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Purchasing

Authors: Brach C, and Fraser I.
Title: Reducing Disparities through Cultural Competent Health Care: An Analysis of the Business Case.
Publication: Quality Management in Health Care 10(4):15-28.
Date: 2002
Abstract: The persistence of racial and ethnic disparities in health care access, quality, and outcomes has prompted considerable interest in increasing the cultural competence of health care, both as an end in its own right and as a potential means to reduce disparities. Health care organizations have financial incentives to become culturally competent, but limitations inherent in these incentives must be overcome if cultural competence is to become widespread.
Availability: AHRQ Publication No. 02-R081 is available from the AHRQ Publications Clearinghouse.

Authors: Fraser I, McNamara P.
Title: Employers: Quality takers or quality makers?"
Publication: Med Care Res Rev 57(Suppl 2):33-52.
Date: 2000
Abstract: Available on PubMed®
Availability: AHRQ Publication No. 01-R012 is available from the AHRQ Publications Clearinghouse.

Authors: Carman K, Short P, Farley D, et al.
Title: Early lessons from CAHPS®: Demonstrations and evaluations.
Publication: Med Care 37(3 Suppl):MS97-MS105.
Date: 1999
Abstract: The main goal of the Consumer Assessments of Health Plans (CAHPS®) survey is to develop an integrated set of tested, standardized surveys to obtain meaningful information from health plan enrollees about their experiences. The CAHPS® project benefits from the complementary strengths of psychometric and cognitive testing. The CAHPS® team conducted 150 cognitive interviews across 3 organizations, in different geographic locations, using multiple interview methods with different consumer populations. This article explains how cognitive testing was used in the CAHPS® survey development process and shares the main findings across the cognitive interviews.

Author: Fraser I, McNamara P, Lehman G, et al.
Title: The pursuit of quality by business coalitions: A national survey
Publication: Health Aff 18(6):158-65.
Date: 1999
Abstract: Available on PubMed®
Availability: AHRQ Publication No. 00-R003 is available from the AHRQ Publications Clearinghouse.

Authors: Harris-Kojetin L, Fowler F, Schnaier J, et al.
Title: The use of cognitive testing for developing and evaluating CAHPS® survey items.
Publication: Med Care 37(3 Suppl):MS10-MS21.
Date: 1999
Abstract: The main goal of the Consumer Assessments of Health Plans (CAHPS®) survey is to develop an integrated set of tested, standardized surveys to obtain meaningful information from health plan enrollees about their experiences. The CAHPS® project benefits from the complementary strengths of psychometric and cognitive testing. The authors found that cognitive testing was integral in developing and refining the CAHPS® instrument. The cognitive testing findings contributed to an improved instrument that should capture consumers' health care and plan experiences with less response error than one not subjected to such testing.

Authors: Schnaier J, Sweeny S, Williams W, et al.
Title: Special issues addressed in the CAHPS® survey of Medicare managed care beneficiaries.
Publication: Med Care 37(3 Suppl):MS69-MS78.
Date: 1999
Abstract: This article describes the process through which the Medicare Managed Care plan (MMC) survey was developed and examines issues in using this survey with Medicare beneficiaries that have implications for all CAHPS® surveys. These implications include the ability of Medicare beneficiaries to use MMC navigational features, whether access measures are meaningful for this population, and whether beneficiaries' familiarity with managed care influences their health plan assessments.

Authors: Brach C, Scallet L.
Title: Managed care challenges for children and family services.
Publication: In Humane Managed Care?, edited by Schamess G, and Lightburn A. Washington (DC): National Association of Social Workers Press.
Date: 1998
Abstract: This chapter highlights five challenges facing those dedicated to the welfare of children and their families who also want to make the most of the opportunity managed care presents: (1) The speed with which managed care is moving through the various systems that serve children and families. (2) The emphasis that has been placed on outcomes. (3) The participation of clients in the design and implementation of managed care policies and programs and the importance of ensuring client protection. (4) The need for the development of culturally competent systems of care. (5) The potpourri of legal considerations that accompany managed care initiatives.

Authors: Brooks J, Dor A, Wong H.
Title: Hospital-insurer bargaining: An empirical investigation of appendectomy pricing.
Publication: Journal of Health Economics 16:417-34.
Date: 1997
Abstract: Employers' increased sensitivity to health care costs has forced insurers to seek ways to lower costs through effective bargaining with providers. What factors determine the prices negotiated between hospitals and insurers? The hospital-insurer interaction is captured in the context of a bargaining model, in which the gains from bargaining are explicitly defined. Appendectomy was chosen because it is a well defined procedure with little clinical variation. The authors' results show that certain hospitals' institutional arrangements (e.g., hospital affiliations), HMO penetration, and greater hospital concentration improve hospitals' bargaining position. Furthermore, hospitals' bargaining effectiveness has diminished over time and varies across States.
Availability: AHCPR Publication No. 97-R089 is available from the AHRQ Publications Clearinghouse.

Author: Brach C, ed.
Title: AHCPR research about managed care.
Publication: Rockville (MD): AHCPR.
Date: 1997
Abstract: This Program Note describes recent research projects supported by AHCPR, some with other agencies in the Department of Health and Human Services, or conducted by AHCPR researchers on managed care. Most research on managed care has been conducted in HMOs, the prototypic managed care organization. These studies are designed to produce information that, ultimately, will improve consumer choice, improve the quality and value of health care services, and support and improve the marketplace. The Program Note organizes the studies into these categories: Changes in Health Care Markets; Organization and Delivery of Services; Impact on Clinical Decisionmaking, Access, and Quality; Interventions that Improve Outcomes; Informing Consumers; Impact on Cost; Rural Studies; Tools; and Fostering Research.
Availability: AHCPR Publication No. 97-0023 is available from the AHRQ Publications Clearinghouse. Online version.

Authors: Brach C, Robinson G.
Title: Mental health.
Publication: In Health Care Choices for Today's Consumer: Families USA Guide to Quality and Cost, edited by M. Miller. New York, NY: Springer Publications.
Date: 1997
Abstract: This chapter in a popularly-sold consumer's guide provides advice on how to choose a provider and how to find appropriate care, and reviews the types of mental health services that are available and how to pay for them. The rights of mental patients are also delineated.

Author: Fraser I.
Title: Access to health care.
Publication: In Health Politics and Policy, edited by L. R. T. Littman. Albany, (NY): Delmar Publishers.
Date: 1997
Abstract: This article examines threats to health care access, dynamics of coverage, and three important trends affecting access to health care in America—the downsizing and decentralization of public programs and restructuring of the private health care market, increased enrollment in managed care organizations, and the greater power of purchasers.
Availability: AHCPR Publication No. 98-R003 is available from the AHRQ Publications Clearinghouse.

Authors: Meyer J, Rybowski L, Eichler R.
Title: Theory and reality of value-based purchasing: Lessons from the pioneers, edited by Fraser I.
Publication: Rockville (MD): AHCPR.
Date: 1997
Abstract: This article describes some of the most promising examples of private business initiatives that build quality considerations into health care purchasing decisions. The article profiles nine companies and coalitions, and summarizes their activities.
Availability: AHCPR Publication No. 98-0004 is available from the AHRQ Publications Clearinghouse.

Author: Brach C.
Title: Privatizing local mental health authorities and mental health services: Raising questions and considering options.
Publication: Boston (MA): Technical Assistance Collaborative, Inc.
Date: 1996
Abstract: This monograph, distributed to state and county mental health agencies, weighs the advantages and disadvantages of privatizing local mental health authorities and the relative merits to different organizational forms (quasi-public v. private non-profit corporation). The monograph also reviews considerations for privatizing the delivery of mental health services, and gives guidance on implementing either type of privatization strategy.
Availability: Select to access information on how to order this monograph on the Web site of the Technical Assistance Collaborative.

Authors: Brach C, Mauch D.
Title: Public sector responsibilities in managed care.
Publication: In Managed care: Challenges for children and family services, edited by L. Scallet, C. Brach and E. Steel. Baltimore, (MD): Annie E. Casey Foundation.
Date: 1996
Abstract: This report poses the question: "What responsibilities must remain with the public sector?" The response comes in three parts. First, the public sector's objectives in caring for vulnerable children and families are defined. Second, core functions of government that cannot be delegated are articulated. Third, strategies are offered for executing core functions and securing the public sector's objectives. Public sector officials who think through these issues and plan accordingly can remain in control while using the private sector effectively to accomplish public objectives.

Authors: Brach C, Scallet L.
Title: Trends.
Publication: In Managed care: Challenges for children and family services, edited by Scallet L, Brach C, Steel E. Baltimore (MD): Annie E. Casey Foundation.
Date: 1996
Abstract: This report was designed to educate the systems that serve children and families (e.g., child welfare, special education, juvenile justice) about managed care. Drawing upon knowledge from the sectors where managed care is relatively more advanced, such as the health and mental health sectors, the authors discuss the implications of the advancement of managed care techniques into child- and family-serving systems.

Author: Drissel A.
Title: Managed care and children and family services: A guide for State and local officials.
Publication: Baltimore (MD): Annie E. Casey Foundation. Edited by Brach C.
Date: 1996
Abstract: This guide is the final product of a project for the Annie E. Casey Foundation, Managed care: Implications for children and family services. A major goal of the project was to provide a bridge from the sectors where managed care is relatively more advanced, such as the health and mental health care systems, to those where managed care is beginning to make inroads.

Authors: McCormack L, Garfinkel S, Schnaier J, et al.
Title: Consumer information development and use.
Publication: Health Care Financing Review 1996;18(1):15-30.
Date: 1996
Abstract: The availability of informational materials to aid consumer health care purchasing decisions is increasing. Organizations developing and disseminating materials include public and private sector employers, agencies, counseling programs, and accreditation bodies. Based on case study interviews with 24 organizations, the authors learned that 10 organizations included consumer satisfaction ratings and performance measures based on medical developed materials with consumer satisfaction ratings exclusively. Printed materials were the most common medium used to convey information to consumers. However, other mechanisms for conveying the information were also employed. On the whole, the materials have not been rigorously evaluated. Evaluations are needed to determine if consumers find the information useful and how different individuals prefer to receive the information.

Authors: McCormack L, Schnaier J, Lee A, et al.
Title: Medicare beneficiary counseling programs: What are they and do they work?
Publication: Health Care Financing Review 18(1):127-40.
Date: 1996
Abstract: Medicare beneficiaries face myriad rules, conditions, and exceptions under the Medicare program. As a result, State Information, Counseling, and Assistance (ICA) programs were established or enhanced with Federal funding as part of the Omnibus Budget Reconciliation Act (OBRA) of 1990. ICA programs use a volunteer-based and locally-sponsored support system to deliver free and unbiased counseling on the Medicare program and related health insurance issues. This article discusses the effectiveness of the ICA model. Because the ICA programs serve as a vital link between the Health Care Financing Administration (HCFA) and its beneficiaries, information about the programs' success may be useful to HCFA and other policymakers during this era of consumer information.

Quality

Authors: Romano P, Elixhauser A, McDonald K, Miller M.
Title: HIM's Role in Monitoring Patient Safety.
Publication: J AHIMA 73(3):72-4.
Date: 2002.
Abstract: The AHRQ Patient Safety Indicators (PSIs) were developed to focus on potentially preventable instances of harm to patients, such as surgical complications and other iatrogenic events. The PSIs are based solely on hospital administrative data, such as data from the Healthcare Cost and Utilization Project (HCUP), which rely upon diagnosis and procedure information that is coded using the International Classification of Diseases—9th revision—Clinical Modification (ICD-9-CM). HIM professionals can make a major contribution to the national effort to monitor and prevent medical errors through their application and ongoing refinement of ICD-9-CM. Several steps can be taken by HIM professionals to improve ICD-9-CM coding to better identify patient safety events, including (1) introduce more specific complication codes, (2) encourage clearer coding of iatrogenic conditions using available codes, (3) address the variability in medical record documentation, and (4) collaborate with local quality improvement leaders to investigate cases that arouse concern. The administrative data that HIM professionals generate have long been used for reimbursement. More recently these data have been used for research and quality assessment and they hold promise for identifying patient safety problems. However, to fulfill this promise, the quality of the data must continue to improve. HIM professionals will be at the forefront in helping to improve the usefulness of administrative data, thereby addressing the national challenge of reducing medical errors.

Authors: Miller M, Elixhauser A, Zhan C and Meyer G.
Title: Patient Safety Indicators: Using administrative data to identify potential patient safety concerns.
Publication: Health Services Research 36 (part II): 110-32.
Date: 2001
Abstract: This study describes the development of Patient Safety Indicators (PSIs) to identify potential in-hospital patient safety problems for the purpose of quality improvement. The data source was the 1997 Healthcare Cost and Utilization Project New York State Inpatient Database. PSI algorithms were developed using systematic literature reviews of indicators and hand searches of the ICD-9-CM code book. The prevalence of PSI events and associations with patient-level and hospital-level characteristics, length of stay, in-hospital mortality, and hospital charges were examined. PSIs were developed for 12 distinct clinical situations and an overall summary measure. The 1997 event rates per 10,000 discharges varied from 1.1 for foreign bodies left during procedures to 84.7 for birth trauma. Compared with discharge records without PSI events, discharge records with PSI events had 2-3 fold longer hospital stays, 2-20 fold higher rates of mortality in the hospital, and 2-8 fold higher total charges. Multivariate logistic regression revealed that PSI events were primarily associated with increasing age, hospitals performing more inpatient surgery, and hospitals with a higher percentage of beds in intensive care units. The PSIs provide an efficient tool to identify potential in-hospital patient safety problems for targeted quality improvement efforts. Until better error reporting systems are developed, the PSIs can serve to shed light on the problem of medical errors.

Research Agenda

Authors: Brach C, Fraser I.
Title: Can cultural competency reduce ethnic and racial health disparities? A review and conceptual model.
Publication: Med Care Res Rev 57(Suppl 1):181-217.
Date: 2000
Abstract: This article investigates cultural competency's potential to reduce racial and ethnic health disparities through a review of both the cultural competency and disparities literatures and development of a conceptual model. It identifies nine major cultural competency techniques described in the literature (interpreter services, recruitment and retention policies, training, coordinating with traditional healers, use of indigenous community workers, culturally competent health promotion, including family/community members, immersion into another culture, and administrative and organizational accommodations). The authors model how cultural competency techniques could improve the ability of health systems and their clinicians to deliver appropriate services to diverse populations that lead to good outcomes, thereby reducing disparities. The authors conclude that while there is substantial evidence to suggest that cultural competency should work, health systems have little evidence about which cultural competency techniques are in fact effective, and less evidence on when and how to implement them properly.
Availability: AHRQ Publication No. 01-R007 is available from the AHRQ Publications Clearinghouse. Copies of this journal supplement can be ordered from the Kaiser Family Foundation (1-800-656-4533, publication #3072).

Authors: Brach C, Sanches L, Young D, et al.
Title: Wrestling with typology: Penetrating the "black box" of managed care by focusing on health care system characteristics.
Publication: Med Care Res Rev 57(Suppl 2):93-115.
Date: 2000.
Abstract: The health care system has undergone a fundamental transformation, undermining the usefulness of the typology of HMO, IPA, PPO, etc. The authors present a new approach to studying the health care system. In matrix form, they have identified a set of organizational and delivery characteristics with the potential to influence outcomes of interest, such as access to services, quality, health status and functioning, and cost. The matrix groups the characteristics by domain (financial features, structure, care delivery and management policies, and products) and by key roles in the health care system (sponsor, plan, provider intermediary organization, and direct services provider). The matrix is a tool for researchers, administrators, clinicians, regulators and policy makers, and data collectors. It suggests a new set of players to be studied; emphasizes the relationships among the players; and provides a checklist of independent, control, and interactive variables to be included in analyses.
Availability: AHRQ Publication No. 01-R014 is available from the AHRQ Publications Clearinghouse.

Authors: Fraser I, McNamara P.
Title: Employers: Quality takers or quality makers?"
Publication: Med Care Res Rev 57(Suppl 2):33-52.
Date: 2000
Abstract: Available on PubMed®
Availability: AHRQ Publication No. 01-R012 is available from the AHRQ Publications Clearinghouse.

Authors: McNamara P, Caldwell B, Fraser I, et al.
Title: New contributions from the field of health services research.
Publication: Med Care Res Rev 57(Suppl 2):5-8.
Date: 2000.
Abstract: Recent publication and wide press coverage of an Institute of Medicine (IOM) study documenting the extent and nature of patient safety problems broadened public understanding of a fundamental and discouraging finding from the field of health services research—the quality of care delivered in the United States varies greatly and cannot be presumed. The IOM report underscores another finding from health services research that offers some guidance for those seeking to improve quality: the safety and quality of patient care can be no better than the system within which it occurs. Improvements in quality require a comprehensive and purposive set of system solutions based on scientific evidence about what works and what doesn't. This introductory article summarizes seven articles included in a special supplement of Med Care Res Rev, which were drawn from centerpiece presentations at two recent national meetings of health plans and health services researchers (Building Bridges 1999, 2000). The family of timely and actionable articles provides insights on organizational and institutional approaches to quality, and inform our future research agenda related to quality by identifying evidence gaps, offering design suggestions, and implicitly identifying research priorities.

Authors: Fraser I, Wong H, Arent J, et al.
Title: Building Bridges IV: Managed care research comes of age.
Publication: Med Care Res Rev 56(Suppl 2):5-12.
Date: 1999
Abstract: This article describes and contrasts the challenges and objectives facing attendees of the May 1998 conference, "Building Bridges IV: Improving the Public's Health through Research Partnerships," with those facing conference attendees of the inaugural Building Bridges conference held in April 1995. The conference was cosponsored by the American Association of Health Plans, AHCPR, Centers for Disease Control, and HMO Research Network. A brief overview of the articles presented in the special issue of Med Care Res Rev demonstrates just how far managed care research has evolved. Five of the most notable changes since the first Building Bridges conference are highlighted: (1) The two worlds of managed care and research are no longer distinct and separate. (2) The conference and the parties to the dialogue have grown substantially. (3) We have moved from broad concern about the impact of managed care to looking inside the black box. (4) Researchers are questioning established theories about how markets do and will work, with particular emphasis on the role of consumers and purchasers. (5) Continued progress in conducting and implementing managed care research will require new bridges and partnerships.

Authors: Simpson L, Fraser I.
Title: Children and managed care: What research can, can't, and should tell us about impact.
Publication: Medical Care Research and Review 56(Suppl 2):13-36.
Date: 1999
Abstract: The speed and ubiquity of the move from fee-for-service to managed care raises questions about how these changes affect children. This article examines: (1) The pace and context of the move to managed care for children. (2) Potential opportunities and challenges emerging from these changes. (3) Research findings on how managed care affects children. (4) Next steps for learning more. The research review provides a consistent answer to whether managed care is good for children: it depends on what kind of managed care, which children, and under what circumstances. This finding suggests lessons for future research:(1) Focus on particular features of managed care. (2) Get inside the "black box" of managed care and examine providers. (3) Expand the portfolio of research on children; research on adults cannot "trickle down" to children. (4) Foster research partnerships and networks. (5) Focus on poor and chronically ill children.
Availability: AHCPR Publication No. 99-R062 is available from the AHRQ Publications Clearinghouse.

Author: Hellinger F.
Title: Cost and financing of care for persons with HIV disease: An overview.
Publication: Health Care Financing Review 19(3):5-18.
Date: 1998
Abstract: This article explores the impact of new combination drug therapies on the cost and financing of human immunodeficiency virus (HIV) disease. Evidence indicates that the proportion of costs attributable to drugs has increased significantly since the diffusion of new combination drug therapies, and that the proportion of costs attributable to hospital inpatient care has decreased. The absence of timely data is the major difficulty in analyzing the impact of recent changes. Only two studies have examined costs since the diffusion of new combination drug therapies, and there are no recent studies of the insurance status of persons with HIV disease.

Authors: Binstock R, Spector W.
Title: Five priority areas for research on long term care.
Publication: Health Services Research 32(5):715-30.
Date: 1997
Abstract: This article presents five priority areas for research in long-term care given the context of rapidly shifting health care market forces and political pressures to contain Medicare and Medicaid expenditures. Areas recommended include quality of care measures, the linkage of costs and quality of care, appropriateness of care in the many types of long-term care settings that have emerged in recent years, evaluation of innovations in care provision with respect to impact on cost and quality, and research on the evolution of managed care and its effects on long-term care provision.
Availability: AHCPR Publication No. 98-R020 is available from the AHRQ Publications Clearinghouse.

Author: Fraser I.
Title: Research on health care organizations and markets—The best and worst of times.
Publication: Health Services Research 32(5):669-78.
Date: 1997
Abstract: This article contains reflections from four short papers commissioned by AHCPR in January 1997 to identify central managed care research questions in the areas of health care markets, access, chronic illness, and long term care.
Availability: AHCPR Publication No. 98-R019 is available from the AHRQ Publications Clearinghouse.

Author: Spector W.
Title: Measuring functioning in daily activities for persons with dementia.
Publication: Alzheimer Disease and Associated Disorders 11(Suppl):81-90.
Date: 1997
Abstract: This article evaluates the state of art of measuring functional disability with IADL and ADL scales for persons with dementia. Generic and dementia specific scales are compared. Among dementia specific scales, performance measures and proxy-respondent approaches are discussed. Recommendations are made for future research.
Availability: AHCPR Publication No. 98-R025 is available from the AHRQ Publications Clearinghouse.

Authors: Gaus C, Fraser I.
Title: Shifting paradigms and the role of research.
Publication: Health Aff 15(2):235-42.
Date: 1996
Abstract: This article discusses the tasks of providing information as well as monitoring and evaluating the impact of change to be carried out by government and foundation researchers. It includes a discussion of a new integrated survey design that relates aspects of health care status, use, cost, and financing to type of service, source of care, and type of payment.
Availability: AHCPR Publication No. 96-R107 is available from the AHRQ Publications Clearinghouse.

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