The relationship of hospital quality and cost per case in Hawaii.

One of the leading questions of our time is whether high-quality care leads to lower health care costs. Using data from Hawaii hospitals, this paper addresses the relationship of overall cost per case to a composite measure of the quality of inpatient care and a 30-day readmission rate. We found that low-cost hospitals tend to have the highest quality but the worst readmission performance. Change in quality and change in cost were also negatively correlated, but not statistically significant. We conclude that high-quality hospital care does not have to cost more, but that the dynamics of the readmission rate differ substantially from other quality dimensions.

Disparities in health, obesity and access to care among an insured population of Asian and Pacific Islander Americans in Hawai'i.

OBJECTIVE: To examine differences in health status, obesity and access among Asian and Pacific Islander Americans in Hawai'i using data from a 2007 health plan survey, including Caucasians, Puerto Ricans, American Indian and Alaska Natives, Chinese, Filipinos, Japanese, Koreans, Native Hawai'ians, Samoans, and Other Pacific Islanders. METHODS: Data were collected through a stratified random sample of adult members of a health plan in Hawai'i (n = 119,563) who saw a physician in the past 12 months. Multivariable logistic and ordinary least squares regression analyses were used to examine racial/ethnic differences in health status, access, and obesity and the impact of obesity and access on health status, after controlling for age, gender, and education. RESULTS: The highest obesity rates were found among Samoans (50%), Puerto Ricans (37%), Native Hawai'ians (36%), and Other Pacific Islanders (35%). Puerto Ricans and Samoans reported the highestnumber of poor physical health days (5.4). Samoans reported the highest number of poor mental health days (4.4). Obesity had a stronger impact than access on self-reported health status. CONCLUSION: Samoans had the highest rate of obesity, low health ratings, and a high number of days of poor health. Targeted interventions may be needed for this group.

Patient outcomes and evidence-based medicine in a preferred provider organization setting: a six-year evaluation of a physician pay-for-performance program.

OBJECTIVE: To determine whether health plan members who saw physicians participating in a quality-based incentive program in a preferred provider organization (PPO) setting received recommended care over time compared with patients who saw physicians who did not participate in the incentive program, as per 11 evidence-based quality indicators. DATA SOURCES/STUDY SETTING: Administrative claims data for PPO members of a large nonprofit health plan in Hawaii collected over a 6-year period after the program was first implemented. STUDY DESIGN: An observational study allowing for multiple member records within and across years. Levels of recommended care received by members who visited physicians who did or did not participate in a quality incentive program were compared, after controlling for other member characteristics and the member's total number of annual office visits. DATA COLLECTION: Data for all PPO enrollees eligible for at least one of the 11 quality indicators in at least 1 year were collected. PRINCIPAL FINDINGS: We found a consistent, positive association between having seen only program-participating providers and receiving recommended care for all 6 years with odds ratios ranging from 1.06 to 1.27 (95 percent confidence interval: 1.03-1.08, 1.09-1.40). CONCLUSIONS: Physician reimbursement models built upon evidence-based quality of care metrics may positively affect whether or not a patient receives high quality, recommended care.

Are physician reimbursement strategies associated with processes of care and patient satisfaction for patients with diabetes in managed care?

OBJECTIVE: To examine associations between physician reimbursement incentives and diabetes care processes and explore potential confounding with physician organizational model. DATA SOURCES: Primary data collected during 2000-2001 in 10 managed care plans. STUDY DESIGN: Multilevel logistic regressions were used to estimate associations between reimbursement incentives and process measures, including the receipt of dilated eye exams, foot exams, influenza immunizations, advice to take aspirin, and assessments of glycemic control, proteinuria, and lipid profile. Reimbursement measures included the proportions of compensation received from salary, capitation, fee-for-service (FFS), and performance-based payment; the performance-based payment criteria used; and interactions of these criteria with the strength of the performance-based payment incentive. DATA COLLECTION: Patient, provider group, and health plan surveys and medical record reviews were conducted for 6,194 patients with diabetes. PRINCIPAL FINDINGS: Without controlling for physician organizational model, care processes were better when physician compensation was based primarily on direct salary rather than FFS reimbursement (four of seven processes were better, with relative risks ranging from 1.13 to 1.23) or capitation (six were better, with relative risks from 1.06 to 1.36); and when quality/satisfaction scores influenced physician compensation (three were better, with relative risks from 1.17 to 1.26). However, these associations were substantially confounded by organizational model. CONCLUSIONS: Physician reimbursement strategies are associated with diabetes care processes, although their independent contributions are difficult to assess, due to high correlation with physician organizational model. Regardless of causality, a group's use of quality/satisfaction scores to determine physician compensation may indicate delivery of high-quality diabetes care.

Copayment level and compliance with antihypertensive medication: analysis and policy implications for managed care.

OBJECTIVE: To measure the impact of medication copayment level and other predictors on compliance with antihypertensive medications, as measured by the medication possession ratio. STUDY DESIGN: Retrospective observational analysis. METHODS: We used claims data from a large managed care organization. The identification of subjects was based on a diagnosis of hypertension and a filled prescription for antihypertensive medication between January 1999 and June 2004. Multivariate logistic regression models were used to evaluate copayment level and patient characteristics as predictors of medication compliance. RESULTS: Analysis of data for 114,232 patients filling prescriptions for antihypertensive medications revealed that compliance was lower for drugs in less preferred tiers. Relative to medications with a 5 dollars copayment, the odds ratio (95% confidence interval) for compliance with drugs having a 20 dollars copayment was 0.76 (0.75, 0.78); for drugs requiring a 20 dollars to 165 dollars copayment, the odds ratio for compliance was 0.48 (0.47, 0.49). Medication compliance also differed by patient age, morbidity level, and ethnicity, as well as by medication therapeutic class--with the best compliance observed for angiotensin receptor blockers, followed by calcium channel blockers, beta-adrenergic receptor antagonists (beta-blockers), angiotensin-converting enzyme inhibitors, and last, thiazide diuretics. CONCLUSIONS: Copayment level, independent of other determinants, was found to be a strong predictor of compliance with antihypertensive medications, with greater compliance seen among patients filing pharmacy claims for drugs that required lower copayments. This finding suggests that patient use is sensitive to price. The potential impact on compliance should be considered when making pricing and policy decisions.

Variations in clinical practice among the Hawaiian islands.

State health surveys and hospital discharge data suggest aspects of health care may vary by island in the state of Hawai'i. This study further examines the issue comparing O'ahu, Maui, Hawai'i, and Kaua'i on 15 indicators of recommended clinical care using data from a large insurer in Hawaii. The Hawaiian Islands differed to a statistically significant extent on 14 of the 15 indicators. O'ahu had the highest percentage of recommended care for six indicators, Maui for four, Kaua'i for three, and Hawai'i for two. In analyses adjusted for age, gender, morbidity, and health plan--and comparing the outer islands individually to O'ahu--O'ahu had more favorable care in 16 of 18 statistically significant comparisons. More focused geographic studies may be warranted to clarify where and why the variations in health care occur.

Remote physiological monitoring: clinical, financial, and behavioral outcomes in a heart failure population.

This article reports on the outcomes associated with remote physiological monitoring (RPM) conducted as part of a heart failure disease management program. Claims data, medical records, data transmission records, and survey results for 91 individuals ages 50-92 (mean 74 years) successfully completing a heart failure RPM program were analyzed for time periods before, during, and after the monitoring intervention. The program was associated with significant reductions in per member per month costs and emergency room and hospital utilization. More detailed analyses were performed for specific gender and age subgroups. Participant surveys indicated high levels of satisfaction, and improvements in self-perceived health status, self-efficacy, and self-management behaviors. This study is the first to assess the impact of a RPM program following removal of the monitoring equipment. The results indicate that RPM, as a component of a traditional disease management program, has a sustained, beneficial effect on participants' lifestyles after the monitoring period has ended.

Prescription drugs: elderly enrollee reports of financial access, receipt of free samples, and discussion of generic equivalents related to type of coverage.

OBJECTIVE: To compare elderly health plan enrollee's survey responses regarding access to prescription drugs, receipt of samples, and discussion of generic equivalents across healthcare delivery systems and to examine the extent to which member characteristics are related to responses. STUDY DESIGN: Cross-sectional, observational study. PATIENTS AND METHODS: Elderly enrollees (aged 65 and over) in the Preferred Provider Organization (PPO in = 10,2201) and Medicare cost contract (n = 14,635) of a single health insurer responded to a 2001 member satisfaction survey. Multivariable logistic regression was used to estimate the relationship between outcomes (eg, not filling prescriptions) and patient characteristics. RESULTS: Elderly enrollees in a PPO had more comprehensive drug coverage and better access to pharmaceuticals than Medicare enrollees, with 14% of Medicare enrollees reporting that they "occasionally" or "always" skipped filling prescriptions due to cost, compared with 6% of PPO members (P < .001). Similarly, 14% of Medicare enrollees reported taking less medication than prescribed to save money, compared with 7% of PPO members. Ethnicity was one of the strongest predictors of financial access to pharmaceuticals among elderly enrollees, with the predicted probability of "occasionally" or "never" filling medications ranging from 0.06 for Japanese to 0.16 for Filipinos. A majority of members in both health plans reported receiving free samples of pharmaceuticals from their physicians. CONCLUSIONS: Further research is needed to determine which medications are not being filled, the impact of sampling on subsequent drug utilization, and specific chronic conditions for which more extensive coverage is cost effective.

Alternate financial incentives in multi-tiered formulary systems to improve accountability for outcomes.

BACKGROUND: Drug manufacturer rebates paid to health plans and pharmacy benefit management companies have come under increased public scrutiny. Over the past several years, numerous articles have appeared in the literature encouraging a shift to a more quality-based decision-making process for health plan drug formularies. OBJECTIVE: To propose a new basis for formulary placement decisions that would include consideration of health-plan-specific measures (clinical outcomes, total cost, adherence, and appropriateness of care) and align incentives for health plans, physicians, pharmacists, and pharmaceutical companies to promote high-quality care. SUMMARY: The proposed approach builds on key components of the Pharmacy's Framework for Drug Therapy Management in the 21st Century and the Academy of Managed Care Pharmacy's Format for Formulary Submission, including a focus on patient outcomes and evidence-based decision making. The proposed approach would lessen the influence of drug manufacturer rebates on formulary placement by shifting the focus to appropriateness of care, clinical outcomes, patient adherence, and total cost of care. Pharmaceutical manufacturers would benefit from the focus on adherence to drug therapy and total cost of care. Health plans and pharmacy benefit management companies would gain in that they may be able to reduce efforts in drug utilization review as pharmaceutical manufacturers are given incentives to market their drugs more appropriately. Physicians and pharmacists would benefit because the rebate money would be used to provide quality-based financial incentives related to adherence and appropriate use of drugs. CONCLUSION: The implementation of this approach would be difficult and require cooperation from employers, pharmacists, pharmaceutical manufacturers, health plans, and pharmacy benefit management companies. Aspects of this approach could be incorporated into existing pharmacy benefit management processes to encourage the delivery of high-quality health care.

Prevalence of heart disease and its risk factors related to age in Asians, Pacific Islanders, and Whites in Hawai'i.

OBJECTIVE: To examine disparities in disease prevalence related to age and race/ethnicity. Study design. Retrospective observational study. METHODS: Eligible population included enrollees with largest insurer in Hawai'i. Chronic diseases were identified from claims data (1999-2009) based on algorithms including diagnostic codes and pharmaceutical utilization. Relative risk of heart disease and its risk factors were calculated for Native Hawaiians and Asian sub-groups by age. RESULTS: Prevalence of heart disease and its risk factors differed substantially by age and race/ethnicity. Native Hawaiians and Filipinos had higher rates of hypertension and diabetes; Asians had highest rates of hyperlipidemia. Whites had the lowest prevalence of risk factors yet their risk of heart disease equaled other groups. CONCLUSION: Prevalence curves began diverging at age 30 for risk factors and age 40 for heart disease. This suggests approaches to reduce the burden of disease for vulnerable groups need to begin in early adulthood if not sooner.

Heart failure patients receiving ACEIs/ARBs were less likely to be hospitalized or to use emergency care in the following year.

Angiotensin-converting enzyme inhibitors (ACEIs) have been shown to decrease morbidity and mortality in heart failure (HF) patients in randomized-controlled trials; observational studies have confirmed this benefit among patients discharged with HF. Investigating the benefit of ACEIs or angiotensin receptor blockers (ARBs) among general HF patients has important implications for quality-of-care measurement and quality initiatives. The objective of this study is to assess the impact of receipt of ACEIs/ARBs among patients with HF on hospitalization, emergency care, and healthcare cost during the following year. Using administrative data, we identified HF patients between 2000 and 2005 in a large health plan (n=2,396 patients). We conducted multivariate analysis to assess the impact of receipt of an ACEI/ARB on likelihood of hospitalization and emergency care, and on total healthcare cost. We found that patients who received ACEIs/ARBs were less likely to be hospitalized (odds ratio [OR]=0.82, p<.05) or use emergency care (OR=0.82, p<.05) in the following year. Receipt of ACEIs/ARBs was not associated with significantly increased cost. Incentivizing the receipt of ACEIs/ARBs in a general population with HF may be a suitable target for pay-for-performance programs, disease management programs, or newer complementary frameworks, such as value-based insurance design.

Does pay for performance improve cardiovascular care in a "real-world" setting?

The objective was to investigate the impact of a pay-for-performance program (P4P) on quality care and outcomes among cardiovascular disease (CVD) patients. Claims data were used to identify CVD patients in a commercial plan in 1999-2006. Multivariate analyses were employed to examine the impact of P4P on quality care (lipid monitoring and treatment) and quality care on outcomes (new coronary events, hospitalizations, and lipid control). Patients who were treated by physicians participating in P4P were more likely to receive quality care than patients who were not. Patients who received quality care were less likely to have new coronary events (odds ratio [OR] = 0.80; 95% confidence interval [CI] = 0.69-0.92), be hospitalized (OR = 0.76; 95% CI = 0.69-0.83), or have uncontrolled lipids (OR = 0.67; 95% CI = 0.61-0.73) than patients who did not. A P4P program was associated with increased lipid monitoring and treatment. Receipt of this quality care was associated with improved lipid control and reduced likelihood of new coronary events and hospitalizations.

Impact of a pay-for-performance program on low performing physicians.

Studies have shown that the lowest performing physicians in pay-for-performance (P4P) programs improved the most; however, it is unclear whether this would occur without the P4P program or be sustained. The objective of this study is to investigate the impact of P4P in a Preferred Provider Organization (PPO) on low performing physicians over a 4-year period. We used administrative claims data from a PPO health plan in Hawaii, which implemented a P4P program, and a PPO plan in the South, which did not implement a P4P program. The difference-indifference model was used to compare the quality scores between the two physician groups in preventive measures, a heart failure measure, and an HbA1c testing measure. We found that P4P programs may be effective in incentivizing low performing physicians to improvement quality of care and sustain improvement, and the positive benefit of the P4P program may not be realized until the 3rd or 4th year of the program.

The effect of a PPO pay-for-performance program on patients with diabetes.

OBJECTIVES: To investigate the effectiveness of a pay-for-performance program (P4P) to increase the receipt of quality care and to decrease hospitalization rates among patients with diabetes mellitus. STUDY DESIGN: Longitudinal study of patients with diabetes enrolled in a preferred provider organization (PPO) between January 1, 1999, and December 31, 2006. METHODS: We used multivariate analyses to assess the effect of seeing P4P-participating physicians on the receipt of quality care (ie, glycosylated hemoglobin and low-density lipoprotein cholesterol testing) and on hospitalization rates, controlling for patient characteristics. RESULTS: Patients with diabetes who saw P4P-participating physicians were more likely to receive quality care than those who did not (odds ratio, 1.16; 95% confidence interval, 1.11-1.22; P <.001). Patients with diabetes who received quality care were less likely to be hospitalized than those who did not (incident rate ratio, 0.80; 95% confidence interval, 0.80-0.85; P <.001). During 1 year, there was no difference in hospitalization rates between patients with diabetes who saw P4P-participating physicians versus those who did not. However, patients with diabetes who saw P4P-participating physicians in 3 consecutive years were less likely to be hospitalized than those who did not (incident rate ratio, 0.75; 95% confidence interval, 0.61-0.93; P <.01). CONCLUSIONS: A P4P can significantly increase the receipt of quality care and decrease hospitalization rates among patients with diabetes in a PPO setting. Although it is possible that the differences observed between P4P-participating physicians and non-P4P-participating physicians were due to selection bias, we found no significant difference in the receipt of quality care between patients with diabetes who saw new P4P-participating physicians versus non-P4P-participating physicians during the baseline year. Further research should focus on defining the effect of P4Ps on intermediate outcomes such as glycosylated hemoglobin and low-density lipoprotein cholesterol levels.

Antihypertensive adherence and drug class among Asian Pacific Americans.

OBJECTIVE: Research on adherence has emphasized the need to consider patient ethnicity when developing adherence plans. The objective of this study is to identify predictors of adherence for specific groups, particularly Asian Americans and Pacific Islanders. METHODS: We examined the factors, including drug class, associated with antihypertensive adherence for 28,395 adults in Hawaii (July 1999-June 2003) using health plan administrative data. The population included Japanese (n=13,836), Filipino (n=3,812), Chinese (n=2,280), Korean (n=450), part-Hawaiian (n=3,746) and white (n=3,920) patients. Members with antihypertensive medication in their possession >or=80% of the time were considered adherent. Multivariable logistic regression models were used to identify factors associated with adherence. RESULTS: Overall adherence rates were less than 65% among all racial/ethnic groups. After adjustment for patient age, gender, morbidity level, health plan type, isle of residence, comorbidities and year of treatment, Japanese were more likely than whites to adhere to antihypertensive therapy [OR=1.21 (1.14-1.29)], whereas Filipino [OR=0.69 (0.64-0.74)], Korean [OR=0.79 (0.67-0.93)] and Hawaiian [OR=0.84 (0.78-0.91)] patients were less likely to adhere. These results were consistent across therapeutic class. Other patient factors associated with lower adherence included younger age, higher morbidity and history of heart disease. Patient factors were also significantly related to adherence, including gender and seeing a sub-specialist. Seeing a physician of the same ethnicity did not appear to improve adherence. CONCLUSIONS: Our findings of substantial disparities among Asian Pacific American subgroups highlight the need to examine subgroups separately. Future qualitative research is needed to determine appropriate interventions, particularly for Filipino, Korean and Hawaiian patients.

Follow-up services after an emergency department visit for substance abuse.

OBJECTIVE: The recent introduction of substance abuse treatment measures to the Health Plan Employer and Data Information Set (HEDIS) highlights the importance of this area for managed care organizations (MCOs). Particularly challenging are members first diagnosed in an emergency department (ED). STUDY DESIGN: Retrospective claims analysis. METHODS: Claims were abstracted for all members who used an ED in 2004 for a diagnosis of substance abuse in a large commercial MCO. General linear models were used to estimate the association between receiving follow-up care within 14 and 60 days and sex, age, type of primary diagnosis, substance abused, and level of use. RESULTS: Of the 1235 patients who visited an ED with a diagnosis of substance abuse, 13% received follow-up substance abuse services within 14 days of their ED visit. An additional 36% of patients had an outpatient service that did not code a substance abuse diagnosis within 2 weeks of an ED visit. The diagnosis breakdown of patients' primary diagnoses was 28% substance use, 13% mental health issues, and 59% nonpsychiatric (medical) disorders. The multivariable regression analyses revealed having a nonpsychiatric (medical) primary diagnosis was the strongest predictor of not receiving follow-up care (relative risk = 0.51) at 14 days compared with patients who had a mental health diagnosis. CONCLUSIONS: Training ED staff and nonbehavioral health outpatient providers in treatment follow-up for substance abuse may improve the quality of care for patients. Encouraging providers to code for substance abuse when treatment or counseling is delivered would improve health plan HEDIS scores. Interventions may be needed for frequent ED users with substance abuse.

Health disparities in 30 indicators of recommended clinical care.

This article examines variations in clinical practice for 30 clinical indicators. Patients' age, gender, and morbidity and certain characteristics of their physicians affected whether they received recommended care. Recommended care increased with patient age for 13 significant clinical indicators and decreased with age for 7 others. Males received recommended care more often for 12 of 13 clinical indicators. Recommended care varied by physician specialties for health screenings, disease management, and medication use. Patients seeing physicians who treated a high volume of patients generally received better care. The variations in recommended care suggest potential targets for healthcare quality improvements.

Aligning financial incentives with quality of care in the hospital setting.

This article describes the structure, implementation, and early results of a performance-based hospital incentive program designed by a large nonprofit health plan. The Hospital Quality Service and Recognition program, developed by the Hawaii Medical Service Association, was launched in 2001 to reward high-quality medical care at the hospital level. This pay-for-performance program used administrative claims data, survey data, and hospital-reported information to assess hospital performance in risk-adjusted complications and risk-adjusted length of stay (LOS), patient satisfaction, and hospital processes of care measures. Financial incentives were provided to participating hospitals based on their performance on these measures. Preliminary outcomes of the program evaluated over a 4-year period after implementation revealed improvements in aggregated rates of risk-adjusted surgical complications and efficiency of care as evidenced by a substantial decrease in risk-adjusted average LOS for several surgical procedures. Quality improvement was demonstrated in several other program components including emergency department satisfaction. This quality incentive program offers an innovative approach for encouraging delivery of high-quality and service-oriented care in a statewide network of participating hospitals.

A quality-driven physician compensation model: four-year follow-up study.

This case report describes a qualitative and preliminary quantitative assessment of a quality-based physician compensation program. The Hawaii Medical Service Association's Physician Quality and Service Recognition program offers an innovative and effective approach for improving delivery of high-quality and cost-effective care to patients enrolled in preferred provider organizations. Support for the program is demonstrated through increasing numbers of voluntarily participating physicians. Preliminary assessment of population outcomes reveals sustained improvements in many clinical areas and mixed findings in others. This study contributes to the body of knowledge available to payers and policy makers considering alternative payment methods to reward improved performance.