Data Are Now Available [Letters]

Rosenfeld, B. — Mon, 02 Nov 2009 17:03:47 PST

Tele-ICU: Positive Return On Investment [Letters]

Rufo, B. — Mon, 02 Nov 2009 17:03:47 PST

Tele-ICU: The Authors Respond [Letters]

Berenson, R. — Mon, 02 Nov 2009 17:03:47 PST

Major Reason For Nigerian Boycott Of Polio Vaccine [Letters]

Frishman, A. — Mon, 02 Nov 2009 17:03:47 PST

Polio Vaccine: The Authors Respond [Letters]

Kaufmann, J. R., Feldbaum, H. — Mon, 02 Nov 2009 17:03:47 PST

Ethical Prescribing [Letters]

Carrera, P. M. — Mon, 02 Nov 2009 17:03:47 PST

Ethical Prescribing: The Authors Respond [Letters]

James, C. D. — Mon, 02 Nov 2009 17:03:47 PST

Private Insurance In Taiwan [Letters]

Yu, S., Lin, A. — Mon, 02 Nov 2009 17:03:47 PST

Private Insurance In Taiwan: An Author Responds [Letters]

Cheng, T.-M. — Mon, 02 Nov 2009 17:03:47 PST

Weakest Links In Polio Vaccination [Letters]

Arya, S. C., Agarwal, N. — Mon, 02 Nov 2009 17:03:47 PST

Ownership Statement [Letters]

Tucker, J. — Mon, 02 Nov 2009 17:03:47 PST

Health Care Reform Requires Law Reform [Web Exclusives]

Jost, T. S. — Tue, 08 Sep 2009 17:02:05 PDT

Health care financing and delivery reform seems to be under way. Reform will in all likelihood originate with Congress but may also come from the states or even the private sector. Federal law, however, limits states’ options for reform, while state law constrains federal reform, and both state and federal law impede private innovation. Congressional action could facilitate state reform. Alternatively, federal preemption of state law may be necessary for federal reform. If neither Congress nor the states act, action by federal agencies could support private innovation. In any event, law reform is a necessary condition for health reform.

Broadened Use Of Atypical Antipsychotics: Safety, Effectiveness, And Policy Challenges [Web Exclusives]

Crystal, S., Olfson, M., Huang, C., Pincus, H., Gerhard, T. — Tue, 08 Sep 2009 17:02:05 PDT

Atypical antipsychotic medications are increasingly used for a wide range of clinical indications in diverse populations, including privately and publicly insured youth and elderly nursing home residents. These trends heighten policy challenges for payers, patients, and clinicians related to appropriate prescribing and management, patient safety, and clinical effectiveness. For clinicians and patients, balancing risks and benefits is challenging, given the paucity of effective alternative treatments. For health care systems, regulators, and policymakers, challenges include developing the evidence base on comparative risks and benefits; defining measures of treatment quality; and implementing policies that encourage evidence-based practices while avoiding unduly burdensome restrictions.

Developing A Policy For Second-Generation Antipsychotic Drugs [Web Exclusives]

Rosenheck, R. A., Sernyak, M. J. — Tue, 08 Sep 2009 17:02:05 PDT

Second-generation antipsychotics (SGAs) have replaced older drugs in the treatment of schizophrenia; their costs in the United States have reached $13 billion a year. Recent research, however, shows that their net risk/benefit profiles are no better than some older, cheaper drugs. Stepped therapy, allowing exceptions with prior authorization and giving preference to generic drugs with low risk of both neurologic and metabolic side effects, could increase the cost-effectiveness and safety of antipsychotic drugs. Educational preparation and monitoring of adverse events would foster better acceptance of such procedures among providers, patients, and families. Research to evaluate these interventions would ideally precede their widespread implementation.

Comparative Effectiveness Research For Antipsychotic Medications: How Much Is Enough? [Web Exclusives]

Meltzer, D. O., Basu, A., Meltzer, H. Y. — Tue, 08 Sep 2009 17:02:05 PDT

Second-generation antipsychotics have attracted practitioners’ and policy-makers’ attention, because of concerns over their health effects and costs. Comparative effectiveness data from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE)—a high-profile National Institutes of Health (NIH)–funded study—have been used to argue for restricting coverage for these costly drugs. But concerns about the design of CATIE and its associated cost-effectiveness analysis and uncertainty about the precision of these findings raise questions about this interpretation. Our work suggests that additional research to increase the precision of comparisons of the effectiveness of antipsychotics would be well worth the cost.

Charitable Expectations Of Nonprofit Hospitals: Lessons From Maryland [Web Exclusives]

Gray, B. H., Schlesinger, M. — Tue, 08 Sep 2009 17:02:05 PDT

Little is known about nonprofit hospitals’ community benefit spending other than for charity care. Better accountability is desirable, but critics have focused too narrowly on charity care. Using data from reporting requirements in Maryland similar to federal rules that take effect in 2010, we describe the broad range of community benefit spending in nonprofit hospitals there, which amounted to 7.4 percent of expenses in 2007. Charity care for hospital services accounted for one-third of this amount (payments to physicians for charity patients are reported separately). Hospitals’ community benefit spending varies with local needs, resources, and resource allocation decisions.

Annual Medical Spending Attributable To Obesity: Payer-And Service-Specific Estimates [Web Exclusives]

Finkelstein, E. A., Trogdon, J. G., Cohen, J. W., Dietz, W. — Tue, 08 Sep 2009 17:02:05 PDT

In 1998 the medical costs of obesity were estimated to be as high as $78.5 billion, with roughly half financed by Medicare and Medicaid. This analysis presents updated estimates of the costs of obesity for the United States across payers (Medicare, Medicaid, and private insurers), in separate categories for inpatient, non-inpatient, and prescription drug spending. We found that the increased prevalence of obesity is responsible for almost $40 billion of increased medical spending through 2006, including $7 billion in Medicare prescription drug costs. We estimate that the medical costs of obesity could have risen to $147 billion per year by 2008.

How Medicare Could Get Better Prices On Prescription Drugs [Web Exclusives]

Outterson, K., Kesselheim, A. S. — Tue, 08 Sep 2009 17:02:05 PDT

Congress may reform drug pricing policies under Medicare Part D as part of a larger health reform effort. Currently, the "noninterference" provision prevents the government from negotiating drug prices on behalf of Medicare Part D prescription drug plans. Commonly considered reform proposals borrow ideas from Medicaid, either through returning dual eligibles to Medicaid drug pricing or by imposing mandatory rebates across the Part D population. We examine a menu of other options, including value-based pricing; expansion of generic and therapeutically equivalent substitution; increased formulary diversity; importation; and limited antitrust waivers. These latter options may reduce federal spending without direct government price negotiations.

Games For Health: The Latest Tool In The Medical Care Arsenal [Web Exclusives]

Hawn, C. — Tue, 08 Sep 2009 17:02:06 PDT

At the heart of any promising plan to transform the health care system lie two priorities: broader access to care for patients, and deeper engagement in health care by patients. Although the problem of expanding access to affordable care remains unresolved, new tools for deepening consumers’ engagement in health care are proliferating like viral spores in a virtual pond. Digital games, including virtual realities, computer simulations, and online play, are valuable tools for fostering patient participation in health-related activities. This is why gaming is the latest tool in the arsenal to improve health outcomes: gaming makes health care fun.

Estimates Of Health Care Professional Shortages In Sub-Saharan Africa By 2015 [Web Exclusives]

Scheffler, R. M., Mahoney, C. B., Fulton, B. D., Dal Poz, M. R., Preker, A. S. — Tue, 08 Sep 2009 17:02:06 PDT

This paper uses a forecasting model to estimate the need for, supply of, and shortage of doctors, nurses, and midwives in thirty-nine African countries for 2015, the target date of the United Nations Millennium Development Goals. We forecast that thirty-one countries will experience needs-based shortages of doctors, nurses, and midwives, totaling approximately 800,000 health professionals. We estimate the additional annual wage bill required to eliminate the shortage at about $2.6 billion (2007 $US)—more than 2.5 times current wage-bill projections for 2015. We illustrate how changes in workforce mix can reduce this cost, and we discuss policy implications of our results.

Job Satisfaction And Morale In The Ugandan Health Workforce [Web Exclusives]

Hagopian, A., Zuyderduin, A., Kyobutungi, N., Yumkella, F. — Tue, 08 Sep 2009 17:02:06 PDT

Ugandan health workers are dissatisfied with their jobs, especially their compensation and working conditions. About one in four would like to leave the country to improve their outlook, including more than half of all physicians. In this paper we report differences by type of health worker, sex, age, sector (public or nonprofit), and location. Policy strategies to strengthen human resources for health in Uganda should focus on salary and benefits (especially health coverage), working conditions and workload, facility infrastructure (including water and electricity), management, and workforce camaraderie.

The Quality Of Emergency Obstetrical Surgery By Assistant Medical Officers In Tanzanian District Hospitals [Web Exclusives]

McCord, C., Mbaruku, G., Pereira, C., Nzabuhakwa, C., Bergstrom, S. — Tue, 08 Sep 2009 17:02:06 PDT

Five countries in sub-Saharan Africa use nonphysicians to perform major emergency obstetrical surgery. In Tanzania, assistant medical officers provide most of this surgery outside of major cities. Questions about the quality of surgery by nonphysicians have kept most African countries from following this example. We reviewed the records of all patients admitted for complicated deliveries to fourteen district hospitals during four months. Among 1,134 complicated deliveries and 1,072 major obstetrical operations, there were no significant differences between assistant medical officers and medical officers in outcomes, risk indicators, or quality. There were significant differences between mission and government hospitals.

Connecting The Ivory Tower To Main Street: Setting Research Priorities For Real-World Impact [Web Exclusives]

Schur, C. L., Berk, M. L., Silver, L. E., Yegian, J. M., O'Grady, M. J. — Tue, 08 Sep 2009 17:02:06 PDT

Health care decisionmakers face increasing pressure to use health care resources more efficiently, but the information they need to assess policy options often is unavailable or not disseminated in a useful form. Findings from stakeholder meetings and a survey of private-sector health care decisionmakers in California begin to identify high-priority issues, the perceived adequacy of current information, and preferred formats and other desired attributes of research. This is a first step in establishing a systematic approach to linking the information priorities of private-sector decisionmakers with those who fund and conduct research.

The Unhealthy State Of Health Policy Research [Web Exclusives]

Majumdar, S. R., Soumerai, S. B. — Tue, 08 Sep 2009 17:02:06 PDT

Health policies often represent large-scale natural experiments with poorly understood risks and benefits. Unfortunately, researchers often stray from the core principles of study design required to provide valid evidence. The result is that policymakers and the public do not always know what to believe. We illustrate the problem in several fields, including pay-for-performance, cost sharing, and health information technology policies. We suggest a few ways to improve health policy research so that evidence can inform policy more often. The way forward should include more credible data for those making the hard trade-offs between cost and quality of care.

Access, Cost, And Financing: Achieving An Ethical Health Reform [Web Exclusives]

Daniels, N., Saloner, B., Gelpi, A. H. — Tue, 08 Sep 2009 17:02:06 PDT

Three key ethical issues should inform the broader debate about health reform: (1) Why pursue universal coverage? (2) Why is cost containment an ethical issue? (3) What is fairness in financing? After examining these issues, we conclude that the core ethical values underlying each of these goals—including expanding opportunity, sharing burdens equally, and respect for persons—limit the means that can be pursued in health reform. Although national health reform will not accomplish all of the objectives of social justice, true comprehensive reform—even under conditions of political compromise—represents an important step forward.

Putting The Public's Money Where Its Mouth Is [Web Exclusives]

Kessler, D. P., Brady, D. W. — Tue, 08 Sep 2009 17:02:06 PDT

This paper reports the results of a 2009 national survey that quantifies Americans’ willingness to pay to expand health insurance coverage. We asked respondents whether they would support a Medicaid expansion, a subsidy for low-income people, or a subsidy for the chronically ill, if they had to pay more income taxes to cover the program’s costs. Based on respondents’ reported income, we told them approximately how much, in dollar terms, their tax increases would be. Our results reflect a tension in public opinion recognized by previous investigators: a desire for reform but limited willingness to pay for it.

Reforming The Medicaid Disproportionate-Share Hospital Program [Web Exclusives]

McKethan, A., Nguyen, N., Sasse, B. E., Kocot, S. L. — Tue, 08 Sep 2009 17:02:06 PDT

Congress and the Obama administration are considering redirecting federal spending on the Medicaid disproportionate-share hospital (DSH) program to help pay for health reform. In this paper, we propose linking federal Medicaid DSH funding to state-level Medicaid enrollment or uninsured populations, or both. This approach could produce as much as $44 billion in federal savings over time without exposing hospitals to uncertain or across-the-board spending cuts. It could also gradually address state variations in Medicaid DSH funding. We also offer ideas to ensure that DSH spending is more directly connected than it is now to improvements in care for vulnerable populations.

Does Telemonitoring Of Patients--The eICU--Improve Intensive Care? [Web Exclusives]

Berenson, R. A., Grossman, J. M., November, E. A. — Tue, 08 Sep 2009 17:02:06 PDT

Intensive care units are an essential and costly component in most U.S. hospitals. However, little is actually known about what staffing and work-process interventions produce the best balance of quality and costs. We explore the reasons hospitals chose to either adopt or reject an innovative telemedicine approach to supporting delivery of intensive care. Hospital clinical leaders hold strong views but have little objective information on which to judge the worthiness of this innovation. We argue that comparative effectiveness initiatives should emphasize delivery-system and work-process innovations, which are relatively understudied compared to specific drugs, devices, and services.

Expert Review Of Drug Patent Applications: Improving Health In The Developing World [Web Exclusives]

Amin, T., Rajkumar, R., Radhakrishnan, P., Kesselheim, A. S. — Tue, 08 Sep 2009 17:02:06 PDT

Many developing countries have enacted intellectual property laws allowing patents on pharmaceutical products. These countries now must figure out how to provide legitimate protection of innovative discoveries while avoiding drug patents that do not conform to their laws. Using case-study examples, including the antiretroviral tenofovir disoproxil fumarate (TDF, or Viread), we demonstrate the importance of having outside experts participate in the review of drug patents. Vibrant patent review systems require sharing information among developing countries and active consultation with local public health authorities.

A Trade Agreement's Impact On Access To Generic Drugs [Web Exclusives]

Shaffer, E. R., Brenner, J. E. — Tue, 08 Sep 2009 17:02:06 PDT

Millions of people lack access to affordable medicines. The intellectual property rules in the Central America Free Trade Agreement (CAFTA) provide pharmaceutical companies with monopoly protections that allow them to market some drugs without competition by less costly generics. We examined availability of certain drugs in Guatemala and found that CAFTA intellectual property rules reduced access to some generic drugs already on the market and delayed new entry of other generics. Some drugs protected from competition in Guatemala will become open for generic competition in the United States before generic versions will be legally available in Guatemala.

Global Drug Discovery: Europe Is Ahead [Web Exclusives]

Light, D. W. — Tue, 08 Sep 2009 17:02:07 PDT

It is widely believed that the United States has eclipsed Europe in pharmaceutical research productivity. Some leading analysts claim that although fewer drugs have been discovered worldwide over the past decade, most are therapeutically important. Yet a comprehensive data set of all new chemical entities approved between 1982 and 2003 shows that the United States never overtook Europe in research productivity, and that Europe in fact is pulling ahead of U.S. productivity. Other large studies show that most new drugs add few if any clinical benefits over previously discovered drugs. I discuss ways in which Congress, employers, and insurers can increase the value of drugs and revitalize the U.S. pharmaceutical industry.

Using Clinical Information To Project Federal Health Care Spending [Web Exclusives]

Huang, E. S., Basu, A., O'Grady, M. J., Capretta, J. C. — Tue, 08 Sep 2009 17:02:07 PDT

Complications from chronic illnesses often do not emerge for many years. Current federal cost projection methods are constrained by ten-year cost estimates, which capture increases in near-term intervention costs but not changes in long-term costs. Current methods also cannot easily capture the cost implications of changes in disease progression. Type 2 diabetes is a prime example of a chronic illness with long-term health and cost consequences. We present results from an epidemiologically based model that projects federal costs for diabetes under alternative policies, and we discuss the potential changes in the federal budget process needed to capture the full impact of these interventions.

Rolling The Rock Up The Mountain [From the Editor]

Dentzer, S. — Tue, 08 Sep 2009 17:02:04 PDT

Increased Spending On Health Care: Long-Term Implications For The Nation [Research UpDate]

Chernew, M. E., Hirth, R. A., Cutler, D. M. — Tue, 08 Sep 2009 17:02:04 PDT

This paper updates one we published in 2003, describing the implications of continued health care spending growth for the consumption of nonhealth goods and services. Our estimates now show that at approximately long-run average rates of excess health spending growth, 119 percent of the real increase in per capita income would be devoted to health spending over the 2007–2083 projection period. We argue that an alternative scenario, under which health spending grew just one percentage point faster than real per capita income, is "affordable," although 53.6 percent of real income growth over the period would go to health care. Moreover, even with the more favorable assumption, the nation would still face important challenges paying for care and dividing up the burden. This analysis thus supports the argument that reforms that would dramatically slow the rate of health care spending growth are necessary, especially if the nation hopes to maintain a reasonable amount of consumption of nonhealth goods and services.

Bending The Curve: The Twists And Turns [Health Reform UpDate]

Marcus, A. — Tue, 08 Sep 2009 17:02:04 PDT

Health Spending: An Overview [Overview]

Tue, 08 Sep 2009 17:02:05 PDT

Is Health Spending Excessive? If So, What Can We Do About It? [Overview]

Aaron, H. J., Ginsburg, P. B. — Tue, 08 Sep 2009 17:02:05 PDT

The case that the United States spends more than is optimal on health care is overwhelming. But identifying reasons for excessive spending is not the same as showing how to wring it out in ways that increase welfare. To lower spending without lowering net welfare, it is necessary to identify what procedures are effective at reasonable cost, to develop protocols that enable providers to identify in advance patients in whom expected benefits of treatment are lower than costs, to design incentives that encourage providers to act on those protocols, and to provide research support to maintain the flow of beneficial innovations.

Income, Insurance, And Technology: Why Does Health Spending Outpace Economic Growth? [Overview]

Smith, S., Newhouse, J. P., Freeland, M. S. — Tue, 08 Sep 2009 17:02:05 PDT

A broad consensus holds that increased medical capability—technology—is the primary driver of health spending growth. However, technology does not expand independently of historical context; it is fueled by rising incomes and more generous insurance coverage. We estimate that medical technology explains 27–48 percent of health spending growth since 1960—a smaller percentage than earlier estimates. Income (gross domestic product, or GDP) growth plays a critical role, primarily through the actions of governments and employers on behalf of pools of consumers. The contribution of insurance is likely to differ, with less of a push from increasing generosity of coverage and more of a push from changes in provider payment.

Public Attitudes Toward Health Care Spending Aren't The Problem; Prices Are [Overview]

Oberlander, J., White, J. — Tue, 08 Sep 2009 17:02:05 PDT

Does the United States spend more on medical care than other nations because Americans desire more medical care than other populations do and dislike constraints on health spending? We argue that the public is not the main barrier to successful cost control in the United States. The preoccupation with excessive demand as the cause of and rationing as the cure for U.S. health spending overlooks an alternative explanation for that spending: higher prices. There is evidence that price regulation can constrain spending and that the public will support that cost-control approach.

Health Care Cost Growth Among The Privately Insured [Overview]

Bundorf, M. K., Royalty, A., Baker, L. C. — Tue, 08 Sep 2009 17:02:05 PDT

Controlling health care cost growth remains a high priority for policymakers and private decisionmakers, yet little is known about sources of this growth. We examined spending growth among the privately insured between 2001 and 2006, separating the contributions of price changes from those driven by consumption. Most spending growth was driven by outpatient services and pharmaceuticals, with growth in quantities explaining the entire growth in outpatient spending and about three-quarters of growth in spending on prescription drugs. Rising prices played a greater role in growth in spending for brand-name than for generic drugs. These findings can inform efforts to control private- sector spending.

Market Failure And The Failure Of Discourse: Facing Up To The Power Of Sellers [Overview]

Vladeck, B. C., Rice, T. — Tue, 08 Sep 2009 17:02:05 PDT

The United States spends far more than other countries do on its health care system, but comparative data strongly imply that Americans are not receiving their money’s worth. There is much hand-wringing about spending, but little attention is paid to the main culprit: lack of market power by purchasers—something that exists in nearly all other countries. This lack of attention is not surprising, however, given that having an open discussion could ultimately lead to more regulation—and a major redistribution of resources away from providers and back to employers, individuals and families, and taxpayers.

Saving Money: What Works And What Doesn't? [Saving Money]

Tue, 08 Sep 2009 17:02:05 PDT

American Medical Home Runs [Saving Money]

Milstein, A., Gilbertson, E. — Tue, 08 Sep 2009 17:02:05 PDT

Four primary care sites in the United States constitute "medical home runs" because their patients incur 15–20 percent less (risk-adjusted) total health care spending per year than patients treated by regional peers, without evidence of reduced quality. The sites achieved this result in a U.S. payment environment that usually penalizes physicians who invest to prevent costly near-term health crises. If the ingredients and accomplishments of these four sites spread, under- and uninsured lower-income Americans could be fully covered in the foreseeable future without increased health spending or lower quality of care. In exchange, sponsors of health benefits would gladly support additional primary care physician payment.

Would Having More Primary Care Doctors Cut Health Spending Growth? [Saving Money]

Chernew, M. E., Sabik, L., Chandra, A., Newhouse, J. P. — Tue, 08 Sep 2009 17:02:05 PDT

Spending on health care in markets with a larger percentage of primary care physicians (PCPs) is lower at any point in time than is true in other markets. The relationship between physician workforce composition and the rate of spending growth is less clear. This analysis of market-level Medicare spending data between 1995 and 2005 reveals that the proportion of PCPs is not associated with spending growth. Additional research is needed before the potential causal impact of PCPs can be fully assessed. However, these findings suggest that changes in the composition of the physician workforce will not be sufficient to address spending growth.

Removing Costs From The Health Care Supply Chain: Lessons From Mass Retail [Saving Money]

Agwunobi, J., London, P. A. — Tue, 08 Sep 2009 17:02:05 PDT

Improved supply-chain management and high-volume purchasing have benefited other industries. This same approach could also reduce health care costs. Streamlining layers in the supply chain and using purchasing volume to reduce prices can save money and may improve care. Providing access to in-store health clinics and low-cost generic drugs are examples of how this approach is being tested by mass retailers. We examine lessons learned from these and similar initiatives and identify opportunities to cut the costs of generic and name-brand drugs, medical supplies, over-the-counter remedies, and vision care.

Writing The New Playbook For U.S. Health Care: Lessons From Wisconsin [Saving Money]

Toussaint, J. — Tue, 08 Sep 2009 17:02:05 PDT

U.S. taxpayers waste far too much money on health care that is merely average or worse. Some health care providers, including ThedaCare, a major Wisconsin health care company, are using the tools of lean manufacturing to eliminate millions of dollars of waste that obstructs the provision of effective medicine. ThedaCare studies care delivery processes to improve care and lower costs. Lessons from lean manufacturing and the Institute for Healthcare Improvement are lowering incidence of preterm births, improving heart attack response rates, and changing the way care is delivered in hospitals to a collaborative, team-based approach.

Combating Fraud In Health Care: An Essential Component Of Any Cost Containment Strategy [Perspectives]

Morris, L. — Tue, 08 Sep 2009 17:02:05 PDT

Federal health care programs, including Medicare and Medicaid, are under attack by dishonest people who lie to the government and exploit its programs to steal taxpayers’ money. The full extent of health care fraud cannot be measured precisely. However, the Federal Bureau of Investigation (FBI) estimates that fraudulent billings to public and private health care programs are 3–10 percent of total health spending, or $75–$250 billion in fiscal year 2009. Successful efforts to stop such abuses, without unduly burdening legitimate providers, require aggressive, innovative, and sustained attention to protect taxpayers and beneficiaries.

Opportunities To Improve The Quality Of Care For Advanced Illness [Perspectives]

Krakauer, R., Spettell, C. M., Reisman, L., Wade, M. J. — Tue, 08 Sep 2009 17:02:05 PDT

Many studies describe a sizable chasm between the care Americans consider optimal for advanced illness and what we actually experience. Aggressive or curative measures may be pursued to the exclusion of comfort, pain relief, and psychosocial support. We briefly describe a care management program that gives people culturally sensitive supportive information, to make informed choices and obtain palliative services in a timely manner. In the sample population, more members chose hospice care; acute care utilization declined. It is possible to assist Americans with advanced illness and remove barriers to selecting hospice care, if that is their choice, without adverse financial impact.

The NICE Way Of Influencing Health Spending: A Conversation With Sir Michael Rawlins [Interview]

Timmins, N. — Tue, 08 Sep 2009 17:02:05 PDT

Ten years ago the National Institute for Health and Clinical Excellence (NICE) was set up to recommend to the National Health Services in England and Wales which treatments and procedures it should and should not pay for and to publish treatment guidelines. As the United States moves to engage in more study of the comparative effectiveness—and possibly the cost-effectiveness—of treatments, Sir Michael Rawlins, chairman of NICE since its inception, reflects on the lessons. A possible surprise: on balance, NICE has added to costs.

Is The United States Ready For QALYs? [Perspective]

Neumann, P. J., Greenberg, D. — Tue, 08 Sep 2009 17:02:05 PDT

Quality-adjusted life-years (QALYs) are used in cost-effectiveness analyses to aid coverage and reimbursement decisions worldwide. QALYs provide a flexible and convenient metric for measuring and comparing health outcomes across diverse diseases and treatments. But their use has stirred controversy about how accurately they reflect preferences for health care and whether their use is fair. We review the debate and the use of QALYs in other countries and discuss prospects for using them in the U.S. health care system. Strict adherence to a QALY approach is likely to prove unacceptable in the United States, but a more flexible use of QALYs could be beneficial.

Changing The Incentives Through Payment Reform [Changing Incentives]

Tue, 08 Sep 2009 17:02:05 PDT

Mission Not Yet Accomplished? Massachusetts Contemplates Major Moves On Cost Containment [Report From The Field]

Bebinger, M. — Tue, 08 Sep 2009 17:02:05 PDT

There is growing concern in Massachusetts that rising health care costs will derail the state’s move to universal health coverage. A special state panel has recommended moving from fee-for-service to a new system of global payments as the best way to reduce unnecessary care and expenses, while improving the health of patients. The commission points to specific examples in the state where global payments seem to be working. But other providers are pushing back.

Medicare Governance And Provider Payment Policy [Changing Incentives]

Pham, H. H., Ginsburg, P. B., Verdier, J. M. — Tue, 08 Sep 2009 17:02:05 PDT

Medicare’s decision-making processes leave policies on provider payment vulnerable to "micromanagement" by Congress and the White House. If they continue as they are, they could jeopardize delivery system changes central to current health reform proposals. Ad hoc intervention in response to pressure from narrow interests can result in policies that do not serve the broader priorities of beneficiaries and taxpayers and that are unsound economically. Establishing a new Medicare policy board, as proposed by the Obama administration and Congress; transforming the Medicare agency into an independent agency or new department; and conducting analyses of congressionally proposed payment policy changes before they are voted on could further insulate payment decisions from political interference.

Setting Hospital Rates To Control Costs And Boost Quality: The Maryland Experience [Changing Incentives]

Murray, R. — Tue, 08 Sep 2009 17:02:05 PDT

For decades Maryland has maintained a hospital payment system in which all payers—public and private—pay the same rates. This paper describes Maryland’s all-payer hospital payment system—the legislative goals and principles that directed regulatory efforts in the state; how well the system performs in meeting these goals; and current initiatives on payment design, quality-based reimbursement, and their application elsewhere in the health sector. Maryland’s rate-setting system is one of the most enduring and successful cost containment programs in the United States. Lessons learned are relevant to other states and provide useful bases for consideration of future health reform strategies.

Episode-Based Performance Measurement And Payment: Making It A Reality [Changing Incentives]

Hussey, P. S., Sorbero, M. E., Mehrotra, A., Liu, H., Damberg, C. L. — Tue, 08 Sep 2009 17:02:05 PDT

Proposals to use episodes of care as a basis for payment and performance measurement are largely conceptual at this stage, with little empirical work or experience in applied settings to guide their design. Based on analyses of Medicare data, we identified key issues that will need to be considered related to defining episodes and determining which provider is accountable for an episode. We suggest a number of applied studies and demonstrations that would facilitate more rapid movement of episode-based approaches from concept to implementation.

From Volume To Value: Better Ways To Pay For Health Care [Changing Incentives]

Miller, H. D. — Tue, 08 Sep 2009 17:02:05 PDT

Payment systems for health care today are based on rewarding volume, not value for the money spent. Two proposed methods of payment, "episode-of-care payment" and "comprehensive care payment" (condition-adjusted capitation), could facilitate higher quality and lower cost by avoiding the problems of both fee-for-service payment and traditional capitation. The most appropriate payment systems for different types of patient conditions and some methods of addressing design and implementation issues are discussed. Although the new payment systems are desirable, many providers are not organized to accept or use them, so transitional approaches such as "virtual bundling," described in this paper, will be needed.

How Can We Make More Progress In Measuring Physicians' Performance To Improve The Value Of Care? [Changing Incentives]

Miller, T. P., Brennan, T. A., Milstein, A. — Tue, 08 Sep 2009 17:02:05 PDT

The lack of good information on providers’ performance is an impediment to improving the affordability and quality of health care. Knowing that certain hospitals or physicians produce more effective and efficient care would help consumers make appropriate purchases and create incentive for improvement. Yet many physicians resist such measurement efforts, unconvinced of their accuracy. Meanwhile, large employers want much more than their insurers provide to them, including attribution of quality and cost of care to individual physicians. Although recent developments in performance measurement illustrate its unsettled state, they also foreshadow how the field may advance.

Measurement Of And Reward For Efficiency In California's Pay-For-Performance Program [Changing Incentives]

Robinson, J. C., Williams, T., Yanagihara, D. — Tue, 08 Sep 2009 17:02:05 PDT

Pay-for-performance (P4P) programs are expanding their purview from quality to include efficiency, and many consider the episode of care as the appropriate unit of measurement. Two years’ experience by the California P4P program, however, reveals that the requisite claims data often are incomplete or poorly coded and that even large physician groups have too few patients experiencing most types of episodes to permit statistically valid measurement for public reporting and incentive payment. The California P4P program is shifting its efficiency focus to metrics not reliant on episode measurement while shifting episode measurement to supporting bundled payment for acute surgical and medical interventions.

A Trillion-Dollar Geography Lesson [Perspective]

Baicker, K., Chandra, A. — Tue, 08 Sep 2009 17:02:05 PDT

Dartmouth researchers have demonstrated that there is tremendous geographic variation in the efficiency of health care delivery systems, fostered by perverse incentives that penalize integration, reward fragmentation, and encourage the use of technologies in the "gray areas" of medicine. This research suggests that it is possible to deliver higher-quality care at lower cost. We argue that integrated delivery systems, bundled payments, and more sophisticated comparative effectiveness analysis, rather than crude across-the-board cuts in payments, are the keys to stemming cost growth, improving value, and raising the trillion dollars needed to cover the uninsured.

Looking Ahead [Looking Ahead]

Tue, 08 Sep 2009 17:02:05 PDT

Enrollment Is Driving Medicaid Costs--But Two Targets Can Yield Savings [Looking Ahead]

Holahan, J., Yemane, A. — Tue, 08 Sep 2009 17:02:05 PDT

This paper examines various reasons for the growth in Medicaid spending in the current decade. Although Medicaid spending has grown faster than the rate of increase in national health spending, much of this is explained by increased enrollment. Per enrollee, Medicaid spending actually compares favorably to increases in medical care prices and gross domestic product. The relative success in Medicaid cost containment seems to be attributable to limits on provider payment rates, expansion of managed care, limits on the use and pricing of prescription drugs, and expansion of community-based long-term care programs. We suggest two strategies for further cost containment.

Is It Time To Reexamine The Patent System's Role In Spending Growth? [Looking Ahead]

Pauly, M. V. — Tue, 08 Sep 2009 17:02:05 PDT

Containing health care spending growth will require changing the amount and form of new health care technology. But even if new technology lowers real resource costs by reducing the use of medical care (as through personalized medicine or by producing cost offsets), it might not lower the rate of growth of spending when patents are present: higher net value may translate into a higher price for patented products. To lower long-run spending growth, it may be necessary to change patent policy by reducing the term of patent life or linking spending growth targets to net benefits from patented products.

Improving Safety And Eliminating Redundant Tests: Cutting Costs In U.S. Hospitals [Health Tracking]

Jha, A. K., Chan, D. C., Ridgway, A. B., Franz, C., Bates, D. W. — Tue, 08 Sep 2009 17:02:05 PDT

High costs and unsafe care are major challenges for U.S. hospitals. Two sources of raised costs and unsafe care are adverse events in hospitals and tests ordered by several different physicians. After reviewing rates of these two occurrences in U.S. hospitals and simulating their costs, we estimated that in 2004 alone, eliminating readily preventable adverse events would have resulted in direct savings of more than $16.6 billion (5.5 percent of total inpatient costs). Eliminating redundant tests would have saved an additional $8 billion (2.7 percent). Addressing these situations could generate major savings to the system while improving patient care.

Medicare's Policy Not To Pay For Treating Hospital-Acquired Conditions: The Impact [Health Tracking]

McNair, P. D., Luft, H. S., Bindman, A. B. — Tue, 08 Sep 2009 17:02:05 PDT

In 2008 Medicare stopped reimbursing hospitals for treating eight avoidable hospital-acquired conditions. Using 2006 California data, we modeled the financial impact of this policy on six such conditions. Hospital-acquired conditions were present in 0.11 percent of acute inpatient Medicare discharges; only 3 percent of these were affected by the policy. Payment reductions were negligible (0.001 percent, or $0.1 million—equivalent to $1.1 million nationwide) and are unlikely to encourage providers to improve quality. Options to strengthen the incentives include further payment modifications for hospital-acquired conditions or expanding the hospital-acquired condition policy to exclude payment for consequences, additional procedures, and readmissions.

The Policy On Paying For Treating Hospital-Acquired Conditions: CMS Officials Respond [Perspective]

Straube, B., Blum, J. D. — Tue, 08 Sep 2009 17:02:05 PDT

Policies that decline payment in the event of hospital-acquired conditions have generated considerable public attention. Although the projected payment reductions are not large, small payment penalties have been effective in changing human behavior and ultimately in improving the hospital care experience for patients. Many state Medicaid programs and commercial payers have adopted similar policies. Medicare payment reductions for hospital-acquired conditions are only one component of several efforts to reduce their incidence. The Centers for Medicare and Medicaid Services (CMS) will refine these policies as appropriate. Other CMS strategies to reduce hospital-acquired conditions include public reporting, quality improvement initiatives, value-based purchasing, quality metrics and guidelines development, and national coverage decisions.

Making The 'Pay' Matter In Pay-For-Performance: Implications For Payment Strategies [Health Tracking]

Werner, R. M., Dudley, R. A. — Tue, 08 Sep 2009 17:02:05 PDT

Although pay-for-performance (P4P) is being widely adopted, little is known about how different P4P strategies affect provider payment. These differences may be essential in motivating and maximizing quality improvement across all providers. We review hospitals’ P4P strategies and describe differences in payments by size of reward; payment differences between high- and low-performing providers; ability to reward improvement in the absence of high performance; and the percentage of payments based on performance. Bonuses vary considerably by payment strategy, which suggests that the strategy selected should vary depending on program goals. These findings are relevant to P4P for any type of provider.

Shingles Does It [Narrative Matters]

Coulehan, J. — Tue, 08 Sep 2009 17:02:05 PDT

Adventures In (Health-Insurance-Claim) Wonderland [Narrative Matters]

Redig, A. J. — Tue, 08 Sep 2009 17:02:05 PDT

Reducing Racial Disparities In Coronary Angiography [DataWatch]

Cantor, J. C., DeLia, D., Tiedemann, A., Stanley, A., Kronebusch, K. — Tue, 08 Sep 2009 17:02:05 PDT

Racial disparities in cardiac services are well documented; however, policies to close these gaps have not been studied. This paper evaluates a New Jersey certificate-of-need reform to reduce disparities in diagnostic coronary angiography. The number of angiography facilities in New Jersey doubled following reform, and a large black-white disparity was eliminated—a trend not observed in nearby states. Surprisingly, increases in service to African American patients following reform were concentrated in hospitals licensed before reform, while the newly licensed facilities contributed relatively little to reducing disparities. We hypothesize that added hospital competition contributed to the reduction in disparities.

Health Risk Appraisals: How Much Do They Influence Employees' Health Behavior? [DataWatch]

Huskamp, H. A., Rosenthal, M. B. — Tue, 08 Sep 2009 17:02:05 PDT

Health plans often use health risk appraisals (HRAs) as a starting point in engaging members in behavioral change. We examine characteristics associated with the voluntary completion of HRAs among enrollees in employer-sponsored insurance plans. We compare health care use, costs, and participation in disease management programs for HRA completers and similar enrollees in plans that do not offer an HRA. Women, healthier people, and people in consumer-driven health plans (CDHPs) are more likely than others to complete an HRA. Among those who complete an HRA, use of office visits, prescription drugs, and cervical cancer screening increases compared to those who are not offered an HRA.

GrantWatch: Outcomes [GrantWatch]

Tue, 08 Sep 2009 17:02:05 PDT

Wrestling With The Dragon: Presidential Power And Health Reform [Book Reviews]

Goldsmith, J. — Tue, 08 Sep 2009 17:02:05 PDT

There Is A Better Way [Book Reviews]

Aaron, H. J. — Tue, 08 Sep 2009 17:02:05 PDT

Medication Treatment For ADHD: Controversy Abounds [Book Reviews]

Busch, S. H. — Tue, 08 Sep 2009 17:02:05 PDT

Average Out-Of-Pocket Spending For Families [Letters]

Trueman, L. C. — Tue, 08 Sep 2009 17:02:05 PDT

Out-Of-Pocket Spending: The Authors Respond [Letters]

Gabel, J. — Tue, 08 Sep 2009 17:02:05 PDT

Inadequacy Of Access To Substance Use Benefits [Letters]

McDaid, C. — Tue, 08 Sep 2009 17:02:05 PDT

Substance Use Benefits: The Author Responds [Letters]

Dixon, K. — Tue, 08 Sep 2009 17:02:05 PDT

Mental Health Conditions Among Returning Veterans [Letters]

Katz, I. R. — Tue, 08 Sep 2009 17:02:05 PDT

Care For Veterans: The Authors Respond [Letters]

Tanielian, T. — Tue, 08 Sep 2009 17:02:05 PDT

Ethical Guidelines For Employee Behavior Change [Letters]

Levin-Scherz, J., Levine, H. — Tue, 08 Sep 2009 17:02:05 PDT

Does Prevention Save Money? [Letters]

Kottke, T. E., Pronk, N. P., Isham, G. J. — Tue, 08 Sep 2009 17:02:05 PDT

Prevention: Goetzel Responds [Letters]

Goetzel, R. — Tue, 08 Sep 2009 17:02:05 PDT

Prevention: Russell Responds [Letters]

Russell, L. — Tue, 08 Sep 2009 17:02:05 PDT

Erratum [Errata]

Tue, 08 Sep 2009 17:02:05 PDT