According to the Los Angeles Times, as the federal government continues to ignore the health care crisis in the United States, state governments are beginning to develop solutions.
According to the New York Times, declining public trust in the safety of new drugs combined with soon to expire patents of current blockbusters are posing a challenge to large pharmaceutical companies.
One-third of patients with health problems in the United States report experiencing medical, medication, or test errors, the highest rate of any nation in a new Commonwealth Fund international survey. Assessing health care access, safety, and care coordination in Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States, the survey found that while no one nation was best or worst overall, the United States stood out for high error rates, inefficient coordination of care, and high out-of-pocket costs leading to barriers to access to care.
The findings are published today in a Health Affairs article, �Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries,� whose lead author is Commonwealth Fund senior vice president Cathy Schoen.
You can read the article here.
�While the consistently high error rates and lack of coordination are disturbing, the findings also highlight the potential for each country to improve,� said Commonwealth Fund president Karen Davis. �Some countries have been able to achieve timely access to needed care while reducing financial barriers. Each country could also gain through strategies to improve the quality and efficiency of care, such as implementing modern information technology systems, supporting patient engagement in care, and improving management of chronic conditions.�
The 2005 survey of adults with health problems is the eighth in an annual series of cross-national surveys conducted by Harris Interactive for the Commonwealth Fund.
One-third (34 percent) of U.S. survey participants reported at least one of four types of errors: They believed that they experienced a medical mistake in treatment or care, were given the wrong medication or dose, were given incorrect results for a test, or experienced delays in being notified about abnormal test results. Three of ten Canadian respondents reported at least one of these errors, as did one-fifth or more of patients in Australia (27 percent), New Zealand (25 percent), Germany (23 percent), and the United Kingdom (22 percent).
U.S. patients who saw four or more doctors in the past two years were especially vulnerable, with about half reporting at least one of these errors; this points toward lapses in communication during care transitions.
Although attention to patient safety has focused chiefly on care in hospitals, a majority of patients (60 percent or more) in each country who reported medical mistakes or medical errors said that these errors occurred outside the hospital, which highlights the need for policies to improve patient safety in ambulatory care settings.
�There were many symptoms of poorly coordinated care in every country, regardless of the type of delivery or financing system,� said Schoen. �Shortfalls were particularly evident for people when discharged from the hospital, and for patients seeing multiple physicians. Improved care coordination during transitions across sites of care and providers offer opportunities for significant improvement. These patients are the �canary in the coal mine� of any health system.�
In all six countries, one-third or more of recently hospitalized patients reported failures to coordinate care during hospital discharge. Germany had the highest rate of patients reporting lack of follow-up care, with three-fifths (60 percent) saying that the hospital did not make arrangements for follow-up visits with a doctor or other health professional or otherwise give instructions about posthospital care, such as symptoms to watch for and when to seek further care.
The United States had the highest rate of patients reporting coordination-of-care problems that reflected inefficient care during doctor visits. One-third of U.S. respondents said that within the past two years, either their test results or records were not available at the time of a doctor�s appointment, or that a doctor had ordered a test that had already been done. Rates of care-coordination problems in the United States were higher than those in the other five countries, which ranged between about one-fifth to one-quarter reporting coordination problems.
Patients with chronic diseases in all of the countries often did not receive the care recommended to manage their condition. At best, about half of diabetics reported receiving all four recommended screening exams to manage their condition. Patients who had supports such as a self-management plan or a nurse included as part of their care management team were more likely than others to have received recommended care.
The United States was an outlier for its financial burdens on patients:
� Half of U.S. adults reported that they had gone without care because of costs in the past year
� In contrast, just thirteen percent of U.K. adults reported not getting needed care because of cost
� One-third of U.S. patients reported out-of-pocket expenses greater than $1,000 in the past year
� U.K. patients were the most protected from high cost burdens, with two-thirds having no out-of-pocket expenses. The variations were notable given the study�s design focus on sicker adults with recent intensive use of medical care.
Access�including after-hours access�and waiting times to see a doctor when sick differed markedly across the countries:
� Canadian and U.S. adults who needed medical care were the least likely to report fast access (same day) to doctors (30 percent or fewer of U.S. or Canadian patients)
� In contrast, majorities of patients in New Zealand (58 percent) and Germany (56 percent) reported that they were able to get same-day appointments, as did nearly half of patients in Australia (49 percent) and the United Kingdom (45 percent)
� Majorities of patients in Germany (72 percent), New Zealand (70 percent), and the United Kingdom (57 percent) also reported easy after-hours (nights, weekends, or holidays) access to a doctor
� In contrast, majorities of patients in the United States (60 percent), Australia (58 percent), and Canada (53 percent) said that it was very or somewhat difficult to get after-hours care
� The four countries with comparatively more rapid access to physicians�Australia, Germany, New Zealand, and the United Kingdom�also had lower rates of emergency room use, with Germany having the lowest rates
� One-fifth of Canadians and one-fourth of U.S. patients who reported going to the ER said that it was for a condition that could have been treated by their regular doctor if available
The findings highlight the need for improved access as well as coordination of care. The authors conclude that �these findings suggest that many of the problems with which policy leaders are grappling transcend specific payment or delivery systems and will require more fundamental transformation.�
The Commonwealth Fund is a private foundation supporting independent research on health care issues and making grants to improve health care practice and policy.
Health Affairs , published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org The full text of each Health Affairs Web Exclusive is available free of charge to all Web site visitors for a two-week period following posting, after which it will switch to pay-per-view for nonsubscribers. The abstracts of all articles are free in perpetuity. Web Exclusives are supported in part by a grant from the Commonwealth Fund.
Southern California employees travel to Mexico, where they receive healthcare that is less expensive and reportedly better, according to the San Diego Union-Tribune.
Employer-based health insurance is an idea whose time had come and gone, according to the Boston Globe, which explores potential alternatives.
General Motors and the United Auto Workers have reached a tentative health care agreement, according to the New York Times.
Physicians who self-refer patients to their own specialty hospitals are reaping financial benefits by "cherry-picking" less severe patients and "cream-skimming& patients with better insurance, a Georgetown University economist said Wednesday at a Wichita health care seminar, according to the Wichita Eagle.
The American public believes strongly that electronic medical records can make the difference between life and death in emergencies, new research being released today shows. Nearly three out of four Americans (72%) say they favor the establishment of a nationwide electronic information exchange that would allow a patient's health information to be shared with authorized individuals quickly, privately, and securely via the Internet. However, ensuring patient privacy and control over their own records is essential to full consumer acceptance of such an exchange. More than three out of four Americans (79%) say making sure their records could be shared only after they provide permission is a priority.
The survey results will be presented Oct. 11 at the first national conference to focus on the needs and concerns of consumers, including privacy, in the rapidly growing field of health information technology. Conference organizers also will present seven consumer and patient principles, which have been endorsed by a wide range of consumer, business, and other organizations involved in health care. The principles are designed to protect privacy and ensure that personal health information is used appropriately in health information exchange. Sponsored by the Markle Foundation, the Robert Wood Johnson Foundation (RWJF), and the Agency for Healthcare Research and Quality (AHRQ), the conference will focus on advances in personal health technology and the core principles for creating a health information environment in which consumers can use information technology to participate more fully in managing their health and health care. More than 700 individuals registered to take part in the conference, including consumer advocates, business leaders, entrepreneurs, medical professionals, and government officials.
"Americans use digital information technology to manage their finances, pay bills, book flights, and customize the music they listen to, and our research shows they now want to use health information technology to get the best care possible for themselves and be better able to manage their own health," said Zo� Baird, president of the Markle Foundation, which funded the research. "People realize that if they or those they love are in an accident or disaster, having their medical records available at a moment's notice through secure, electronic information exchange could mean the difference between life and death."
"We are on the cusp of a technological revolution in health care, as more personal digital health products are developed, and consumers in the 'iPod generation' are more receptive to using them," said David Lansky, senior director of the health program at the Markle Foundation. "Each device that is developed should meet consumers' needs for privacy and security, as should the entire nationwide health information environment in which consumers and health professionals will be using these digital tools. That is why these new patient and consumer principles are being proposed."
The number and types of personal digital health technologies is growing rapidly, and a bipartisan group of national leaders is keenly interested in how information technology can transform health care. Business leaders, including Andy Grove of Intel, and national leaders, including President Bush, Senate Majority Leader Bill Frist (R-Tenn.), Sen. Hillary Clinton (D-N.Y.), Rep. Nancy Johnson (R-Conn.), Rep. Patrick Kennedy (D-R.I.), and former House Speaker Newt Gingrich, are advocating the use of information technology to improve the quality of health care, reduce medical errors, and increase efficiency. President Bush has called for all Americans to have an electronic personal health record within 10 years.
The survey released at today's conference shows that four in five Americans (80%) believe that if physicians kept electronic medical records on their patients, health care quality would improve and medical errors would be reduced, because authorized doctors would be able to retrieve a patient's medical history in a matter of seconds. An equal number (81%) believe that the ability of researchers to review millions of records anonymously to determine best treatment practices would help all doctors improve the quality of medical care.
Despite these high levels of support for health information technology, keeping electronic medical information private and secure remains a top concern for consumers. Today's research shows that people are much more likely to support online medical records if they have control over their own information and safeguards to protect privacy are in place. Public Opinion Strategies, Alexandria, VA, conducted the survey Sept. 20-22, 2005. The survey of 800 adults has a margin of error of +/- 3.46 percent. According to the poll:
Individuals want to review who has seen their medical information.
Eighty-one percent of respondents say reviewing who has had access to their personal health information is a "top" or "high" priority.
Patients want to be asked before their information is shared.
Seventy-nine percent of respondents say it is a "top" or "high" priority that their medical information be shared electronically only with their permission.
Consumers want the identity of anyone who sees their records to be carefully confirmed.
Ninety-one percent of respondents say carefully confirming the identity of anyone using the system to prevent unauthorized access or cases of mistaken identify is a "top" or "high" priority.
The public does not want employers to have access to workers' health information.
Sixty-eight percent of respondents say it is a "top" or "high" priority that employers not have access to secure health information networks.
A separate study, conducted by Public Opinion Strategies on Sept. 28-Oct. 2, 2005, (800 adults; margin of error +/- 3.46%) showed that consumers would use their own secure, online "personal health record" account to better manage their health care. Nearly seven out of 10 respondents (69%) said they would use this online service to check for mistakes in their medical records, as well as to check and refill prescriptions (68%). Nearly six in 10 respondents said they would like to get medical results over the Internet (58%) or conduct secure and private email communications with their doctors (57%). Taken together, these results show a strong interest among consumers in using health information technology to more fully participate in their own health care.
The new consumer and patient principles to guide the development of online health information exchange were developed by the Personal Health Technology Council, a group of 44 leading consumer and privacy advocates, medical professionals, informatics experts, payers, technologists, federal policymakers, bio-ethicists, and researchers. The group believes these principles should guide developments in the private and public sectors, including several pieces of legislation that have already been introduced in Congress and would increase the use of electronic health records within any new nationwide health information exchange.
The seven patient and consumer principles endorsed by the Personal Health Technology Council are:
1. Individuals should be able to access their health and medical data conveniently and affordably.
2. Individuals should be able to authorize when and with whom their health data are shared. Individuals should be able to refuse to make their health data available for sharing by opting out of nationwide information exchange.
3. Individuals should be able to designate someone else, such as a loved one, to have access to and exercise control over how their records are shared.
4. Individuals should receive easily understood information about all the ways that their health data may be used or shared.
5. Individuals should be able to review which entities have had access to their personal health data.
6. Electronic health data exchanges must protect the integrity, security, privacy, and confidentiality of an individual's information.
7. Independent bodies, accountable to the public, should oversee local and nationwide electronic health data exchanges. No single stakeholder group should dominate these oversight bodies, and consumer representatives selected by their peers should participate as full voting members.
"When all Americans have the ability to review their own medical records online, we then will begin to see a health care system that reduces disparities in medical care, and increases the quality of care for all Americans," said John R. Lumpkin, M.D., M.P.H., senior vice president and the director of the Health Care Group for RWJF. "People want to take advantage of health information technology, but they need to trust that the new information environment respects their privacy and ensures the security of their information. Therefore, the new health information technologies that are being created, as well as the health information environment itself, must focus on consumers' concerns about privacy, security, and personal control."
"Consumers have clearly understood how electronic records can improve quality of care, and the recent experience of lost medical records in hurricane Katrina has made this lesson even more vivid," said AHRQ Director Carolyn Clancy, M.D. "But access and control for the patient must be built in from the beginning. Under HHS Secretary Mike Leavitt's leadership, AHRQ will help lay the groundwork for privacy and security as an integral part of building the technical foundation for electronic health records."
To view today's research, read the draft consumer principles, or locate information on today's conference, go to www.phrconference.org or www.markle.org
Paying clinicians to reach a common, fixed performance target may produce little gain in overall quality, and may largely reward those with higher performance at baseline, according to a study in the October 12 issue of JAMA.
The number of health plans and purchasers in the United States that have adopted pay-for-performance mechanisms for quality improvement is growing rapidly, according to background information in the article. However, most of these programs are in the early stages of trial, evaluation, and adjustment. Although there is intense interest in and optimism about pay-for-performance programs among many policy makers and payers, there is little published research on pay-for-performance in health care. There have been a few studies demonstrating that pay-for-performance leads to improved quality of care.
Meredith B. Rosenthal, Ph.D., of the Harvard School of Public Health, Boston, and colleagues conducted a study on the impact of a prototypical physician pay-for-performance on quality of care within one of the nation's largest health plans, PacifiCare Health Systems. In 2003, PacifiCare began paying its California medical groups bonuses according to meeting or exceeding 10 clinical and service quality targets. The researchers examined the performance of California medical groups that were subject to pay-for-performance, and a comparison group in the Pacific Northwest (Oregon and Washington). Quality improvement reports were included from October 2001 through April 2004 issued to approximately 300 large physician organizations. There were three process measures of clinical quality: cervical cancer screening, mammography, and hemoglobin A1c testing.
The researchers found that clinical quality scores improved as follows: for cervical cancer screening, 5.3 percent for California vs. 1.7 percent for Pacific Northwest; for mammography, 1.9 percent vs. 0.2 percent; and for hemoglobin A1c testing, 2.1 percent vs. 2.1 percent. Compared with physician groups in the Pacific Northwest, the California network demonstrated greater quality improvement after the pay-for-performance intervention only in cervical cancer screening (a 3.6 percent difference in improvement). For all 3 measures, physician groups with baseline performance at or above the performance threshold for receipt of a bonus improved the least but garnered the largest share of the bonus payments.
"In the first year of its quality incentive program (QIP), the plan paid $3.4 million of a potential bonus pool of $12.9 million. Three quarters of the 172 physician groups eligible at some point during the year for the program received some funds from the bonus pool. We also observed that few groups reached a majority of targets, consistent with the low correlation in performance across clinical areas that has been observed in other studies. Physician groups whose performance was initially lowest improved the most, whereas physician groups that had previously achieved the targeted level of performance improved the least. Unlike quality improvement, which followed an inverse relationship to baseline performance, bonus dollars were garnered in direct proportion to baseline performance. Physician groups whose performance was above the bonus threshold at baseline captured 75 percent of bonus payments on average across the 3 quality domains we examined, despite their limited improvement," the authors write.
"Our findings give rise to a number of speculations about the effects of pay-for-performance. First, groups with baseline performance already above the targeted threshold appeared to understand that they needed only to maintain the status quo to receive the bonus payments. More surprising, perhaps, is that low-performing groups improved as much as they did, given that their short-run chances of receiving a bonus were likely to be low. One possibility is that the groups viewed the QIP as a larger signal of a changing environment in which they would face increasing pressure to improve their care systems and decided to begin moving in that direction. Paying explicitly for quality improvement might alter the incentives for high-performing and low-performing groups, distribute bonus dollars more toward the latter group, and possibly increase the overall impact of pay-for-performance."
The authors add that one possible reason that the QIP failed to yield a greater response is that the financial rewards for quality were too low to motivate substantial departures from the underlying trend in quality improvement. Per enrollee, the maximum annual bonus was a relatively modest $27, or about 5 percent of the professional capitation amount. Moreover, PacifiCare accounts for only about 15 percent of the average group's revenue.
"PacifiCare's QIP, like most current pay-for-performance programs, should be viewed as a first step in the direction of aligning payment incentives with health system quality goals. Realization of the full potential of pay-for-performance to reduce the persistent gap between evidence-based and actual practice will require that payers adapt their incentive strategies as evidence to support best practices accumulates. The principal lesson we derive from this experience is that incentive design matters. The accumulating evidence from the continuing experimentation with pay-for-performance in the market will highlight these initial findings and other potential design lessons," the researchers conclude.
Florida physicians reportedly continued to decrease or eliminate important health services in 2004 in response to difficulties in finding or paying for professional liability insurance, according to a study in the October 10 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
Despite growing concern about possible effects of instability in the professional liability insurance (PLI) market on patient access to health care, there has been little formal, systematic assessment of how physicians may be changing their services to adapt, according to background information in the article. Understanding the impact of professional liability insurance market instability on health service delivery is important to clinicians and policymakers concerned with patients' access to needed medical care, the authors suggest.
Robert G. Brooks, M.D., of Florida State University, Tallahassee, and colleagues surveyed rural and urban/suburban physicians in Florida in 2004 to determine recent changes in services offered, professional liability insurance premium changes, satisfaction with practice and future practice plans.
Overall, 727 (54.4 percent) of the 1,346 responding physicians (380/685 rural and 347/661 urban/suburban physicians) stated that they had decreased or eliminated the delivery of patient services in the previous year, the researchers report. "The most common services eliminated were nursing home coverage (42.1 percent), vaginal deliveries (29.1 percent) cesarean deliveries (26.0 percent), emergency department coverage (22.8 percent) and mental health services (21.2 percent). In addition to outright elimination, a number of physicians responded that they had decreased services in these areas as well. . Surgical specialists (70.2 percent) and general surgeons (68.5 percent) respectively, had the highest number of decreased or eliminated services. Obstetricians/gynecologists (63.6 percent) and family medicine physicians (60.2 percent) were also commonly represented in this group."
"Changes in health care services seemed to be related to changes in PLI premiums," the authors write. "Overall, physicians who had premium changes in the highest quartile (increase > 50 percent) (61.1 percent) were more likely to indicate that they had decreased or eliminated services compared with those in the lowest quartile (increase < 15 percent) (51.4 percent). . Similarly, we noted statistically significant relationships between increases in PLI premiums and decrease in or elimination of services for rural physicians (66.2 percent vs. 48.1 percent) and for actual premiums for urban/suburban physicians (64.7 percent vs. 43.0 percent.)"
The authors conclude that the findings presented in the study "strongly suggest that physicians across Florida have continued to decrease or eliminate important health care services. This trend seems to be affecting a broad array of services and types of physicians, both generalists and specialists. Given the importance of access to health care for vulnerable populations, these statewide trends suggest the need for additional attention by physician leaders and policy-makers to the ongoing effects of the PLI market."