Peter S. Hussey

Continuity and the Costs of Care for Chronic Disease

IMPORTANCE Better continuity of care is expected to improve patient outcomes and reduce health care costs, but patterns of use, costs, and clinical complications associated with the current patterns of care continuity have not been quantified. OBJECTIVE To measure the association between care continuity, costs, and rates of hospitalizations, emergency department visits, and complications for Medicare beneficiaries with chronic disease. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of insurance claims data for a 5% sample of Medicare beneficiaries experiencing a 12-month episode of care for congestive heart failure (CHF, n = 53,488), chronic obstructive pulmonary disease (COPD, n = 76,520), or type 2 diabetes mellitus (DM, n = 166,654) in 2008 and 2009. MAIN OUTCOMES AND MEASURES Hospitalizations, emergency department visits, complications, and costs of care associated with the Bice-Boxerman continuity of care (COC) index, a measure of the outpatient COC related to conditions of interest. RESULTS The mean (SD) COC index was 0.55 (0.31) for CHF, 0.60 (0.34) for COPD, and 0.50 (0.32) for DM. After multivariable adjustment, higher levels of continuity were associated with lower odds of inpatient hospitalization (odds ratios for a 0.1-unit increase in COC were 0.94 [95% CI, 0.93-0.95] for CHF, 0.95 [0.94-0.96] for COPD, and 0.95 [0.95-0.96] for DM), lower odds of emergency department visits (0.92 [0.91-0.92] for CHF, 0.93 [0.92-0.93] for COPD, and 0.94 [0.93-0.94] for DM), and lower odds of complications (odds ratio range, 0.92-0.96 across the 3 complication types and 3 conditions; all P < .001). For every 0.1-unit increase in the COC index, episode costs of care were 4.7% lower for CHF (95% CI, 4.4%-5.0%), 6.3% lower for COPD (6.0%-6.5%), and 5.1% lower for DM (5.0%-5.2%) in adjusted analyses. CONCLUSIONS AND RELEVANCE Modest differences in care continuity for Medicare beneficiaries are associated with sizable differences in costs, use, and complications.

The Association Between Health Care Quality and Cost: A Systematic Review

BACKGROUND Although there is broad policy consensus that both cost containment and quality improvement are critical, the association between costs and quality is poorly understood. PURPOSE To systematically review evidence of the association between health care quality and cost. DATA SOURCES Electronic literature search of PubMed, EconLit, and EMBASE databases for U.S.-based studies published between 1990 and 2012. STUDY SELECTION Title, abstract, and full-text review to identify relevant studies. DATA EXTRACTION Two reviewers independently abstracted data with differences reconciled by consensus. Studies were categorized by level of analysis, type of quality measure, type of cost measure, and method of addressing confounders. DATA SYNTHESIS Of 61 included studies, 21 (34%) reported a positive or mixed-positive association (higher cost associated with higher quality); 18 (30%) reported a negative or mixed-negative association; and 22 (36%) reported no difference, an imprecise or indeterminate association, or a mixed association. The associations were of low to moderate clinical significance in many studies. Of 9 studies using instrumental variables analysis to address confounding by unobserved patient health status, 7 (78%) reported a positive association, but other characteristics of these studies may have affected their findings. LIMITATIONS Studies used widely heterogeneous methods and measures. The review is limited by the quality of underlying studies. CONCLUSION Evidence of the direction of association between health care cost and quality is inconsistent. Most studies have found that the association between cost and quality is small to moderate, regardless of whether the direction is positive or negative. Future studies should focus on what types of spending are most effective in improving quality and what types of spending represent waste. PRIMARY FUNDING SOURCE Robert Wood Johnson Foundation.

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.

Episode-Based Performance Measurement And Payment: Making It A Reality

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.

Patient Sharing Among Physicians and Costs of Care: A Network Analytic Approach to Care Coordination Using Claims Data

BACKGROUNDImproving care coordination is a national priority and a key focus of health care reforms. However, its measurement and ultimate achievement is challenging.OBJECTIVETo test whether patients whose providers frequently share patients with one another—what we term ‘care density’—tend to have lower costs of care and likelihood of hospitalization.DESIGNCohort studyPARTICIPANTS9,596 patients with congestive heart failure (CHF) and 52,688 with diabetes who received care during 2009. Patients were enrolled in five large, private insurance plans across the US covering employer-sponsored and Medicare Advantage enrolleesMAIN MEASURESCosts of care, rates of hospitalizationsKEY RESULTSThe average total annual health care cost for patients with CHF was

Physicians With The Least Experience Have Higher Cost Profiles Than Do Physicians With The Most Experience

29,456, and

Controlling health care spending in Massachusetts: an analysis of options

14,921 for those with diabetes. In risk adjusted analyses, patients with the highest tertile of care density, indicating the highest level of overlap among a patient’s providers, had lower total costs compared to patients in the lowest tertile (

Comparing VA and Non-VA Quality of Care: A Systematic Review

3,310 lower for CHF and

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

1,502 lower for diabetes, p < 0.001). Lower inpatient costs and rates of hospitalization were found for patients with CHF and diabetes with the highest care density. Additionally, lower outpatient costs and higher pharmacy costs were found for patients with diabetes with the highest care density.CONCLUSIONPatients treated by sets of physicians who share high numbers of patients tend to have lower costs. Future work is necessary to validate care density as a tool to evaluate care coordination and track the performance of health care systems.

Consumers’ And Providers’ Responses To Public Cost Reports, And How To Raise The Likelihood Of Achieving Desired Results

Health plans and Medicare are using cost profiles to identify which physicians account for more health care spending than others. By identifying the costliest physicians, health plans and Medicare hope to craft policy interventions to reduce total health care spending. To identify which physician types, if any, might be costlier than others, we analyzed cost profiles created from health plan claims for physicians in Massachusetts. We found that physicians with fewer than ten years of experience had 13.2 percent higher overall costs than physicians with forty or more years of experience. We found no association between costs and other physician characteristics, such as having had malpractice claims or disciplinary actions, board certification status, and the size of the group in which the physician practices. Although winners and losers are inevitable in any cost-profiling effort, physicians with less experience are more likely to be negatively affected by policies that use cost profiles, unless they change their practice patterns. For example, these physicians could be excluded from high-value networks or receive lower payments under Medicares planned value-based payment program. We cannot fully explain the mechanism by which more-experienced physicians have lower costs, but our results suggest that the more costly practice style of newly trained physicians may be a driver of rising health care costs overall.