Health Policy Research

Reports

• "Provider Payment: Trends and Methods in the Massachusetts Health Care System.” Allison Barrett and Timothy Lake, February 2010. This report investigates provider payment methods in Massachusetts. Payments include fee-for-service, the predominant model; global payments, which pay providers a single fee for all or most required services during a contract period; and pay-for-performance models, which layer quality incentives onto payments.
• "Analysis of Transition Events in Health Insurance Coverage." John Czajka and James Mabli, August 2009. This report analyzes factors that contribute to people losing or gaining health care coverage, prioritizes future research areas, and offers findings to inform future health care reform policy. Over time, the number of people lacking health insurance coverage in the U.S. is determined by dynamic processes. Comparatively few of the uninsured remain in that state indefinitely, but those who gain coverage are offset by insured persons who lose coverage. Achieving a long-term reduction in the number uninsured will require reducing the rate at which people lose coverage and increasing the rate at which they (re)gain coverage.
• “Strategies for Reining in Medicare Spending Through Delivery System Reforms: Assessing the Evidence and Opportunities.” Randall Brown, September 2009. This paper reviews proposed reforms to strengthen Medicare’s long-term fiscal outlook. Looking beyond provider payment reductions, the author assesses leading strategies to improve quality of care and efficiency within Medicare as well as the overall health care system. The paper argues that many of the most prominent proposed reforms are not likely to achieve savings for Medicare in the next 10 years, but identifies approaches that hold real promise for generating savings by either reducing chronically ill beneficiaries’ need for expensive services or changing providers’ practices in ways that decrease unnecessary procedures and inefficiencies. A companion paper synthesizes evidence on cost-effective interventions, identifies issues to resolve for ongoing research, and recommends care coordination policies supported by available evidence. Read more about Mathematica's evaluation of the Medicare Coordinated Care Demonstration. 
• “Enhanced Primary Care Case Management Programs in Medicaid: Issues and Options for States.” James Verdier, Vivian Byrd, and Christal Stone, September 2009. This report examines how five states—Oklahoma, North Carolina, Pennsylvania, Indiana, and Arkansas—have enhanced their Medicaid primary care case management (PCCM) programs to provide more intensive care management and care coordination for high-need beneficiaries, improve financial and performance incentives for primary care providers, and increase use of performance and quality measures. The report is aimed at states that may not have the option of contracting with fully capitated at-risk managed care organizations (MCOs), or that may want to use PCCM programs as an option for beneficiaries and as a source of competition and comparison for MCOs.
• "Evaluation of Mountain Health Choices: Implementation, Challenges, and Recommendations." Michael Hendryx, Carol Irvin, James Mulligan, Sally Richardson, Johanna S. Beane, and Margo Rosenbach, August 2009. In 2006, West Virginia established Mountain Health Choices, a key component of the state’s Medicaid redesign efforts. The program offers low-income parents and children the choice of two benefit plans. Beneficiaries receive additional benefits when they follow basic rules that are designed to increase personal responsibility and strengthen their relationship to a medical home. This report shows that despite widespread support for the goals of the program, Mountain Health Choices has yet to realize its potential. Many people in the state believe the program may have difficulty achieving its goals because of implementation challenges. For example, beneficiaries and providers say they have not been receiving the continuous education and outreach they need to help beneficiaries make an informed choice of benefit plans. The authors recommend a series of improvements to enhance the program, including immediate and meaningful rewards for positive behavior changes.
• "Recommendations of the Special Commission on the Health Care Payment System." Deborah Chollet, Robert Schmitz, Tim Lake, Michael Bailit, and Margaret Houy, July 2009. The Massachusetts Special Commission met from January to July 2009 to investigate reforming and restructuring the state’s health care system to provide incentives for efficient and effective patient-centered care and reduce variations in the quality and cost of care. This report details the principles that guided the Special Commission, reports input from key stakeholders, assesses alternative payment approaches, and reports the Special Commission’s recommendations for payment policy and implementation.

Journal Articles

• "How Temporary Insurance for High-Risk Individuals May Play Out Under Health Reform." Deborah Chollet, Health Affairs, June 2010. This article identifies continuing issues and barriers for many consumers seeking health coverage in high-risk insurance pools under the new Patient Protection and Affordable Care Act. The article notes how the new federal program is intended to serve only the currently uninsured—leaving in place until 2014 the states’ existing high-risk pools for many denied private coverage.
• A national symposium on the patient-centered medical home brought together experts in primary care, health services and implementation research, health systems and insurance, as well as policymakers to develop a research agenda. The commissioned papers, reflecting discussions at the conference, are in the June issue (subscription required) of the Journal of General Internal Medicine:

• "Using Evidence to Inform Policy: Developing a Policy-Relevant Research Agenda for the Patient-Centered Medical Home." Bruce Landon, James Gill, Richard Antonelli, and Eugene Rich. This paper summarizes the symposium.
  

  "U.S. Approaches to Physician Payment: The Deconstruction of Primary Care." Robert Berenson and Eugene Rich. This paper addresses why the three dominant alternatives to compensating physicians (fee-for-service, capitation, and salary) fall short of what is needed to support enhanced primary care in the patient-centered medical home and the relevance of payment reforms, such as pay-for-performance and episodes/bundling.

  "How to Buy a Medical Home? Policy Options and Practical Questions." Robert Berenson and Eugene Rich. This paper describes payment options to support the patient-centered medical home and identifies conceptual strengths and weaknesses.

• "Prospects for Rebuilding Primary Care Using the Patient-Centered Medical Home." Bruce Landon, James Gill, Richard Antonelli, and Eugene Rich, Health Affairs (subscription required), May 2010. This article analyzes potential barriers in the U.S. to the patient-centered medical home model, which is considered policy shorthand for the reinvention of primary care. Barriers include developing new payment models, personnel and infrastructure funding, and methods to facilitate transforming existing practices to functioning medical homes.

• "Beyond Affordability: The Impact of Nonfinancial Barriers on Access for Uninsured Adults in Three Diverse Communities." Jeffrey Kullgren and Catherine McLaughlin, Journal of Community Health (subscription required), June 2010. To shed light on the multidimensional issue of health care access, this study identifies nonfinancial barriers to health care uninsured low-income adults in three diverse communities face. It also determines how frequently nonfinancial barriers and financial access barriers coexist in this population.
• "Racial Disparities in Hospitalizations for Ambulatory Care—Sensitive Conditions." Sasigant O’Neil, Timothy Lake, Angela Merrill, Ander Wilson, David Mann, and Linda Bartnyska, American Journal of Preventive Medicine (subscription required), April 2010. This study identified differences in hospitalization rates for elderly African Americans and whites in Maryland for eight ambulatory care-sensitive conditions and estimated excess costs associated with these disparities. The study found that African Americans had significantly higher hospitalization rates for five of eight conditions, indicating that race may be a key predictor of preventable hospitalizations. Improving care for minorities, may reduce differences in care and lower hospital costs.
• "Yes, We Can Make a Dent in Medicare Costs." Randall Brown, American Society on Aging Online (subscription required), February 2010. This article suggests that strong evidence exists on how Medicare costs can be reduced and quality of care improved for patients with chronic illnesses through enhanced attention to patients around the time they are released from the hospital. Two models of transitional care, both relying on advance practice nurses but in different ways and for differing lengths of time, have been shown to significantly reduce hospital readmission rates and costs for patients with congestive heart failure and a range of other chronic conditions. 
• "Temporal Trends in Anti-Diabetes Drug Use in TRICARE Following Safety Warnings in 2007 About Rosiglitazone." Kate Stewart, Brenda Natzke, Thomas Williams, Elder Granger, S. Ward Casscells, and Thomas Croghan, Pharmacoepidemiology and Drug Safety (subscription required), November 2009. In 2007, highly publicized warnings suggested rosiglitazone, a drug used to treat type 2 diabetes, may be associated with an increased risk of heart attack and cardiovascular-related death. This article details the response to these warnings by analyzing anti-diabetes drug use before and after the 2007 warnings in the military health system. We found that the total number of prescriptions for all anti-diabetes medications remained constant before and after the warnings, although prescriptions of rosiglitazone declined by more than 50 percent after the warnings.

Issue Briefs

• "Politics and Policy of Comparative Effectiveness: Looking Back, Looking Ahead." Topics in Health Care Effectiveness #1. Eugene C. Rich and Elizabeth Docteur, June 2010. Interest in evaluating which health care interventions work best under what circumstances has surged in recent years as health care spending has risen. This brief, the first from Mathematica’s Center on Health Care Effectiveness, looks at the new comparative effectiveness research (CER) initiative passed as part of health care reform. The authors discuss the status of four ongoing policy challenges relevant to the successful implementation of CER: funding mechanism, how the research gets used, how the CER enterprise is directed, and perhaps most fundamentally, the proper scope of CER. They note important questions remain whose resolution may prove critical to the future role of this research in U.S. health care.
• "Medicare Advantage 2010 Data Spotlight: Plan Enrollment Patterns and Trends." Marsha Gold, Dawn Phelps, Gretchen Jacobson, and Tricia Neuman, June 2010. This spotlight examines enrollment trends in Medicare Advantage plans, including health maintenance organizations (HMOs), preferred provider organizations (PPOs), and private fee-for-service (PFFS) plans. Despite the availability of many private Medicare Advantage plans, enrollment is highly concentrated among a small number of firms.
• "The Starting Point: The Balance of State Long-Term Care Systems Before the Implementation of the Money Follows the Person Demonstration." Carol Irvin and Jeffrey Ballou, Reports from the Field #4, May 2010. The fourth report of the Money Follows the Person (MFP) Demonstration provides an early assessment of the balance of home and community-based care services (HCBS) and institutional long-term care systems in states before MFP was implemented. By looking at the status of these long-term systems state-by-state, the assessment helps to develop a baseline to measure the program’s impacts on long-term care systems.
• "Medical Homes: Will They Improve Primary Care?" Reforming Health Care Issue Brief #6, Jill Bernstein, Deborah Chollet, Deborah Peikes, and G. Gregory Peterson, June 2010. The sixth brief in a new series on reforming health care looks at federal and state efforts to establish medical homes and notes considerations for policymakers seeking to improve access to services and the quality of care.
• "Financial Incentives for Health Care Providers and Consumers." Reforming Health Care Issue Brief #5, Jill Bernstein, Deborah Chollet, and Stephanie Peterson, May 2010. Show them the money. Health reform will emphasize financial incentives for providers and consumers to promote the use of effective health services and discourage use of marginally effective or inappropriate services. The fifth brief in a new series from Mathematica looks at evidence on the impacts of these financial incentives and draws lessons for policymakers.
• ”Disease Management: Does It Work?” Reforming Health Care Issue Brief #4, Jill Bernstein, Deborah Chollet, and G. Gregory Peterson, May 2010. Disease management programs seek to control health care costs by focusing on two major drivers:  high-cost chronic illness and inpatient hospitalizations for acute conditions. The fourth brief in a new series from Mathematica looks at the research evidence on the effectiveness of disease management programs and the role of disease management in health care reform.
• "Basing Health Care on Empirical Evidence." Reforming Health Care Issue Brief #3, Jill Bernstein, Deborah Chollet, and Stephanie Peterson, May 2010. What does the evidence show? Federal reform embraces the development of evidence-based practice as a way to control health care costs and improve quality. The third brief in a new series from Mathematica reviews initiatives under way to develop evidence of comparative effectiveness and put it into practice.
• "Encouraging Appropriate Use of Preventive Health Services." Reforming Health Care Issue Brief #2, Jill Bernstein, Deborah Chollet, and G. Gregory Peterson, May 2010. Is an ounce of prevention worth a pound of cure? The second brief in a new series from Mathematica summarizes evidence on the benefits and cost-effectiveness of preventive health services, noting that health reform brings significant new opportunities to improve access to preventive care.
• "How Does Insurance Coverage Improve Health Outcomes?" Reforming Health Care Issue Brief #1, Jill Bernstein, Deborah Chollet, and Stephanie Peterson, April 2010. This brief synthesizes the compelling research evidence linking health insurance coverage to good health outcomes for both adults and children.
• "System of Care Approaches in Residential Treatment Facilities Serving Children with Serious Behavioral Health Needs." Kamala Allen, Sheila Pires, and Jonathan Brown, March 2010. This issue brief describes findings from a national survey of residential treatment facilities (RTFs) serving children and adolescents with serious behavioral health challenges. The survey explored how system of care principles are reflected in RTFs’ policies and practices as well as how RTFs are providing home- and community-based services and supports in addition to traditional offerings.
• "Quality’s New Frontier: Reducing Hospitalizations and Improving Transitions in Long-Term Care." Debra J. Lipson and Samuel Simon, March 2010. Hospitals and post-acute care providers have developed quality measures to evaluate their effectiveness in preventing readmissions, but these measures are lacking in long-term care. This issue brief discusses the need for similar measures to assess the quality of long-term care for people in nursing homes and other home- and community-based service settings. It also identifies evidence-based care models and interventions for reducing potentially avoidable hospitalizations and highlights the need to develop financial incentives for providers to measure and improve performance.
• "Coordinating and Improving Care for Dual Eligibles in Nursing Facilities: Current Obstacles and Pathways to Improvement." James M. Verdier, March 2010. More than half of all nursing facility residents are dually eligible for both Medicare and Medicaid, enmeshing them in a system of care and coverage that is complex, fragmented, uncoordinated, and inefficient. This policy brief suggests that coordination of care for these dual eligibles could be improved by shifting responsibility for long-term nursing facility services from Medicaid to Medicare. Some incremental steps could also increase accountability for prescription drug use, reduce avoidable hospitalizations, cut costs, and improve overall care. It is important to ensure that Medicaid home- and community-based service programs and nursing facility care remain coordinated for those who can be cared for in the community.

Other

• Massachusetts has been a leader in experimenting with and implementing health care reform initiatives. The Massachusetts Special Commission on the Health Care Payment System recently endorsed recommendations for improving the quality of health care by dramatically changing the way patients pay for care. Staff from Mathematica, led by Deborah Chollet, Bob Schmitz, and Tim Lake, drafted the report and background material for the commission. Read about the recommendations and access the full report. (See page 73 for Mathematica’s role; Appendix C contains the memos we prepared.) The report was covered in the New York Times, Wall Street Journal, Boston Globe, and other media.
• “Chartbook: Medicaid Pharmacy Benefit Use and Reimbursement in 2005.” Ann Bagchi, James Verdier, and Dominick Esposito, June 2009. This chartbook highlights national and state-by-state data on Medicaid prescription drug use and expenditures for 2005 by beneficiary characteristics (age, sex, and race), basis of eligibility (children, adults, disabled, and aged), and type of drug (brand vs. generic, top 10 drug groups, top 7 therapeutic categories, and drugs excluded by statute from Medicare Part D). Separate graphs highlight Medicare-Medicaid dual eligibles, whose drug coverage shifted to Medicare in 2006, and nondual beneficiaries, who continue to receive their drug coverage from Medicaid. The detailed state-by-state and national tables for 1999 and 2001-2005 on which the chartbook is based (statistical compendiums) are on the Centers for Medicare & Medicaid Services website.
• Recent media coverage, including a New Yorker article (June 1, 2009) on “The Cost Conundrum” has policymakers concerned about how per-capita health care costs vary widely across the country, what to make of this variation, and how to respond as health reform and Medicare spending dominate the health policy debate. For Robert Wood Johnson Foundation's Synthesis Project, Marsha Gold sought to help policymakers better understand these issues. Her review confirms the existence of wide variations in Medicare per capita spending across the nation that appear connected with differences in use of health services and not associated with improvements in outcomes. Framing an effective response is challenging because any solution will create winners and losers, and a lot remains unknown about why areas that appear to be similar actually differ. Simply lowering payments to high cost areas without changing the underlying dynamics of care delivery will not necessarily translate into more effective care. Policies that modify the culture of medical practice, the financial incentives embedded in the system, and the way doctors communicate with one another are likely to be critical to having all patients, wherever they live, gain access to appropriate care.