Medicare Uses of AHRQ Research
The Agency for Healthcare Research and Quality (AHRQ) includes health care topics of direct relevance to elderly persons and considers the needs and priorities of the Medicare program in its sponsored research and other activities.
- AHRQ research has addressed all of the 10 health care conditions that are most costly to the Medicare program, including heart disease, pneumonia, and diabetes.
- AHRQ has been a vital source of science-based information for Medicare decisionmakers at the Centers for Medicare & Medicaid Services (CMS) through its evidence-based practice and technology assessment efforts.
- Information developed through AHRQ-sponsored research also helps Medicare beneficiaries and their providers make decisions about treatments, health plans, long-term care, and other aspects of health care.
Choosing Health Plans
Medicare beneficiaries interested in enrolling in managed care plans need up-to-date, accurate information to help them select the plans that best meet their needs. To provide this information and to help encourage plans to compete on the basis of quality, AHRQ sponsored the development of the Consumer Assessment of Health Plans (CAHPS®), a survey of people's experiences with care. CAHPS® is an invaluable resource for CMS and for Medicare beneficiaries.
Under a partnership with CMS, AHRQ researchers developed a version of CAHPS® that specifically addresses the needs of Medicare enrollees.
- The results of this survey are available in a format that employs user-friendly graphics and summaries to help beneficiaries compare the features and quality of particular plans.
- Reports based on the Medicare CAHPS® survey are available to more than 39 million Medicare beneficiaries to help them make decisions about their health care plans.
CMS and AHRQ have collaborated on other efforts:
- Development of a CAHPS® survey to obtain consumers' assessments of health and services received in nursing homes. Data will be collected from residents and next-of-kin and used to help people who are choosing a nursing home.
- A Medicare CAHPS® disenrollment survey of beneficiaries enrolled in managed care plans. The survey, developed in conjunction with the CAHPS® Consortium, was fielded recently by CMS; results will help CMS and policymakers distinguish between disenrollments that are related to quality (for example, limited access to specialists) and those that are unrelated to quality (for example, moving out of the area served by the plan).
- Planning and development of the recently published Choosing a Medicare Health Plan. This guide for people with Medicare gives information on the types of Medicare health plans, including Medicare managed care, and lists resources for beneficiaries to help them choose a health plan.
A recently funded AHRQ study also has implications for helping elders consider quality in their health plan choice. Researchers at the Research Triangle Institute in North Carolina will develop and evaluate an integrated information and decision support tool for use by employee benefits staff in counseling employees ages 60 to 64 about their Medicare health plan options.
Making Treatment and Care Decisions
Data and tools for clinicians. AHRQ research emphasizes the results of care from the patient's perspective. This is particularly important when patients and health care providers are choosing a hospital or long-term care facility or considering how to manage chronic illness or diseases common to older Americans, such as pneumonia, prostate disease, diabetes, and stroke.
AHRQ-supported research has provided both data and tools needed to implement evidence-based improvements in patient care. For example:
- Sixty percent of urologists now use a scientifically valid patient questionnaire, developed with AHRQ support, to measure the symptoms and quality of life for elderly men with benign prostate disease.
- AHRQ-supported researchers developed a way for clinicians to determine which patients with pneumonia can be safely treated at home, thus avoiding hospitalization entirely. Studies of health systems that have implemented this decision tool found that it not only reduces hospitalization rates (by 26 percent in one major hospital) but that home treatment is preferred by patients.
- A measure, developed with AHRQ support, that uses patients' reports of foot exams can improve the rate, which physicians routinely perform these exams and reduce the estimated 40,000 annual amputations that result from diabetes-related foot and leg problems. This measure of care was among those tested by the Diabetes Quality Improvement Program, an effort by CMS and others to use a common set of quality indicators to improve care for people with diabetes.
- Subsequent to AHRQ research on the effectiveness of the anticoagulant drug warfarin in preventing stroke, Medicare Peer Review Organizations (PROs) implemented projects in over 40 States to increase the anticoagulation rates in certain patient categories. Researchers estimate that these quality improvement projects have prevented hundreds of strokes.
Current AHRQ research continues to provide information and tools to improve quality of care:
- Dartmouth University researchers are studying the implications of regionalizing hospital care based on the strong empirical relationship between hospital service volume and health care outcomes. Findings have been provided to CMS on potential consequences of encouraging Medicare beneficiaries to use such information in their hospital treatment decisions.
- AHRQ-supported investigators at the Medical University of South Carolina are examining how a quality improvement model using academic detailing and electronic medical records affects adherence to treatment guidelines for the prevention of cardiovascular disease and stroke in primary care settings.
- Researchers at the Minneapolis Medical Research Institute are assessing the effectiveness of a model for accelerating the use of evidence-based treatment guidelines for acute ischemic stroke in four urban and rural hospitals in Minnesota.
Resources for consumers. Medicare beneficiaries and other consumers also benefit from the results of AHRQ research. For example:
- CMS's popular Web-based tool, Nursing Home Compare, grew out of an AHRQ-funded project which developed a consumer information system to help people find data on nursing homes. Launched in 1999, this important tool for Medicare beneficiaries now averages 475,000 page views per month. Nursing Home Compare gives detailed information about the performance of every Medicare and Medicaid certified nursing home in the country.
- An AHRQ-supported University of Colorado project is addressing the need for quality information to make informed choices on nursing homes. The study team is developing and assessing a prototype "report card" that consumers can use in choosing a nursing home. Investigators will determine what available information can be used to assess nursing home quality from both consumer and provider viewpoints.
- AHRQ and CMS have collaborated on other guides for Medicare beneficiaries to use when choosing their health care providers, treatments, and long-term care settings. These user-friendly booklets, available both in print and online, give step-by-step information and available resources to aid beneficiaries in making informed health care choices.
- AHRQ has worked with several partners to achieve broad dissemination of Staying Healthy at 50+, a new guide on preventive health for adults ages 50 and older. AHRQ's partners include CMS, the Administration on Aging, and the Kansas State Employees Health Care Commission.
Strengthening Program Management
Monitoring and evaluation. CMS uses information from AHRQ's Medical Expenditure Panel Survey (MEPS) to help in assessing the impact of Medicare policies on families of beneficiaries, a group that is not included in CMS's own Medicare Beneficiary Survey. In addition, the detailed data on health care use provided by MEPS have expanded CMS's ability to track the use of health care services by nonelderly Medicare beneficiaries.
AHRQ is working to assess alternative sample designs to enhance the size of the transition population in CMS's Medicare Current Beneficiary Survey. AHRQ provides technical assistance to enhance CMS's use of MEPS data, in particular collection of data on insurance and retiree estimates. AHRQ is also currently collaborating with CMS in research efforts to analyze Medicare Health Outcomes Survey data, claims data, and the Medicare component of CAHPS®.
Policy and coverage decisions. AHRQ assesses new and existing technologies to provide a scientific basis for coverage decisions and inform Medicare policies. For example:
- An AHRQ-sponsored review of the evidence for colorectal cancer screening, which concluded that screening is effective in reducing deaths from colon cancer, contributed to Congress' decision to cover this technology as a Medicare program benefit and to CMS's decisions on how to pay for it.
- CMS revised its Medicare Coverage Issues Manual to include a national policy permitting coverage for treatment of actinic keratoses (AK), a common skin condition that often is a precursor of skin cancer, based largely on AHRQ's technology assessment for actinic keratoses treatment. Previously, coverage decisions were made by local Medicare carriers who had policies with varying degrees of restriction. The new national CMS policy eliminates these variations in coverage.
Topics of other technology assessments now being prepared for CMS include:
- Patient access to audiology services.
- Use of air fluidized beds in treating pressure ulcers at home.
- Use of neuroimaging techniques in evaluating breast cancer, Alzheimer's disease, and dementia.
In addition to its technology assessments for CMS, AHRQ has published evidence reports on topics specifically nominated by CMS such as telemedicine coverage under Medicare, pharmaceutical treatment for prostate cancer, and treatment for swallowing disorders in the elderly.
Other evidence reports by AHRQ's Evidence-based Practice Centers that have direct relevance to the care of older Americans include diagnosis and treatment for cardiac ischemia, stroke, osteoporosis, stable and unstable angina, cataract and glaucoma, renal failure, spinal stenosis, and atrial fibrillation.
Many of these reports are used by clinicians and hospital administrators. For example, AHRQ and North Carolina's peer review/quality improvement organization collaborated in disseminating AHRQ's evidence report on atrial fibrillation to more than 700 physicians and 114 acute care hospitals in the State.
AHRQ-supported researchers are investigating various Medicare coverage issues. Recent examples are:
- A project at Boston University that examines health plan responses to Medicare payment policies, specifically a new formula that was used in 1998 and 1999 to set HMO capitation rates. This is important because in 1998, while overall Medicare HMO enrollment grew by 8 percent, 45 HMOs cancelled their Medicare contracts and 54 others reduced their service areas.
- Research at Harvard University examining the influence of different types of private and public drug coverage on costs of antihypertensive medicines and drug use by a 1995 national sample of Medicare beneficiaries with high blood pressure. Findings reveal beneficiaries with high blood pressure who did not have supplemental drug coverage consistently obtained fewer prescription drugs to lower blood pressure and paid more out of pocket for the medications they did get. About one-third of Medicare beneficiaries have no supplemental drug coverage to help defray costs.
Meeting Medicare's Needs Today and Tomorrow
As the Medicare program increases the number and variety of health care options available to beneficiaries under its Medicare+Choice program, administrators and policymakers need to understand the quality-of-care implications of these managed care options. Understanding the effects of specific features of managed care and providing decisionmakers with tools necessary to promote effective care are critical to maintaining program quality without losing efficiency.
To address these information needs, AHRQ is sponsoring wide-ranging research, including several projects by its Integrated Delivery System Research Network, to study how particular managed care policies affect health services delivery and quality of care for the Medicare population.
- Researchers at the Center for Health Care Policy and Evaluation, a division of United Health Services, are surveying a sample of Medicare+Choice enrollees to examine how different out-of-pocket requirements affect their prescription medicine-taking behavior.
- Investigators at the Lovelace Clinic Foundation, Kaiser Permanente of Georgia, the University of Texas Health Science Center, and the Houston School of Public Health are developing models to help managed care organizations plan for and provide culturally and linguistically appropriate services to Medicare patients. This study is supported by CMS through an agreement with AHRQ.
- A research team at the University of Minnesota is assessing the frequency of negative events (such as patient falls, hip fractures, and pressure ulcers) and determining the extent to which variation in occurrence can be explained by the characteristics of the nursing home and its clinical and administrative practices.
- Researchers at the University of Nebraska Medical Center are examining why rural providers create managed care organizations as a result of Medicare+Choice program expansions and the consequences of rural provider participation in Medicare managed care plans.
- Investigators at the New England Medical Center are comparing the performance and outcomes of primary care providers in conventional (fee-for-service) Medicare with Medicare managed care plans. Study findings related to prescription drug coverage and disenrollment from managed care plans are being considered by the Medicare Payment Advisory Commission.
Through such research, AHRQ-funded investigators are laying the groundwork for future strategies—to learn not only what is effective, but how to manage health care and service delivery so that Medicare beneficiaries get the best care possible in all care settings.