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Both nationally and locally, health care markets continue to
undergo rapid change. Through a variety of mechanisms, purchasers
have increased price competition between plans and providers and
some are using available tools to measure, monitor, and reward
quality. Insurers' and providers' response to this purchaser
activity is varied and complex. As a major purchaser and provider
of care, the federal government must understand, monitor and
evaluate the impact of these changes.
In recent years, investigator-initiated research at AHCPR has
provided rigorous evidence about the nature of these developments
and their impact on consumers and communities, in an effort to
take public and private decision makers beyond anecdotes and
speculation. AHCPR's market forces research provided evidence of
the extent of these changes in market structure, ownership, and
contracting patterns, and the impact of these developments on
physicians, consumers, and others. These findings include the
first empirical evidence that physicians' nominal earnings
dropped 4 percent from 1993 to 1994, the first time earnings have
declined since 1982 (the first year that salary data was
More recently, the November issue of Health Affairs included
seven articles by AHCPR-supported researchers and staff from this
initiative, meeting AHCPR's goal of producing useful research
products in less than two years. These articles provide
fundamental knowledge about the link between financing and
delivery of health care and the quality of services. Highlights
- Segmentation of Hospital Markets: Where Do HMO Enrollees Get
Care? Jose Escarce and colleagues suggest that health
maintenance organizations (HMOs) may not systematically
channel their enrollees to high-volume or low-mortality
hospitals. These findings are consistent with other
evidence that in many areas of the country, incentives for
managed care plans to lower costs may outweigh incentives to
- Which Types of Hospital Mergers Save Consumers Money?
Robert A. Connor and colleagues find that, overall,
horizontal mergers benefit consumers but more antitrust
scrutiny is needed.
- Effects of HMO Penetration on Physicians' Work Effort and
Satisfaction Jack Hadley and Jean M. Mitchell document the
extent and nature of physicians' reservations about how they
now practice medicine.
- HMO Market Structure and Performance: 1985-1995 Douglas R.
Wholey and colleagues take a comprehensive look at a decade
of managed care data and find evidence confirming the widely
held perception that hospital days are declining among HMO
patients, while use of ambulatory care is up. Their
analysis not only documents the role of plan competition but
also provides a closer look at the differential patterns of
competition for different kinds of managed care
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Over 80 percent of privately insured Americans now depend on some
form of managed care for their health needs, as do roughly 30
percent of Medicaid recipients and nearly 14 percent of Medicare
beneficiaries. To determine the impact of different features of
health plans on the quality of care provided to patients with
chronic illnesses and on outcomes, AHCPR, with the American
Association of Health Plans' Foundation (AAHPF), announced the
availability of up to $7 million, over a three-year period
beginning in FY 1998, to support peer-reviewed, outcomes-focused
This research has moved beyond questions of differences between
managed and fee-for-service care or between types of health
maintenance organizations. The focus is now on how changes in
organizational structures and care models being developed by
health plans impact patient health. This research will focus on
special populations, including women, minorities and the elderly.
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More than half of all Americans are now covered by managed care
plans, which often require the use of a primary care physician or
gatekeeper to manage the referral of patients from primary to
specialty care. Primary care is the most frequent site of health
care delivery, and the source of most referrals to secondary and
tertiary care. The rate of referral to specialists from primary
care affects both the cost and quality of health care. More
referrals drive costs up, while inappropriate referrals or
non-referrals harm quality.
AHCPR's research in this area focuses on the processes of
referrals and consultations by primary care clinicians and on
variations in referral patterns. Research also evaluates
strategies that lead to changes in provider behavior and improved
quality of care. Outcomes from recent studies include:
- Investigators from Boston University assessed the cost-effectiveness of interventions to prevent infections in
patients with HIV; the cost-effectiveness of current
protocols varies widely. The results can be used by
physicians and health care organizations to prioritize
treatment for patients with HIV.
- Use of a specialized treatment unit in the Emergency
Department for patients with asthma can reduce costs without
affecting outcomes (relapse rates or subsequent
- Depression and coexisting (medical) illnesses should be
treated together to reduce costs and improve outcomes.
Older primary care patients who are depressed have higher
overall costs than those who are not depressed. However,
the costs are not due to depression but to the effects of
depression on other medical conditions. Improving care and
reducing costs for older patients with depression and other
medical conditions requires that physicians treat both
In addition, AHCPR published a targeted solicitation in March
1996, Referrals from Primary to Specialty Care, to address
further research issues in this area.
In the area of advance directives, the Patient Self-Determination
Act passed in 1991 requires health care institutions to educate
patients about advance directives and document their wishes for
life-sustaining treatments in certain situations. However,
multiple studies have demonstrated that these discussions are
difficult for both patients and physicians, and either do not
occur or happen too late to influence treatment. AHCPR has
supported a number of studies in this area. Findings include:
- Less than one in five nursing home residents has a written
advance directive or durable power of attorney, suggesting
that health care providers may have to rely on decision
making by surrogates (family, friends or court-appointed
guardian) whose understanding of the affected individual's
preferences may be limited.
- Advance directives are often not specific enough to be
useful. Many individuals are asked to say they would want
to "treat everything" or "comfort care only" but these
general recommendations are not helpful to physicians in
developing treatment strategies consistent with patients'
- Computerized reminders to physicians at the time of
outpatient visits significantly enhanced the number of
patients who completed an advance directive (less than 5
percent in the control group vs. 20 percent in the
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Quality Measurement and Improvement
Research on quality measurement and improvement is essential to
efforts to integrate knowledge about health care into clinical
practice, especially at this time of rapid and profound changes
in the health care system. There are anecdotes, but not much
reliable information, about the effects of these changes on
quality of care and the effectiveness of attempts to assess and
assure quality. Understanding the effects of these changes
requires reliable and valid information about clinical quality of
care and methods for obtaining and using that information to
assure and improve quality.
When based on the science of AHCPR's Evidence-based Practice
Centers and on medical outcomes and effectiveness research,
clinical performance measures provide meaningful information
- Enables providers to "benchmark," to identify best
practices, and to prioritize areas for clinical quality
- Enables providers to manage their patients better, to
produce high quality care.
- Allows assessment of the impact of changes in delivery
systems on patient care and health outcomes.
- Permits purchasers and consumers to make informed
choices about their health care.
The Computerized Needs-Oriented Quality Measurement Evaluation
System (CONQUEST) is a key AHCPR project in this area, focusing on
collecting and evaluating existing clinical quality measures.
There are literally hundreds, if not thousands, of performance
measures developed by public and private organizations, but there
is a lack of information about the quality of those measures.
CONQUEST provides validated quality measures for a large variety
of clinical conditions and has helped to identify where new
performance measures are needed, e.g., complex and chronic
illnesses; for children in general and children with special
health care needs; for individuals with disabilities; and for
those who suffer from mental health or substance abuse problems.
To address these needs, AHCPR-funded eight, five year awards
collectively known as Q-SPAN (Expanding Quality of Care
Measures). Select for a more detailed information on the Q-SPAN
projects. These new studies support the development
and testing of new performance measures for specific conditions
such as hip fracture, dental care, home care, and asthma. Upon
their availability, AHCPR may include measures produced by the
studies in the CONQUEST system.
Q-Span Projects (Quality Measure Expansion Projects)
Clinical Performance Measures for Dental Plans || UNC, Chapel Hill: Kaiser Permanente Center for Health Res. & Dental Program; Group Health Foundation/Health Partners ||2 dental HMOs:
Kaiser Permanente, Health Partners |
Developing & Testing Asthma Quality of Care Measures ||University of Texas Southwestern Medical Center ||Parkland Memorial Center
Ongoing Development & Evaluation of HEDIS Measures ||Harvard Medical School; RAND; NCQA; Center for Survey Research ||Through NCQA, 22 health plans are participating
Measuring Quality by Achievable Benchmarks of Care ||University of Alabama, Birmingham; AL Quality Assurance Foundation ||20 Alabama hospitals; BCBS of Alabama; Triton/VIVA HMO; Physician Practices
Adult Global Quality Assessment Tool ||RAND ||United HealthCare; PacifiCare; Harvard Pilgrim; Aetna-US Healthcare
Quality of Care Measures for Cardiovascular Care ||Harvard Medical School; Harvard School of Public Health ||Allina; PacifiCare;
Education & Research
Quality Outcomes in Subacute & Home Care Programs ||Hebrew Rehabilitation Center for Aged; University of Michigan; Harvard University; Prism Health Group || Patients served
by Prism Health
subacute & home
care settings (w/
Center for Aged)
To expand research on quality measurement and improvement, AHCPR
issued a Request for Applications in FY 1998 to fund up to 10
grants for research in three priority areas:
- Methods and Measures. Improved quality depends on better
methods and measures including development and testing of
outcomes measures and severity adjustment methods, and
refinement and expansion of health and functional status and
health-related quality of life. Research also is needed in
relatively unexplored areas such as timeliness of care; the
importance of communication in quality of care; and the
translation of information about quality of care into health
- Organizational Change and Quality Measurement and Improvement.
Research is needed to incorporate new methods and measures
effectively into ongoing health care programs and to determine
how health care measurement can lead to improved care in a
variety of settings. Organization and system issues include
how different approaches to designing and implementing quality
improvement interventions work in and across health care
delivery settings. Through this RFA, AHCPR seeks to form
partnerships with the private sector—employers, payers and
providers to examine ways to improve quality.
- Using Quality-related Information. Research is needed on how
information on quality affects decision making at various
levels of the health care system. Research issues include how
the use of information on quality improves the ability of
patients, providers, employees, employers, health care
purchasers and health plans to work together effectively.
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A critical role for Government is conducting research and
evaluations to assess how well the market is meeting critical
health care objectives. That role has never been more important.
Public programs are being reorganized, downsized, and privatized.
Recent Federal legislation has made some of the most significant
changes in Federal health policy in nearly two decades—revisions in Medicare and Medicaid policy, the Medical Savings
Accounts demonstrations, and the State Child Health Insurance Program—which require evaluation. An even more dramatic revolution is
taking place in the private sector with the phenomenal growth of
managed care, increasing vertical and horizontal integration, and
new alliances and relationships among insurers, providers, and
purchasers in an increasingly competitive marketplace.
The recent public debate regarding the impact of managed care on
the quality of health care services has highlighted the need for
putting in place the capacity to assess and track at the national
and state and levels the impact of these changes. National
spending on health care continues to be an issue, as indications
emerge that costs may increase rapidly once again. There are many
questions about current spending: are we spending too much or too
little; is the spending efficient in purchasing value for money;
is the spending equitable; and how does it affect access and
To address these questions, it is important to collect and
examine nationally representative data on:
- The types of health care services Americans use.
- How frequently they use them.
- How much is paid for the services used.
- Who pays what portion of those payments.
It is also important to have information on the types and costs
of private health insurance available to, and held by, the U.S.
HIV Cost and Services Utilization Study (HCSUS)
In FY 1998, AHCPR supported the final year of the HIV Cost and
Services Utilization Study (HCSUS), a large-scale study that
assists in health care policy making by providing vital
information on costs and services resulting from health care
delivery to the HIV-infected persons. In addition to providing
estimates of utilization rates for inpatient, outpatient, home
health, and mental health services, HCSUS collected primary data
about access and barriers to care in different geographic
locations and health care delivery system settings. It provided
current information about relevant demographic and socioeconomic
variables (e.g., race, gender, insurance status, income,
education, exposure category). In addition, HCSUS specifically
addressed access to and cost and use of protease inhibitors. It
is expected to provide information about patients attitudes
toward antiretroviral treatment and factors that may facilitate
compliance with complex medical regimes.
A unique feature of HCSUS is the use of probability sampling
techniques to obtain a nationally representative sample of
persons with HIV disease receiving treatment. The population from
which this sample was drawn consists of persons receiving
HIV-related medical care in the two-month population definition
period of January-February, 1996. HCSUS used a three-stage
sampling design, in which geographic locales were sampled,
providers were sampled within locales, and patients sampled
within providers. Women were oversampled at a 2:1 ratio.
Overall, 2,865 HIV-infected patients were enrolled into the
sample and completed a baseline interview (with a coverage rate
of 70%). The HCSUS design includes a baseline interview and two
follow-up interviews, 6 months and 12 months after baseline. The
6-month and 12-month interviews have been completed, with a
completion rate over 85%. Initial findings from this project
will be presented at scientific meetings and submitted for
publication this year.
HCSUS was funded through a cooperative agreement with RAND for
four years beginning in FY 1994. The National Institute of Mental
Health, National Institute of Drug Abuse and the Health Resources
and Services Administration have provided support for HCSUS
through interagency agreements. This intra-Department
partnership allowed this survey to achieve an adequate rural
sample, a specific focus on mental health, and an expanded drug
abuse research component
Select for a discussion of the Medical Expenditures Panel Surveys
(MEPS) (23 KB), a critical resource for tracking the Nation's health
care use and expenditures.
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