Hospital strategies to engage physicians in quality improvement.

In the last decade, growing evidence that the quality of U.S. health care is uneven at best has prompted greater attention to quality improvement, especially in the nation's hospitals. While physicians are integral to hospital quality improvement efforts, focusing physicians on these activities is challenging because of competing time and reimbursement pressures. To overcome these challenges, hospitals need to employ a variety of strategies, according to a Center for Studying Health System Change (HSC) study of four communities--Detroit, Memphis, Minneapolis-St. Paul and Seattle. Hospital strategies include employing physicians; using credible data to identify areas that need improvement; providing visible support through hospital leadership; identifying and nurturing physician champions to help engage physician peers; and communicating the importance of physicians' contributions. While hospitals are making gains in patient care quality, considerably more progress likely could be made through greater alignment of hospitals and physicians working together on quality improvement.

Massachusetts health reform: high costs and expanding expectations may weaken employer support.

Passage of health reform legislation in Massachusetts required significant bipartisan compromise and buy in among key stakeholders, including employers. However, findings from a recent follow-up study by the Center for Studying Health System Change (HSC) suggest two important developments may threaten employer support as the reform plays out. First, improved access to the non-group--or individual--insurance market, the availability of state-subsidized coverage, and the costs of increased employee take up of employer-sponsored coverage and rising premiums potentially weaken employers' motivation and ability to provide coverage. Second, employer frustration appears to be growing as the state increases employer responsibilities. While the number of uninsured people has declined significantly, the high cost of the reform has prompted the state to seek additional financial support from stakeholders, including employers. Improving access to health care coverage has been a clear emphasis of the reform, but little has been done to address escalating health care costs. Yet, both must be addressed, otherwise long-term viability of Massachusetts' coverage initiative is questionable.

The transition from managed care to consumerism: a community-level status report.

This paper assesses the evolving "facilitated consumerism" model of health care at the community level using data from the Community Tracking Study (CTS). We find that in a relatively short time, large employers and health plans have made notable progress in putting the building blocks in place to support their vision of consumerism. However, developments in the CTS communities suggest that the consumerism strategy evolving in local markets is more nuanced than implied by some descriptions of health care consumerism.

Getting what we pay for: innovations lacking in provider payment reform for chronic disease care.

Despite wide recognition that existing physician and hospital payment methods used by health plans and other payers do not foster high-quality and efficient care for people with chronic conditions, little innovation in provider payment strategies is occurring, according to a new study by the Center for Studying Health System Change (HSC) commissioned by the California HealthCare Foundation. This is particularly disconcerting because the nation faces an increasing prevalence of chronic disease, resulting in continued escalation of related health care costs and diminished quality of life for more Americans. To date, most efforts to improve care of patients with chronic conditions have focused on paying vendors, such as disease management firms, to intervene with patients or redesigning care delivery without reforming underlying physician and hospital payment methods. While there is active discussion and anticipation of physician and hospital payment reform, current efforts are limited largely to experimental or small-scale pilot programs. More fundamental payment reform efforts in practice are virtually nonexistent. Existing payment systems, primarily fee for service, encourage a piecemeal approach to care delivery rather than a coordinated approach appropriate for patients with chronic conditions. While there is broad agreement that existing provider payment methods are not well aligned with optimal chronic disease care, there are significant barriers to reforming payment for chronic disease care, including: (1) fragmented care delivery; (2) lack of payment for non-physician providers and services supportive of chronic disease care; (3) potential for revenue reductions for some providers; and (4) lack of a viable reform champion. Absent such reform, however, efforts to improve the quality and efficiency of care for chronically ill patients are likely to be of limited success.

Health and wellness: the shift from managing illness to promoting health.

Despite an acknowledged lack of evidence of investment payoff, health plan initiatives to promote health and wellness are now commonplace, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. Much of the impetus has come from employers--primarily large employers--that are incorporating health and wellness activities into benefit designs that place more responsibility on employees for health care decisions and costs. Health plans now offer a range of health and wellness activities, including traditional worksite health fairs, screenings and educational seminars; access to behavior modification programs, such as weight management and smoking cessation; and online tools, including health risk assessments. Engaging enrollees in these activities, however, is challenging because participation typically is voluntary. Another barrier is employee privacy concerns. More health plans and employers are turning to financial incentives to secure greater participation. Ultimately, however, the credibility of health and wellness activities as mechanisms to improve health and contain costs is dependent on evidence demonstrating their clinical and financial effectiveness, as well as consumers' acceptance and validation of their legitimacy.

The role of nurses in hospital quality improvement.

As the nation's hospitals face increasing demands to participate in a wide range of quality improvement activities, the role and influence of nurses in these efforts is also increasing, according to a new study by the Center for Studying Health System Change (HSC). Hospital organizational cultures set the stage for quality improvement and nurses' roles in those activities. Hospitals with supportive leadership, a philosophy of quality as everyone's responsibility, individual accountability, physician and nurse champions, and effective feedback reportedly offer greater promise for successful staff engagement in improvement activities. Yet hospitals confront challenges with regard to nursing involvement, including: scarcity of nursing resources; difficulty engaging nurses at all levels--from bedside to management; growing demands to participate in more, often duplicative, quality improvement activities; the burdensome nature of data collection and reporting; and shortcomings of traditional nursing education in preparing nurses for their evolving role in today's contemporary hospital setting. Because nurses are the key caregivers in hospitals, they can significantly influence the quality of care provided and, ultimately, treatment and patient outcomes. Consequently, hospitals' pursuit of high-quality patient care is dependent, at least in part, on their ability to engage and use nursing resources effectively, which will likely become more challenging as these resources become increasingly limited.

Public health workforce shortages imperil nation's health.

After the 9/11 terrorist attacks, interest in the state of America's public health system spiked, especially related to emergency preparedness. Significant new federal funding flowed to state and local agencies to bolster public health activities. But the spotlight on shoring up the nation's public health system has faded, and the public appears unaware of escalating threats to such basic services as disease surveillance. Local health departments face a mounting workforce crisis as they struggle to recruit, train and retain qualified workers to meet their communities' needs, according to a new study by the Center for Studying Health System Change (HSC). Factors influencing the workforce shortage include inadequate funding, uncompetitive salaries and benefits, an exodus of retiring workers, insufficient supply of trained workers, and lack of enthusiasm for public health as a career choice. Local public health agencies have pursued strategies to improve workforce monitoring and planning, recruitment, retention, development and training, and academic linkages. However, little progress has been made to alleviate the shortages. Without additional support to address workforce issues, including the recruitment of the next generation of public health leaders, it is unlikely that local public health agencies will succeed in meeting growing community need, a situation potentially imperiling the public's health.

Hospital emergency on-call coverage: is there a doctor in the house?

The nation's community hospitals face increasing problems obtaining emergency on-call coverage from specialist physicians, according to findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. The diminished willingness of specialist physicians to provide on-call coverage is occurring as hospital emergency departments confront an ever-increasing demand for services. Factors influencing physician reluctance to provide on-call coverage include decreased dependence on hospital admitting privileges as more services shift to non-hospital settings; payment for emergency care, especially for uninsured patients; and medical liability concerns. Hospital strategies to secure on-call coverage include enforcing hospital medical staff bylaws that require physicians to take call, contracting with physicians to provide coverage, paying physicians stipends, and employing physicians. Nonetheless, many hospitals continue to struggle with inadequate on-call coverage, which threatens patients' timely access to high-quality emergency care and may raise health care costs.

Health care cost and access challenges persist: initial findings from HSC's 2007 site visits.

Little has changed in local health care markets since 2005 to break the cycle of rising costs, falling insurance coverage and widening access inequities, according to initial findings from the Center for Studying Health System Change's (HSC) 2007 site visits to 12 nationally representative metropolitan communities. As intense competition among hospitals and physicians for profitable specialty services continues, employers and health plans are looking to consumers to take more responsibility for medical costs, lifestyle choices and treatment decisions. While consumer-directed health plans have not gained widespread adoption, other developments-including a heightened emphasis on prevention and wellness, along with nascent provider cost and quality information-are advancing health care consumerism. However, concerns exist about whether these efforts will slow cost growth enough to keep care affordable or whether the growing problem of affordability will derail efforts to decrease the rising number of uninsured Americans and stymie meaningful health care reform.

High-performance health plan networks: early experiences.

Health plans have introduced high-performance networks to encourage use of network providers--predominantly physician specialists--deemed high performing on efficiency and quality measures. Early adopters of these networks are large national employers, and, while other employers are interested, actual adoption has lagged, according to a study by the Center for Studying Health System Change (HSC). Enrollment in products using high-performance networks is limited, and objective evidence on the impact on service use, costs and quality is lacking. Early lessons learned indicate the need for effective communication between plans and providers, use of both efficiency and quality measures, industry standards of provider performance, and employer support.

Managed care redux: health plans shift responsibilities to consumers.

Confronted with conflicting pressures to stem double-digit premium increases and provide unfettered access to care, health plans are developing products that shift more financial and care management responsibilities to consumers, according to findings from the Center for Studying Health System Change's (HSC) 2002-03 site visits to 12 nationally representative communities. Plans are pursuing these strategies in collaboration with employers that want to gain control over rapidly rising premiums while continuing to respond to employee demands for less restrictive managed care practices. Mindful of the managed care backlash, health plans also are stepping up utilization management activities for high-cost services and focusing care management on high-cost patients. While the move toward greater consumer engagement is clear, the impact on costs and consumer willingness to assume these new responsibilities remain to be seen.

Medicaid managed care: the last bastion of the HMO?

States rely on health maintenance organizations (HMOs) for their Medicaid beneficiaries because they offer guaranteed access to comprehensive benefits at a predictable cost. This is true despite movement away from HMOs, or at least the more restrictive variants, in the private sector. Plans that focus on Medicaid are becoming more central to states' programs as commercial plans exit. Publicly traded, Medicaid-focused plans are also emerging. Medicaid participating plans are aggressively managing costs and care, contrasting sharply with commercial insurance where the trend is toward less intrusive managed care. In this context, state Medicaid managed care programs are facing important policy challenges related to plan participation, mainstreaming, and product design.

Community responses to national healthcare firms.

Over the last 25 years, national Health Maintenance Organization (HMO) and hospital firms attempted to enter local markets, either by acquiring formerly independent, locally based HMOs and hospitals or by directly entering local markets. While national HMOs have been relatively successful, national hospital firms have had much less success. This paper explores the reasons for this difference. It reviews changes in presence of national HMO and hospital firms in markets, discusses common conceptual lenses through which national entry into local markets typically has been viewed, and shows how social network theory can be used to develop a better understanding of why the entry experience of national HMO and hospital firms varies across markets. The paper concludes with a research agenda that addresses issues raised by social network theory and its application to national firm entry into local markets.

How DSH payments might mislead the financial assessment of government-owned hospitals.

Hospitals are eligible for and receive Medicaid disproportionate share hospital (DSH) payments for caring for the indigent/uninsured; however, county hospitals may also be obligated to transfer these funds to the state. These transfers occur in order for state governments to utilize these funds to receive federal matching funds. Thus, not only do gross DSH payments overstate how much county-owned hospitals have available to cover their financial obligations, they may also overstate the hospital's financial condition. Using detailed California Office of Statewide Health Planning and Development (OSHPD) financial data, this study demonstrates how hospital revenue, profit, and credit measures are overvalued because they do not include the outflow of DSH funds through the intergovernmental transfers (IGTs).

Provider risk sharing in Medicaid managed care plans.

Provider risk sharing was common throughout the 1990s. Recent evidence suggests waning interest, although no information exists that is specific to Medicaid. This paper examines risk-sharing arrangements in Medicaid managed care through a survey of participating plans in eleven states conducted during 2001. Risk sharing is prevalent among Medicaid-participating plans and often involves traditional providers. The "flight from risk" that others describe is not yet apparent in Medicaid, but Medicaid's idiosyncrasies might mean that trends appearing in other lines of business do not apply.

The changing face of managed care.

Managed care plans--pressured by a variety of marketplace forces that have been intensifying over the past two years--are making important shifts in their overall business strategy. Plans are moving to offer less restrictive managed care products and product features that respond to consumers' and purchasers' demands for more choice and flexibility. In addition, because consumers and purchasers prefer broad and stable networks that require plans to include rather than exclude providers, plans are seeking less contentious contractual relationships with physicians and hospitals. Finally, to the extent that these changes erode their ability to control costs, plans are shifting from an emphasis only on increasing market share to a renewed emphasis on protecting profitability. Consequently, purchasers and consumers face escalating health care costs under these changing conditions.

Health plan responses to managed care regulation.

Little effort has been made to understand operational responses of health plans to the cascade of regulation imposed on them in the past decade. Using data from the Community Tracking Study, we cast some light on this area and illustrate how regulatory initiatives have produced both intended and unintended consequences. The findings both confirm speculation about regulatory effects and reveal some surprising and troubling developments.

Medicaid confronts a changing managed care marketplace.

After two decades of concerted efforts, more than one-half of all Medicaid beneficiaries are now enrolled in managed care arrangements. Most States appear strongly committed to continued reliance on managed care, but the contemporary managed care marketplace is undergoing a number of significant changes. We describe how several of these developments are being revealed in commercial managed care and discuss implications for Medicaid purchasers and beneficiaries. State Medicaid agencies will have to adapt managed care strategies to respond to the evolving products and practices of managed care plans and their interest in public sector product lines.