Timothy K. Lake

Racial disparities in hospitalizations for ambulatory care-sensitive conditions.

BACKGROUND Variation in the quality of ambulatory care may be a key factor in explaining disparities in health, and these disparities have large cost implications. PURPOSE This study identified differences in hospitalization rates for elderly African-American and white Marylanders for eight ambulatory care-sensitive conditions (ACSCs). It assessed the relative contribution of race to disparities in preventable hospitalizations after controlling for demographic and socioeconomic factors as well as underlying prevalence. It also estimated the excess cost associated with these disparities. METHODS Using prevention quality indicator specifications from the Agency for Healthcare and Research Quality applied to 2006 Medicare claims data, eight ACSC hospitalization measures were developed for 569,896 Maryland Medicare beneficiaries. The analysis was conducted in 2008. A Poisson regression model identified race, age, gender, and income as factors associated with differences in ACSC hospitalization rates. Excess costs were estimated from excess hospitalizations of African Americans and the median cost per admission. RESULTS African Americans had significantly higher rates of ACSC hospitalizations than whites for five of eight conditions after controlling for demographic, socioeconomic, and geographic factors. Excess costs from disparities in quality ranged from

Factors Contributing to Variations in Physicians’ Use of Evidence at The Point of Care: A Conceptual Model

8 million (heart failure) to

Implementation of Mental Health Parity: Lessons From California

38,000 (urinary tract infection). CONCLUSIONS Race may be a key predictor of preventable hospitalizations for some ACSCs. Racial disparities in these hospitalizations represent excess costs to Medicare. Because ACSC admissions are potentially preventable with optimal ambulatory care, improving care for minority populations may reduce disparities and lower hospital costs.

Paying more wisely: effects of payment reforms on evidence-based clinical decision-making

ABSTRACTThere is ample evidence that many clinical decisions made by physicians are inconsistent with current and generally accepted evidence. This leads to the underuse of some efficacious diagnostic, preventive or therapeutic services, and the overuse of others of marginal or no value to the patient. Evolving new payment and delivery models place greater emphasis on the provision of evidence-based services at the point of care. However, changing physician clinical behaviors is likely to be difficult and slow. Policy makers therefore need to design interventions that are most effective in promoting greater evidence-based care. To help identify modifiable factors that can influence clinical decisions at the point of care, we present a conceptual model and literature review of physician decision making. We describe the multitude of factors—drawn from different disciplines—that have been shown to influence physician point-of-care decisions. We present a conceptual framework for organizing these factors, dividing them into patient, physician, practice site, physician organization, network, market, and public policy influences. In doing so, we review some of the literature that speak to these factors. We then identify areas where additional research is especially needed, and discuss the challenges and opportunities for health services and policy researchers to gain a better understanding of these factors, particularly those that are potentially modifiable by policymakers and organizational leaders.

Coordinating Care in the Medical Neighborhood Critical Components and Available Mechanisms

OBJECTIVE This article reports the experiences of health plans, providers, and consumers with Californias mental health parity law and discusses implications for implementation of the 2008 federal parity law. METHODS This study used a multimodal data collection approach to assess the first five years of Californias parity implementation (from 2000 to 2005). Telephone interviews were conducted with 68 state-level stakeholders, and in-person interviews were conducted with 77 community-based stakeholders. Six focus groups included 52 providers, and six included 32 consumers. A semistructured interview protocol was used. Interview notes and transcripts were coded to facilitate analysis. RESULTS Health plans eliminated differential benefit limits and cost-sharing requirements for certain mental disorders to comply with the law, and they used managed care to control costs. In response to concerns about access to and quality of care, the state expanded oversight of health plans, issuing access-to-care regulations and conducting focused studies. Californias parity law applied to a limited list of psychiatric diagnoses. Health plan executives said they spent considerable resources clarifying which diagnoses were covered at parity levels and concluded that the limited diagnosis list was unnecessary with managed care. Providers indicated that the diagnosis list had unintended consequences, including incentives to assign a more severe diagnosis that would be covered at parity levels, rather than a less severe diagnosis that would not be covered at such levels. The lack of consumer knowledge about parity was widely acknowledged, and consumers in the focus groups requested additional information about parity. CONCLUSIONS Experiences in California suggest that implementation of the 2008 federal parity law should include monitoring health plan performance related to access and quality, in addition to monitoring coverage and costs; examining the breadth of diagnoses covered by health plans; and mounting a campaign to educate consumers about their insurance benefits.

Episode-Based Payments: Charting a Course for Health Care Payment Reform

This article reviews the recent research, policy and conceptual literature on the effects of payment policy reforms on evidence-based clinical decision-making by physicians at the point-of-care. Payment reforms include recalibration of existing fee structures in fee-for-service, pay-for-quality, episode-based bundled payment and global payments. The advantages and disadvantages of these reforms are considered in terms of their effects on the use of evidence in clinical decisions made by physicians and their patients related to the diagnosis, testing, treatment and management of disease. The article concludes with a recommended pathway forward for improving current payment incentives to better support evidence-based decision-making.