M. Susan Ridgely

Controlling U.S. health care spending--separating promising from unpromising approaches.

Peter Hussey and colleagues identify several policy options that have the potential to reduce health care spending in the United States.

Contextual Issues Influencing Implementation and Outcomes Associated With an Integrated Approach to Managing Pain, Agitation, and Delirium in Adult ICUs

Objective:This pilot study was designed to identify which contextual factors facilitate/hinder the implementation of the awakening, breathing, coordination, delirium, and early mobility (ABCDE) bundle for guidance in future studies. Design:The sources of data for this study included document review, planned site visits (including interviews and observations), a brief online contextual factors survey, and self-reported process and outcome data. Patients:All patients in the four participating SF Bay Area ICUs were eligible to be included in this pilot study. Setting:This study took place in the four San Francisco Bay Area ICUs participating in the ICU Clinical Impact Interest Group, funded by the Gordon and Betty Moore Foundation from January 2012 through June 2013. Interventions:This was a pilot evaluation study to identify factors that facilitated/hindered the implementation of the ABCDE bundle, interventions designed to decrease the prevalence of ICU-acquired delirium and muscle weakness. The ABCDE bundle consists of spontaneous awakening trials, spontaneous breathing trials, coordination of awakening and breathing trials, choice of sedation, delirium screening and treatment, and early progressive mobility. Measurements:Process data related to bundle element compliance were collected at baseline and monthly during the intervention period. Outcome data (average ICU length of stay and average days on mechanical ventilation) were collected at baseline and quarterly during the intervention period. Hospital-specific results of the online contextual factors survey and information gathered through interviews and observations during site visits also contributed to the analysis. Main Results:Factors related to structural characteristics of the ICU, an organizational-wide patient safety culture, an ICU culture of quality improvement, implementation planning, training/support, and prompts/documentation are believed to have facilitated the rate and success of ABCDE bundle implementation. Excessive turnover (both in project and ICU leadership), staff morale issues, lack of respect among disciplines, knowledge deficits, and excessive use of registry staff are believed to have hindered implementation. Conclusions:Successful implementation of the elements of the ABCDE bundle can result in significant improvements in ICU patient care. The results of this study highlight specific structural and cultural elements of ICUs and hospitals that can positively and negatively influence the implementation of complex care bundles like the ABCDE bundle. Further research is needed to assess the influence of these contextual factors across a broader variety of ICUs and hospitals.

Florida's medicaid mental health carve-out: Lessons from the first years of implementation

Florida, like many other states, has embarked on an experiment with managed mental health care for Medicaid enrollees. Under a 1915(b) waiver, the states Medicaid agency began a mental health carve-out demonstration in March 1996 in the Tampa Bay area. This qualitative case study seeks to ascertain the impact of the carve-out (and, by comparison, HMO arrangements) on the public mental health sector. Findings suggest that the carve-out demonstration has succeeded in creating a fully integrated mental health delivery system with financial and administrative mechanisms that support a shared clinical model. However, other findings raise concerns about the HMO model in terms of stability, access to care, efficiency, and more generally about the shifting of risk and public responsibility “downstream” to private organizations without sufficient governmental oversight. These findings may offer guidance for other states implementing major managed care policy initiatives for disabled Medicaid enrollees.

The Effect of Malpractice Reform on Emergency Department Care

BACKGROUND Many believe that fear of malpractice lawsuits drives physicians to order otherwise unnecessary care and that legal reforms could reduce such wasteful spending. Emergency physicians practice in an information-poor, resource-rich environment that may lend itself to costly defensive practice. Three states, Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005), enacted legislation that changed the malpractice standard for emergency care to gross negligence. We investigated whether these substantial reforms changed practice. METHODS Using a 5% random sample of Medicare fee-for-service beneficiaries, we identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. Using a quasi-experimental design, we compared patient-level outcomes, before and after legislation, in reform states and control states. We controlled for characteristics of the patients, time-invariant hospital characteristics, and temporal trends. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions. RESULTS For eight of the nine state-outcome combinations tested, no policy-attributable reduction in the intensity of care was detected. We found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval, 0.9 to 6.2) in per-visit emergency department charges. CONCLUSIONS Legislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates. (Funded by the Veterans Affairs Office of Academic Affiliations and others.).

Controlling health care spending in Massachusetts: an analysis of options

Massachusetts passed legislation in 2006 ensuring health insurance to most residents, but rising costs and a weak economy threaten the sustainability of the reform. We analyzed 21 options for reducing health care spending in the state and identify those options that might produce savings over the next decade. Long-term solutions will require significant investments in information infrastructure and primary care capacity and fundamental change in health care delivery.

Impact of full mental health and substance abuse parity for children in the Federal Employees Health Benefits Program.

OBJECTIVE. The Federal Employees Health Benefits Program implemented full mental health and substance abuse parity in January 2001. Evaluation of this policy revealed that parity increased adult beneficiaries’ financial protection by lowering mental health and substance abuse out-of-pocket costs for service users in most plans studied but did not increase rates of service use or spending among adult service users. This study examined the effects of full mental health and substance abuse parity for children. METHODS. Employing a quasiexperimental design, we compared children in 7 Federal Employees Health Benefits plans from 1999 to 2002 with children in a matched set of plans that did not have a comparable change in mental health and substance abuse coverage. Using a difference-in-differences analysis, we examined the likelihood of child mental health and substance abuse service use, total spending among child service users, and out-of-pocket spending. RESULTS. The apparent increase in the rate of children’s mental health and substance abuse service use after implementation of parity was almost entirely due to secular trends of increased service utilization. Estimates for children’s mental health and substance abuse spending conditional on this service use showed significant decreases in spending per user attributable to parity for 2 plans; spending estimates for the other plans were not statistically significant. Children using these services in 3 of 7 plans experienced statistically significant reductions in out-of-pocket spending attributable to the parity policy, and the average dollar savings was sizeable for users in those 3 plans. In the remaining 4 plans, out-of-pocket spending also decreased, but these decreases were not statistically significant. CONCLUSIONS. Full mental health and substance abuse parity for children, within the context of managed care, can achieve equivalence of benefits in health insurance coverage and improve financial protection without adversely affecting health care costs but may not expand access for children who need these services.

Bundled Payment Fails To Gain A Foothold In California: The Experience Of The IHA Bundled Payment Demonstration

To determine whether bundled payment could be an effective payment model for California, the Integrated Healthcare Association convened a group of stakeholders (health plans, hospitals, ambulatory surgery centers, physician organizations, and vendors) to develop, through a consensus process, the methods and means of implementing bundled payment. In spite of a high level of enthusiasm and effort, the pilot did not succeed in its goal to implement bundled payment for orthopedic procedures across multiple payers and hospital-physician partners. An evaluation of the pilot documented a number of barriers, such as administrative burden, state regulatory uncertainty, and disagreements about bundle definition and assumption of risk. Ultimately, few contracts were signed, which resulted in insufficient volume to test hypotheses about the impact of bundled payment on quality and costs. Although bundled payment failed to gain a foothold in California, the evaluation provides lessons for future bundled payment initiatives.

Language access services for Latinos with limited English proficiency: lessons learned from Hablamos Juntos.

BACKGROUNDThe Robert Wood Johnson Foundation funded Hablamos Juntos (HJ), a

Clinical Decision Support and Malpractice Risk

10-million multiyear demonstration to improve access to health care for Latinos with limited English proficiency and to explore cost-effective ways for health care organizations to provide language access services.HABLAMOS JUNTOSIn this manuscript, the authors draw on their experiences in evaluating HJ, provide brief descriptions of innovative interventions, estimate operating costs, and synthesize lessons learned about implementation. A number of barriers and facilitators are documented.CONCLUSIONThe experience of HJ grantees provides guidance for organizations contemplating similar efforts. In particular, it highlights the need for health care organizations to involve physicians in the design and adoption of language services.

Crossed Wires: How Yesterday’s Privacy Rules Might Undercut Tomorrow’s Nationwide Health Information Network

CLINICAL DECISION SUPPORT (CDS) REFERS TO electronic technology used to enhance clinical decision making. For example, computerized physician order entry with integrated CDS in principle offers an electronic layer of review for ordering prescriptions. An important feature of CDS is automated warnings issued whenever potential drug interactions or other contraindications arise. In practice, however, CDS systems often have been overinclusive in the warnings they generate, to a point at which physician “alert fatigue” may in large part undermine the utility the systems offer. The current generation of CDS systems includes alert parameters for thousands of drug interaction types. Meanwhile, a recent review of empirical studies on computerized physician order entry with integrated CDS observed that physicians override automated warnings a substantial fraction of the time— according to one study, in as many as 19 out of 20 instances. One paradoxical result of overly abundant warnings may be to exacerbate malpractice risk for physicians who either ignore or turn off CDS alerts, even as CDS systems create an audit trail to show that those physicians have done so. Another paradoxical result may be impeded adoption of CDS technologies because of physician and institutional concerns about malpractice risk. These sorts of results could prevent the technologies from achieving their potential benefits in making patients safer and in reducing the risks of medication error. The Office of the National Coordinator for Health Information Technology (ONC) is addressing this problem through its Advancing Clinical Decision Support project. The ONC effort includes a series of tasks designed to promote CDS development and adoption and to overcome barriers to CDS use. One element of the project involved a review of some liability challenges that have impeded CDS; in particular, the development of an optimized clinically meaningful drug-drug interaction list. The use of this list could potentially ameliorate the problem of overinclusive CDS warnings but may create the risk of another set of liability concerns on the part of vendors. Consequently, policy makers may need to untie a liability knot that threatens to strangle CDS. Better understanding of the liability knot, and of strategies available to loosen it, is important for both the policy and the health care communities.