The potential for health care reform in the near future makes the need for organizational research even more pressing, as reform will likely look not only at current financing structures, but also delivery system changes that will facilitate high quality, efficient, patient-centered care.1 Policymakers will need a wide range of information to resolve a number of complex problems. They will ask who, what, where, when, and how types of questions about the current structure of our health care system and look to organizational research for answers.
Who Delivers Care
While determining the likelihood and magnitude of health care workforce shortages over time is certainly important, perhaps the more critical questions for policy include: why do providers select some practice locations over others; what mechanisms should be used to recruit and retain high quality physicians, nurses and allied professionals; how can health care employers foster workforce diversity; what is the optimal hospital staff mix; how should hospitals use physician extenders; what is the correct balance of specialties; and to what extent will formal and informal caregivers support the aging population. A new survey, for example, finds that only 2 percent of graduating medical students plan to practice in primary care, down from 9 percent in 1990.2 A very real question facing policymakers is whether the current health care labor market will be able support the needs of aging baby boomers,3 the influx of patients that would follow the development of possible insurance mandates,4 or the care of a growing immigrant population. HCFO researcher Richard Johnson, Ph.D., Urban Institute, has concluded that an increase in the older disabled population will likely occur while the availability of family caregivers is decreasing, which will intensify the need for a greater number of paid home care workers.5 More organizational research is needed to examine the multitude of workforce issues in the context of current demographic trends in this country and identify ways to structure the care system to make it easier for health care workers to "do the right thing."
What Kind of Care is Delivered
In 2003, researchers funded in part by the Robert Wood Johnson Foundation reported that "the degree to which health care in the United States is consistent with basic quality standards is largely unknown."6 They then analyzed one dimension of quality and concluded that Americans receive about half of recommended medical care processes.7 While progress has been made in the past five years in terms of collecting and reporting quality data, more organizational research is needed to analyze and diffuse this information to policymakers, providers, and consumers.8 Moreover, research is needed to identify ways to ensure that all providers practice evidence-based medicine, some of which will be identified through comparative effectiveness studies.
Where is Care Delivered
Health care is delivered in a complex and not entirely complementary system of physician offices, hospitals, clinics, imaging centers, and nursing homes, among other settings. As policymakers develop health care reforms, among the questions they are likely to consider are: what organizational structures influence cost and quality; what is the optimal organizational structure to facilitate the management of chronic conditions; how do outcomes differ when care is provided in various settings; and what mix of settings will be needed as the population ages and lives longer.9 HCFO research addresses some of these questions. For example, Yu-Chu Shen, Ph.D., Naval Postgraduate School Graduate School of Business and Public Policy, is examining the emergency room setting and, in a new study, will explore whether decreased emergency department access results in adverse patient outcomes or changes in other health indicators.10 David Grabowski, Ph.D., Harvard Medical School, is examining the impact of assisted living growth on the market for nursing home care.11
When is Care Delivered
Too often, care is delivered when a patient has reached an acute stage of illness. To address this problem, reduce "absenteeism," avoid "presenteeism" and, in theory, save money, a number of employers are developing disease management and wellness programs to promote healthy behavior and provide employees with preventive care.12 But, while few would argue the health benefits of smoking cessation and diabetes management, the evidence on preventive services suggests savings for some services but additional costs for others. For those services that add costs, the level of health benefit may vary substantially.13 Organizational research is needed to examine the continuum from preventive to acute care and determine how best to design and promote the services that are most effective for ensuring the best overall health of an individual, a population, and the country as a whole. Currently, HCFO researcher Deborah Peikes, Ph.D., Mathematica Policy Research, Inc., is testing the ability of disease management (DM) and care coordination (CC) programs to control health care costs, examining which features make certain programs effective for which target populations, and considering how they can be replicated.14
How is Care Delivered
Care is most often delivered in isolation, with little coordination among providers and insufficient attention given to transitions between care settings. Organizational research is needed to explore new models for delivering care that is collaborative and patient-centered, and delivered by providers who are accountable to and interact with both the patient and each other in support of the patient. One model receiving recent attention is the medical home.15
Relevant HCFO research on care delivery includes a study by Amira El-Bastawissi, Ph.D., Washington State Department of Health, who is exploring the impact of the Washington State Diabetes Collaborative on patient health and economic outcomes.16 Researcher Ann O'Malley, M.D., Center for Studying Health System Change, is identifying and documenting "best practices" in physician offices that have developed care coordination processes in order to determine the financial implications of increased coordination.17 James D. Reschovsky, Ph.D., Center for Studying Health System Change, is examining key physician practice and market characteristics that may contribute to high costs and inefficient care in the Medicare program.18 Eric C. Schneider, M.D., Harvard University School of Public Health, is developing new measures of care fragmentation that can be used to assess fragmentation within episodes of care and evaluate the relationship between care fragmentation and the costs of care for Medicare beneficiaries.19
In addition to studies addressing issues of coordination and collaboration, organizational research is needed to examine alignment between internal and external incentives to improve quality and evidence-based care and assess the impact of these efforts on outcomes. In particular, research is needed to examine how different organizations respond to the influence of payment and other incentives on care delivery (e.g. no-pay events, Pay for Performance, technology, etc.). For example, HCFO researcher Douglas Conrad, Ph.D., University of Washington, is evaluating the impact of a quality-based scorecard and financial incentives developed by Premera Blue Cross on physicians' clinical quality, patient satisfaction, and efficiency.20 Information is also needed on the impact of referral networks on diffusion of innovation and quality improvement and the effectiveness of provider communication on processes of care and outcomes.
Conclusion
While the need for information is boundless, resources available to support critically needed studies are limited. The challenge for researchers will be to identify those organizational questions of greatest import for policymakers and develop rigorous studies which will generate timely information.
For related HCFO-sponsored research, see the grants listed below or visit www.hcfo.org.
Title: Effect of Decreased Emergency Department Access on Patient Outcomes
Institution: Naval Postgraduate School Graduate School of Business and Public Policy
Principal Investigator: Yu-Chu Shen, Ph.D.
Grant Period: April 2008 - March 2010
The researchers will examine whether decreased emergency department (ED) access results in adverse patient outcomes or changes in other health indicators. There is a great deal of literature documenting decreased access to EDs. However, there is little empirical evidence linking access to EDs and health outcomes. The researchers will use acute myocardial infarction (AMI) patients to examine health outcomes, since AMI patients are relatively homogeneous and the time sensitivity of treatment should be reflected in differences in outcomes. They will examine two types of ED access between 1995 and 2005: permanent ED closure and temporary ED closure as measured by ambulance diversion time. Specifically, the researchers will focus on how changes in distance to the closed ED affect health outcomes of two types of AMI patients: (1) those who survived the ambulance ride and have an outpatient claim from the ED; and 2) those who survived the ED admission to have an inpatient claim. The objective of this project is to provide improved understanding of the impact of ambulance diversion in the health care system.
Title: Can Disease Management Control Costs?
Institution: Mathematica Policy Research, Inc.
Principal Investigator: Deborah N. Peikes, Ph.D.
Grant Period: March 2008 - August 2009
The researchers will test the ability of disease management (DM) and care coordination (CC) programs to control health care costs, examine which features make certain programs effective, for which target populations, and how they can be replicated. They will build on prior work for CMS' Medicare Coordinated Care Demonstration that estimated program impacts over the first four years of program operations, described the basic features of the 15 programs' interventions, and linked program features to overall program effectiveness. Five interrelated studies would determine: 1) the effects of DM/CC on costs over a longer follow-up period and the types of beneficiaries for whom DM/CC is most effective; 2) the operational features of DM/CC programs that were able to reduce costs and how they can be replicated; 3) what features of the DM/CC programs did not work and why; 4) whether intensifying contacts at the time of hospital discharge contributes to reducing costs; and 5) whether DM/CC interventions are more effective at reducing costs if the doctor has a greater number of patients receiving the intervention. The objective of this study is to help decision makers determine whether to offer disease management and care coordination to Medicare beneficiaries, as well as chronically ill patients with commercial insurance and Medicaid, and will provide information about how best to implement this intervention.
Title: Cost and Efficiency in Treating High-Cost Medicare Beneficiaries: The Role of Physician Practice and Health System Factors
Institution: Center for Studying Health System Change
Principal Investigator: James D. Reschovsky, Ph.D.
Grant Period: March 2008 - August 2009
The researchers will examine key physician practice and market characteristics that may contribute to high costs and inefficient care in the Medicare program. The study is composed of three phases. In phase one, they will analyze the treatment of high-cost Medicare beneficiaries in order to identify key physician, practice, and market characteristics associated with differences between actual and predicted Medicare payments and medical care use. In phase two, they will examine whether the factors associated with greater than predicted resource use affect high-cost beneficiaries' health outcomes. Finally, the researchers will examine possible sources of geographic cost variations for high-cost beneficiaries and the extent to which these variations reflect differences in patient characteristics or supply-related factors and practice patterns of providers in a particular region. The objective of this project is to identify potential policy levers that can influence cost effectiveness in the delivery of medical care to high-cost Medicare patients.
Title: How Does Fragmentation of Care Contribute to the Costs of Care?
Institution: Harvard University School of Public Health
Principal Investigator: Eric C. Schneider, M.D.
Grant Period: March 2008 - August 2009
The researchers will develop new measures of care fragmentation that can be used to assess fragmentation within episodes of care and evaluate the relationship between care fragmentation and the costs of care for Medicare beneficiaries. They hypothesize that a higher degree of fragmentation of care will be associated with higher episode-specific costs of care after controlling for type of clinical episode, severity of clinical episode, clinical comorbidities, and the sociodemographic characteristics of patients. To test this hypothesis, the researchers will modify existing measures of fragmentation and develop new measures based on their relevance for episodes of care, select an approach to measuring costs, and select the clinical episodes for which they will test for the association between fragmentation and costs. The objective of this study is to improve quality and reduce the growth of health care costs in the U.S. by assisting the Medicare program and other insurers to measure and monitor fragmentation and target improvements to episodes with higher fragmentation.
Title: The Impact of Pay for Performance on Hospitals that Care for Minorities and the Poor
Institution: Harvard University School of Public Health
Principal Investigator: Ashish Jha, M.D., M.P.H.
Grant Period: February 2008 - January 2009
The researchers will examine the impact of financial incentives to improve quality on hospitals that care for minority or other underserved populations. The Centers for Medicare and Medicaid Services have implemented pay for performance (P4P) demonstrations, and are considering implementing P4P nationally. However, the impact of P4P has not been widely evaluated. Hospitals that care for underserved populations may have greater potential for quality improvement; conversely these facilities lack the tools and resources to improve quality and compete for the additional resources. The researchers will examine changes in quality for hospitals in the Medicare Premier P4P Demonstration that serve disadvantaged populations (minority and poor); these changes will be compared with changes in hospitals in the demonstration that do not serve disadvantaged populations and with hospitals not in the demonstration (and not subject to P4P) that serve disadvantaged populations. The objective of the project is to provide more information about the impact of P4P on hospitals that serve disadvantaged populations, and help policymakers to design incentive systems that encourage higher quality care without disproportionately harming hospitals that care for these populations.
Title: Identifying Best Practices in the Coordination of Care
Institution: Center for Studying Health System Change
Principal Investigator: Ann S. O'Malley, M.D., M.P.H.
Grant Period: October 2007 - September 2008
The researchers will examine how care is coordinated in ambulatory care settings. Specifically, they will identify and document "best practices" in physician offices that have developed care coordination processes and determine the financial implications of increased coordination. For example, the researchers will assess whether a periodic care coordination fee or itemized billing for coordination activities is more efficient. They will also examine a group of "average practices" to assess how they set priorities for coordination activities and what barriers they encounter. The objective of the proposed project is to better inform the replication of organized care coordination processes in medical practices.
Title: Paying Physician Group Practices for Quality: A Regional Natural Experiment
Institution: University of Washington School of Public Health and Community Medicine
Principal Investigator: Douglas A. Conrad, Ph.D.
Grant Period: October 2007 - March 2009
The researchers will evaluate the impact of a quality-based scorecard and financial incentives developed by Premera Blue Cross in Washington State. They will compare clinics exposed to two waves of a progressive "paying for quality" intervention with a control group of clinics not subject to the intervention. Specifically, the researchers will assess the joint effects of quality-based financial incentives and the quality scorecard on physicians' clinical quality, patient satisfaction, and efficiency in caring for patients. They will distinguish the effects on quality, patient satisfaction, and efficiency of providing information to medical groups relative to their performance on an array of clinical quality measures from the incremental effect on quality and efficiency of clinical quality-based financial incentives. The objective of the project is to assist organizational leaders and public policymakers to craft more cost-effective quality incentives.
Title: The Impact of Assisted Living Growth on the Market for Nursing Home Care
Institution: Harvard Medical School
Principal Investigator: David Grabowski, Ph.D.
Grant Period: June 2007 - May 2009
How is the growth in assisted living linked with decreased occupancy rates, increased resident acuity, and increased resident reliance on Medicaid in nursing homes? In particular, they will: 1) document the growth of the assisted living sector over time; 2) isolate the effect of assisted living growth on nursing home utilization; 3) examine the relationship between assisted living growth and nursing home payer mix; 4) estimate the effect of assisted living growth on nursing home resident acuity; and 5) assess whether the growth in assisted living has implications for nursing home quality. They will also establish a national assisted living database to facilitate empirical work to isolate the effect of assisted living growth on the nursing home market. The objective of the project is to better inform policymakers as they address the best incentives for meeting the nation's growing long term care needs, at reasonable cost, in a dynamic market.
Title: Examining the Quality of Hospital Care and Simulating the Impact of Several Pay-for-Performance Scoring Methods on Hospital Rankings
Institution: Massachusetts General Hospital Institute for Health Policy
Principal Investigator: Joel S. Weissman, Ph.D./Lisa I. Iezzoni, M.D.
Grant Period: March 2007 - August 2008
The researchers will examine the quality of hospital care. Using patient-level data from a large sample of hospitals collected by the Hospital Quality Alliance (HQA), they will estimate the proportion of patients receiving recommended care, create new measures of patient care quality, and simulate the impact of several pay-for-performance (P4P) scoring methods on hospital rankings. They will also examine the extent to which care varies by race, ethnicity, or insurance status within and across hospitals. The objective of the study is to assist CMS, other public and private payers, and accrediting organizations in developing strategies to improve hospital performance measurement and payment methods, and, ultimately, the quality of patient care.
Title: Impact of the Washington State Diabetes Collaborative on Patient Health and Economic Outcomes
Institution: Washington State Department of Health
Principal Investigator: Amira El-Bastawissi, Ph.D.
Grant Period: July 2006 - February 2009
How do the clinics and primary care physicians participating in Collaborative III of the Washington State Diabetes Collaborative affect the health and economic outcomes of diabetic patients? The collaborative combines elements from Collaboratives of the Institute for Healthcare Improvement and the Chronic Care Model developed by Edward Wagner and colleagues. The researchers would capture the later-stage results of the collaborative, "thus offering an impact evaluation of a mature system-change model." In particular, the researchers would explain how different components of the collaborative approach to diabetes care management directly affect health and economic outcomes (utilization and costs). The objective of the study is to better inform health plans, public payers, health care providers, and employers about the economic impact of the collaborative, to inform their quality improvement, benefit design, and payment decisions for diabetic patients.
Title: Single Specialty Hospitals and Competition in the Hospital Industry
Institution: Boston University
Principal Investigator: Kathleen Carey, Ph.D.
Grant Period: February 2006 - July 2007
Do specialty hospitals enhance the competitive process in the U.S. hospital industry? The researchers addressed the economic foundations underlying the growing specialty hospital phenomenon. In particular, they addressed the following research questions: 1) How do specialty hospitals compare with community hospital competitors on efficiency? 2) Do specialty hospitals capture economies of scale compared with community hospitals (for some services)? Between inpatient and outpatient services? 3) Do specialty hospitals charge higher prices than community hospitals to non-Medicare patients for the same services? and 4) Does the performance and behavior of multi-hospital systems differ from freestanding specialty hospitals? How do specialty hospitals compare with for-profit community hospital competitors? The objective of this study was to provide evidence on the economic logic of organization of hospital services and specialty hospitals to inform the current Congressional debate.
Title: Improving Access to Improve Quality: Evaluation of an Organizational Innovation
Institution: University of Washington
Principal Investigator: David Grembowski, Ph.D.
Grant Period: November 2004 - November 2006
Can quality be improved by creating patient-centered delivery systems? The researchers evaluated an initiative comprising six patient-centered changes in Group Health Cooperative's (GHC's) delivery system. The six changes, designed to improve quality by increasing enrollee access to physicians and information, were: 1) same-day appointments with primary and specialist physicians; 2) direct patient access to specialist physicians (removal of gatekeeping); 3) patient-physician email messaging (with physician compensation for responding to patient emails); 4) physician compensation with productivity and quality incentives; 5) patient internet access to GHC electronic medical record; and 6) health promotion information on the GHC Web site. The researchers estimated enrollee utilization of same-day appointments, direct access to specialists, email with physicians and nurse practitioners, and electronic medical records. They also examined the percentage of physicians' salaries from incentives. Physician awareness of changes, as well as physician and enrollee satisfaction, was assessed and utilization statistics and continuity of care, before and after the changes, were compared. The objective of the project was to better understand the impact of new IT and payment incentives on patient and provider health care decisions and utilization.
Title: Meeting the Future Long-Term Care Needs of the Baby Boomers: How the Changing Structure of Families Will Affect Paid Helpers and Institutions
Institution: The Urban Institute
Principal Investigator: Richard W. Johnson, Ph.D.
Grant Period: December 2003 - February 2007
How do families choose among types of long-term care services for older adults and what will be the demand for these services over the next 40 years? The researchers estimated a model of informal family care, nursing home care, paid home care, and residence in assisted living settings. The model showed the impact of health status, financial resources, family networks, and relative prices, determined in part by family characteristics and in part by public policy. They also used the model to simulate the effects of potential changes in public policy on long-term care decisions, including the impact of an expansion of Medicaid eligibility or of expansions in Medicare coverage of long-term care services. The objective of the project was to better understand how competing social, demographic, and economic trends combine to determine future demand for long-term care services.
1 The September/October 2008 issue of Health Affairs, sponsored by the California HealthCare Foundation, includes a series of articles addressing facets of the health care delivery system, including new models like the medical home and retail health clinics.
2 Hauer, KE, et al. "Factors Associated With Medical Students' Career Choices Regarding Internal Medicine," Journal of the American Medical Association, Vol. 200, No. 10, September 8, 2008, Also see http://jama.ama-assn.org/cgi/content/short/300/10/1154
3 Colwill, JM, et al. "Will Generalist Physician Supply Meet Demands of an Increasing and Aging Population?" Health Affairs, Web Exclusive, Vol. 27, Nos. 3-4, April 29, 2008.
4 Walsh, T. "Physicians and Patients Grappling with Access Challenges as Newly Insured Enter the System," Vital Signs, Massachusetts Medical Society, September 2008 (reporting that the growth in the state's newly insured has resulted in difficulties in finding a physician). Also see www.massmed.org/AM/Template.cfm?Section=vs_current_top&TEMPLATE=/CM/
ContentDisplay.cfm&CONTENTID=22588
5 grants/meeting-future-long-term-care-needs-baby-boomers-how-changing-structure-families-will-affect-6 McGlynn, EA, et al. "The Quality of Health Care Delivered to Adults in the United States," New England Journal of Medicine, Vol. 348, No. 26, pp. 2635-45, June 26, 2003.
7 Ibid.
8 HCFO researcher David Grembowski, Ph.D., University of Washington, has examined whether quality can be improved by creating patient-centered delivery systems. He and colleagues evaluated an initiative comprising six changes in Group Health Cooperative's delivery system, which were designed to improve quality by increasing enrollee access to physicians and information. For grant findings see http://www.hcfo.org/files/hcfo/HCFOfindings0808.pdf
9 Joynt, J. "Snapshot: Beds for Boomers: Will Hospitals Have Enough?" Report, California HealthCare Foundation, September 2008, Also see www.chcf.org/topics/hospitals/index.cfm?itemID=133749
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12 Mendelsohn, A. "Give 'Em Well!" New York Post, June 16, 2008, www.nypost.com/seven/06162008/jobs/give_em_well__115771.htm ; Dollarhide, M. "Can Your Company Force You to be Healthy?" CNN, July 1, 2008, www.cnn.com/2008/LIVING/worklife/07/01/force.u.2b.healthy/index.html
13 Cohen, JT, et al. "Does Preventive Care Save Money? Health Economics and the Presidential Candidates," New England Journal of Medicine, Vol. 358, No. 7, pp. 661-3, February 14, 2008.
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15 Mathematica Policy Research Inc. will assist the Centers for Medicare and Medicaid Services (CMS) in designing a Medicare Medical Home Demonstration, scheduled for launch in up to eight states in January 2010. Also see www.cms.hhs.gov/demoprojectsevalrpts/md/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=3&sortOrder=descending&itemID=CMS1199247&intNumPerPage=10 The Roger C. Lipitz Center at Johns Hopkins will support this work through a grant from the John A. Hartford Foundation. Also see www.jhsph.edu/publichealthnews/press_releases/2008/boult_medical_home_demo.html ; also see, Health Affairs, Vol. 27, No. 5, Sept/Oct 2008 (articles on the medical home).
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