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National Health Care Reform: Selected Publications

Access | Efficiency | Equity | Transition

Access

"Study of Rhode Island's Uninsured: Current Costs and Future Opportunities." Deborah Chollet, Jeffrey Ballou, Allison Barrett, and Thomas Bell, March 2010. In 2008, the average cost of employer-based family coverage in Rhode Island was $8,023 per year, roughly 24 percent of average Rhode Island wages. From 2001 to 2008, the share of state residents under age 65 with employer-sponsored insurance dropped from 73 to 67 percent, while the number of uninsured Rhode Islanders under age 65 increased to nearly 12 percent of the population. This report helps policymakers and stakeholders understand the number of uninsured in Rhode Island, current health care spending by and for the uninsured,and the change in health care spending that would occur if they became insured.

"Synthesis of 10 Case Studies: Exploring Medicaid and SCHIP Enrollment Trends and Their Links to Policy and Practice."Covering Kids & Families Evaluation. Judith Wooldridge, Christopher Trenholm, and Angela Gerolamo, April 2009. 

"SCHIP Children: How Long Do They Stay and Where Do They Go?" Christopher Trenholm, James Mabli, and Ander Wilson, January 2009. This brief highlights findings from a seven-state study examining retention of children in the State Children's Health Insurance Program (SCHIP) and coverage after they leave the program. Once children enrolled in SCHIP leave public insurance, they are far more likely to become uninsured—and remain uninsured for some time—than they are to obtain private coverage. The findings suggest that the extent to which SCHIP has substituted for private insurance may be well below the rates estimated in some studies.

"State Policies to Encourage High-Deductible and Limited-Benefit Health Plans: Costs, Constituents, and Concerns." Lynn Quincy, March 2009. Limited-benefit plans offer less comprehensive coverage at lower premiums because they require high deductibles, exclude coverage of some services, or both. This policy brief looks at state efforts to encourage the use of these plans as a way to provide some coverage amid escalating costs. The brief describes different types of plans, their costs and enrollment, and state policies designed to promote them. Some state programs that heavily subsidize premiums for limited-benefit plans have succeeded in enrolling people who were previously uninsured, but in the absence of subsidies or in the presence of modest subsidies, there is little evidence that limited-benefit plans enroll a significant number of uninsured people.

"Using Section 125 Premium-Only Plans to Expand Health Coverage." Trends in Insurance Coverage Issue Brief #5. Lynn Quincy, October 2008. IRS Section 125 employee benefit plans lower taxable income and tax liability by letting employees pay their share of employer health insurance premiums on a pre-tax basis. This issue brief explores how states are using these plans to increase access to health coverage. Workers whose employers offer them health coverage but pay their premiums after taxes could benefit from policies expanding use of Section 125, which makes offered coverage more affordable. Despite advantages for workers, many small employers do not offer these plans because employers are not familiar with them or with the tax treatment of employer-sponsored health benefits more generally.

"Improving Public Coverage for Children: Lessons from CKF in New Jersey." Chioma Uzoigwe, Sheila Hoag, and Judith Wooldridge, August 2008. Health insurance coverage in New Jersey is threatened seemingly on all sides: private insurance coverage is eroding; the number of uninsured individuals is growing; and state budget pressure, combined with federal policy pressure, could lead to public insurance coverage cutbacks. Thus, the need for advocates for health insurance coverage is greater than ever. An historical review of the Robert Wood Johnson Foundation’s Covering Kids & Families grant in New Jersey reveals that advocates for insurance coverage, working in concert with state officials, can positively impact public insurance policy and procedures, and can sustain this work even after its funding ends.

"Analysis of Reform Models for Extending Health Care Coverage in New Mexico." Deborah Chollet and Lee Reynis, March 2008. Despite New Mexico’s significant and ongoing effort to enroll residents who are eligible for Medicaid or SCHIP in those programs, the number of New Mexicans who are uninsured at least six months during the year is projected to reach 18 percent of the noninstitutionalized civilian population under age 65 by FY2010. Responding to concerns about the high and growing number of New Mexicans without coverage, the Legislative Council Service (LCS) requested that Mathematica Policy Research, Inc. develop estimates of the cost of four alternative reform models intended to ensure that all New Mexicans become and remain insured.

"Leading The Way? Maine's Initial Experience in Expanding Coverage Through Dirigo Health Reforms." Debra Lipson, James Verdier, Lynn Quincy, Robert Hurley, Elizabeth Seif, Shanna Shulman, and Matt Sloan, November 2007. Since enacting comprehensive health care reform in 2003, Maine's Dirigo Health program has helped expand coverage for low- and moderate-income individuals. By September 2006, about 16,100 individuals were enrolled in two coverage initiatives—DirigoChoice, a subsidized insurance product, and a Medicaid eligibility expansion for low-income parents of dependent children. While these programs are making health coverage more affordable to low-income individuals, small firms, and sole proprietors, with subsidies targeting those most in need, by late 2006 the initiatives had enrolled less than 10 percent of previously uninsured residents. To pay for this expanded coverage, Maine has utilized savings in the overall health care system due to lower uncompensated care and cost controls. However, the funds raised thus far are insufficient to pay for greater subsidized enrollment in Dirigo programs, leading to a search for other financing sources to sustain the program.

"Three Independent Evaluations of Healthy Kids Programs Find Dramatic Gains in Well-Being of Children and Families." In Brief #1. Christopher Trenholm, Embry Howell, Ian Hill, and Dana Hughes, November 2007. Since 2001, initiatives have emerged in 25 of California’s 58 counties to expand health insurance coverage for children. These initiatives make use of a new insurance product, Healthy Kids, that covers children who are ineligible for Medi-Cal and Healthy Families, California’s public programs for children in families with incomes up to 250 percent of the federal poverty level. This brief presents highlights from evaluations of Healthy Kids programs in Los Angeles, San Mateo, and Santa Clara counties. The brief notes that children’s access to and use of medical care improved, unmet health care needs declined, and parents of children enrolled in Healthy Kids reported far more confidence that they could obtain care for their children.

"Increasing Children's Coverage and Access: A Decade of SCHIP Lessons." Margo Rosenbach, September 2007. Expanding health coverage for children is at the center of health policy debates as reauthorization of the 10-year-old State Children’s Health Insurance Program (SCHIP) continues. This brief is based on Mathematica’s national evaluation of SCHIP conducted for the Centers for Medicare & Medicaid Services (CMS). The analysis highlights states’ progress in conducting outreach, averting substitution, improving access, and reducing the number of uninsured low-income children.

"SCHIP at 10: A Synthesis of the Evidence on Substitution of SCHIP for Other Coverage." So Limpa-Amara, Angela Merrill, and Margo Rosenbach, September 2007. When SCHIP was enacted in 1997, policymakers sought to safeguard against the substitution of SCHIP for other insurance coverage. This report synthesizes and assesses evidence from published and unpublished literature and state SCHIP annual reports on the magnitude of substitution in SCHIP. Wide-ranging estimates across studies are explained as a function of differences in purposes, methods, and analytic perspectives.

“Stable Coverage Benefits Healthy Kids Children." Christopher Trenholm, June 2007. Launched in January 2001 by the Santa Clara County Children’s Health Initiative (CHI), the Healthy Kids program provides health insurance coverage to over 13,000 children in the county with household incomes up to 300 percent of the federal poverty level ($62,000 for a family of four) who are ineligible for the two major state insurance programs in California, Medi-Cal and Healthy Families. The vast majority of Healthy Kids children have household incomes below 250 percent of the federal poverty level, low enough to qualify them for one of the state programs, but they are ineligible for these programs because of their immigration status. This brief presents findings from two surveys of families with incomes below 250 percent of the federal poverty level with a child enrolled in Healthy Kids. Families were first surveyed after their child had been enrolled for about one year. They were surveyed again after their child had been enrolled for about four years. The brief describes changes in children’s medical care and other outcomes between these two surveys—that is, during the most recent three years that they had stable Healthy Kids coverage.

“Santa Clara County Children’s Health Initiative Improves Children’s Health.” Embry Howell and Christopher Trenholm, March 2007. This brief presents findings from a survey of families with children who are enrolled in the Healthy Kids program in Santa Clara County, California. Launched in January 2001 by the Santa Clara County Children’s Health Initiative (CHI), Healthy Kids provides health insurance coverage to children in the county with household incomes up to 300 percent of the federal poverty level ($62,000 for a family of four) who are ineligible for the two major state insurance programs, Medi-Cal and Healthy Families. The vast majority of Healthy Kids children have household incomes below 250 percent of the federal poverty level, low enough to qualify them for one of the state programs, but they are ineligible for these programs because of their immigration status. This brief describes the impact of Healthy Kids on children’s health status, including perceived health, functional limitations, and school days missed because of health problems.

"A Compendium of State and Local Initiatives to Expand or Retain Employer-Based Coverage." Deborah Chollet and Lynn Taylor, November 2005. Many states and some local communities are experimenting with programs to expand access to employer-based coverage. Recognizing that there are a variety of reasons that workers are uninsured, these programs take different approaches that target those reasons. Many programs target employers that do not offer coverage—the most common reason that workers lack employer-based coverage. Most programs to expand employer-based coverage offer a subsidy, either to induce employers to begin offering coverage or to assist the significant number of uninsured workers who cannot afford their share of the premium even when offered coverage. Typically, these programs target workers or children at family income levels that also would qualify them for coverage from Medicaid or the State Children’s Health Insurance Program (SCHIP). Very few programs rely solely on unsubsidized approaches to expand coverage, although several take a “hybrid” approach, combining subsidies with unsubsidized strategies to expand group coverage. Unsubsidized strategies may include authorizing the sale of one or more limited-benefit insurance products (stripped of state-mandated benefits) or the development of purchasing pools to help streamline the purchase of insurance for small employers and provide additional coverage options for workers. Small firms (with fewer than 50 employees)—which have difficulty affording coverage and also may find the market for insurance difficult to navigate—are the usual targets for these strategies. This report reviews major state and local programs that attempt to expand or retain employer-based coverage.

"Congressionally Mandated Evaluation of the State Children's Health Insurance Program." Judith Wooldridge, Genevieve Kenney, Christopher Trenholm, Lisa Dubay, Ian Hill, Myoung Kim, Lorenzo Moreno, Anna Sommers, and Stephen Zuckerman, October 2005. Across the country, children without health insurance are a cause for concern. This report examines the design and implementation of State Children's Health Insurance Programs, noting that they were succeeding in almost all areas examined. The study focused on 10 states with a large proportion of eligible and enrolled children nationwide, developing findings from surveys of enrolled and recently disenrolled children in those states. The study incorporated a national perspective, drawing on a national survey of state program administrators, and from a national survey of low-income uninsured children.

Health Policy and the Uninsured, edited by Catherine McLaughlin, 2004. As part of the Economic Research Initiative on the Uninsured (ERIU), this publication is a comprehensive and rigorous review of health insurance coverage trends in the United States. The United States is unique in the industrialized world in the number of people without health insurance. In 2002, nearly 44 million Americans did not have health insurance coverage. Despite long-running study of this problem, the political debate on health insurance is often based on conventional wisdom and studies that haven’t been integrated into a careful theoretical framework. In Health Policy and the Uninsured, leading experts in health policy survey the literature on this subject, synthesizing a wide range of health insurance studies into a comprehensive overview of the uninsured. They consider the methodological hurdles involved in the research, explore the complex interaction between health insurance and labor supply, and highlight the special issues facing children, racial or ethnic minorities and immigrants, the near-elderly, and people with psychiatric or substance abuse disorders. This coordinated critique serves several purposes: First, it summarizes for policymakers what we do not know about the uninsured. Second, it provides a framework for the health policy research needed to fill the remaining gaps in our knowledge. And finally, it serves as a useful primer for economists and other policy analysts.

"Approaching Universal Coverage: Minnesota's Health Insurance Programs."  Deborah Chollet and Lori Achman, February 2003. Ninety-five percent of nonelderly people in Minnesota had health insurance in 2001, relating in part to widespread employer-sponsored coverage. However, this study finds that five state-sponsored programs are important partners in this achievement, providing coverage for low-income children and adults, as well as individuals who have trouble finding insurance in the private market because of health problems. Together, these programs cover about 11 percent of the state's nonelderly population. Executive Summary

"Counting the Uninsured: A Review of the Literature." Occasional Paper Number 8. John Czajka, Kimball Lewis, and Marilyn Ellwood, July 1998. This publication is a seminal paper on the methodology for counting the uninsured in the United States. Assessing the New Federalism is a multi-year Urban Institute project designed to analyze the devolution of responsibility for social programs from the federal government to the states, focusing primarily on health care, income security, job training, and social services. Researchers monitor program changes and fiscal developments. In collaboration with Child Trends, Inc., the project studies changes in family well-being. The project aims to provide timely, nonpartisan information to inform public debate and to help state and local decisionmakers carry out their new responsibilities more effectively. Key components of the project include a household survey, studies of policies in 13 states, and a database with information on all states and the District of Columbia, available at the Urban Institute's Web site. This paper is one in a series of occasional papers analyzing information from these and other sources.

Efficiency

"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.

"Experience from 2006: State Health Care Expenditures." Baltimore, MD: Maryland Health Care Commission, Deborah Chollet and Eric Schone (contributing authors), January 2008.

"The Business Case for Accurate Data on Quality and Savings in Medical Home Programs." Presentation. National Medical Home Summit, March 2010, Debbie Peikes. 

"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. Medical homes are part of our nation’s overall efforts to reform the health care system. For decades, medical homes have been a model for coordinating health care for children, particularly those with special health care needs.This brief 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. 

"Encouraging Appropriate Use of Preventive Health Services" Reforming Health Care Issue Brief # 2. Jill Bernstein, Deborah Chollet, and G. Gregory Peterson, May 2010. This brief 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.

"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. This brief looks at the research evidence on the effectiveness of disease management programs and the role of disease management in health care reform.

"Quality's New Frontier: Reducing Hospitalizations and Improving Transitions in Long-Term Care." Trends in Health Care Quality, Issue Brief #7. Debra J. Lipson and Samuel Simon,  March 2010. This brief reviews recent efforts to measure and reduce potentially avoidable hospitalization and improve care transitions for individuals who use long-term care, including residents of nursing homes and people in home- and community-based service settings. The authors describe three areas in which progress is needed: (1) validated measures of avoidable hospitalizations and care transitions for use in long-term care; (2) wider adoption of evidence-based care models and
interventions that work in these settings; and (3) payment reforms that give providers a financial incentive to measure and improve performance.

"Using Qualitative and Quantitative Methods to Evaluate Small-Scale Disease Management Pilot Programs." Subscription required. Population Health Management, vol. 12, no. 1, February 2009, Dominick Esposito, Erin Fries Taylor, and Marsha Gold. This paper describes a multi-method approach for evaluating 10 small interventions that participated in the Medicaid Value Program, which sought to improve quality of care for Medicaid beneficiaries with multiple chronic conditions. The approach relied on quantitative and qualitative methods to develop a complete understanding of each intervention. The collective experiences suggest that well-conceived efforts to integrate care across the range of services required by beneficiaries with chronic conditions may have some promise if the interventions target the proper patient groups, are standardized ahead of time, receive buy-in from key clinical staff, and are supported by organizational leadership.

"Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries: 15 Randomized Trials." Journal of the American Medical Association, February 2009, Deborah Peikes, Arnold Chen, Jennifer Schore, and Randall Brown. Presents findings from the third report to Congress on the Medicare Coordinated Care Demonstration.

"Enhanced Primary Care Case Management Programs in Medicaid: Issues and Options for States." James M. 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.

"Promising Models of Care Coordination in Medicare: Lessons for Medicaid Beneficiaries with Chronic Illnesses." National Academy for State Health Policy Annual Conference, Deborah Peikes, Randall Brown, Greg Peterson, and Jennifer Schore, October 2009. 

"Financial Incentives for Health Care Providers and Consumers." Reforming Health Care Issue Brief No. 5. Jill Bernstein, Deborah Chollet, and Stephanie Peterson, May 2010. 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. This brief looks at evidence on the impacts of these financial incentives and draws lessons for policymakers.

"Using Payment Incentives to Improve Care for the Chronically Ill in Medicare: First Year Implementation of the Medicare Care Management Performance Demonstration (MCMP)." Suzanne Felt-Lisk, Christopher Fleming, Brenda Natzke, and Rachel Shapiro, March 2009. The MCMP demonstration aims to improve quality and coordination of care for chronically ill Medicare beneficiaries and to promote adoption and use of health information technology (HIT) by small-to medium-sized primary care practices. This report looks at implementation experiences, use of electronic health records, and care management activities in eight primary care practices in each of the four participating states: Arkansas, California, Massachusetts, and Utah. MCMP appears to have prompted improvements to documentation of care and, to a lesser extent, modest positive operational changes in many of the practices. Changes are typically inconsistently applied based on practitioner and staff time and interest.

"Strategies for Reining in Medicare Spending Through Delivery System Reforms: Assessing the Evidence and Opportunities." Randall Brown, September 2009. Menlo Park, CA: The Henry J. Kaiser Family Foundation. 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.

"The Promise of Care Coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses." Randall Brown, March 2009. Las Vegas, NV: American Society on Aging and the New York Academy of Medicine National Forum on Care Coordination. Numerous studies have documented that a relatively small percent of Medicare beneficiaries with multiple chronic conditions account for the vast majority of Medicare spending. This paper synthesizes evidence on cost-effective interventions and their components, identifies issues that must be resolved for ongoing research, and presents recommendations for care coordination policies in health care reform that can be supported by available evidence. The author highlights three interventions that have reduced hospitalizations for the target population: transitional care, self-management education, and coordinated care. Policy recommendations include offering vehicles for physicians in small practices to participate in an effective care coordination intervention, targeting medical homes and care coordination interventions to beneficiaries at substantial risk of hospitalization in the coming year, and creating incentives for hospitals to participate in transitional care interventions. Executive Summary

"Matching Patients to Medical Homes: Ensuring Patient and Physician Choice." Policy Perspective: Insights into Health Policy Issues, No. 1. Deborah Peikes, Hoangmai H. Pham, Ann S. O'Malley, and Myles Maxfield, December 2008. Key operational issues facing medical home initiatives include how to qualify physician practices as medical homes; how to match patients to their medical homes; how to engage patients and other providers to work with medical homes in care coordination; and how to pay practices that serve as medical homes.

"Disabled Americans' Long Wait for Health Coverage." Interview with Gina Livermore. The Commonwealth Fund website, December 2008. Newly disabled adults face innumerable challenges, not the least of which is securing affordable health insurance coverage. After waiting months to begin receiving cash benefits from the Social Security Disability Insurance (SSDI) program, they must wait an additional two years to begin receiving Medicare benefits. Mathematica and the Commonwealth Fund are studying the impact of Medicare's waiting period on people with disabilities, and the struggles they encounter as they must navigate the maze of SSDI and Medicare while trying to obtain the health care they need.

"Using Physician Payment Reform to Enhance Health System Performance." Marsha Gold and Suzanne Felt-Lisk, December 2008. The United States health care system performs poorly on many key objectives, and enhancing the system is at the top of the policy agenda. Improving the payment methods used to compensate and reward physicians could go a long way toward creating a more high-performing health care system. This policy brief explores what is known about using physician payment to improve health system performance, suggesting that future priorities move beyond pay for performance of individual services and reward physicians for influencing totality of a patient’s care across all providers and settings.

"Medicare's Private Plans: A Report Card on Medicare Advantage." Marsha Gold, November 2008, Health Affairs, Web Exclusive (subscription required). With higher payments and expanded private-plan authority, Medicare Advantage (MA) has caused the market to grow. One in three Medicare beneficiaries with Part D now gets this coverage through MA. Analysis of the sources of and reasons for enrollment growth suggest a troubling report card. Clearly, the Medicare Modernization Act (MMA) has expanded choice and the private-sector role. But it also has added to Medicare's complexity and costs and has created potential inequities, without apparent improvements in quality. However the debate ends, a stronger system of performance monitoring and accountability is needed to meet Medicare's essential fiduciary requirements and oversight responsibilities.

"15-Site Randomized Trial of Coordinated Care in Medicare Fee-for-Service." Randall Brown, Deborah Peikes, Arnold Chen, and Jennifer Schore, Health Care Financing Review, fall 2008. This study randomly assigned Medicare fee-for-service beneficiaries who had chronic illnesses and volunteered to participate in 15 care coordination programs to treatment or control status. Nurses provided patient education (mostly by telephone) to improve adherence and ability to communicate with physicians. The findings after two years show that few programs improved patient behaviors, health, or quality of care. The treatment group had significantly fewer hospitalizations in only one program; no program reduced gross or net expenditures. However, effects may be observed after four years of followup are available and sample sizes increase.

"Impacts of a Disease Management Program for Dually Eligible Beneficiaries." Dominick Esposito, Randall Brown, Arnold Chen, Jennifer Schore, and Rachel Shapiro, Health Care Financing Review, fall 2008. This articles examines interim impacts of a disease management demonstration for Medicare fee-for-service beneficiaries also enrolled in Medicaid (dual eligibles). The study randomly assigned dual eligibles with congestive heart failure, coronary artery disease, and/or diabetes to treatment or control groups for a population-based program that provides telephone patient education and monitoring services. Findings during the first 18 months show virtually no overall impacts on hospital or emergency room use, Medicare expenditures, quality of care, or prescription drug use for the 33,000 enrollees. However, for beneficiaries with congestive heart failure who resided in high-cost counties, the program reduced Medicare expenditures by 9.6 percent.

"Health Benefits for the Uninsured: Design and Early Implementation of the Accelerated Benefits Demonstration." David Wittenburg, Peter Baird, Lisa Schwartz, and David Butler, September 2008. Many Social Security Disability Insurance (SSDI) beneficiaries have serious health care needs, but, under current law, most are not eligible for Medicare until 29 months after the Social Security Administration (SSA) has established the onset of their disability. To test whether providing immediate health care and related services leads to improved health and better return-to-work outcomes for newly entitled SSDI beneficiaries, SSA funded the five-year Accelerated Benefits (AB) Demonstration. AB will provide the first set of rigorous findings on the efficacy of providing earlier access to health benefits for a population of beneficiaries who have no medical coverage when they first become entitled to disability cash benefits. The early findings from the demonstration indicate substantial variation exists in uninsurance rates across metropolitan areas and a large demand for health benefits and related services exists among uninsured new SSDI beneficiaries.

"Medicare Advantage in 2008." Marsha Gold, June 2008. Medicare Advantage (MA), a voluntary program that provides beneficiaries with an alternative way to access traditional Medicare benefits, replaced the Medicare+Choice program in 2004 and became fully operational in 2006. This issue brief reviews recent trends in the program and includes information trends in firm participation and market share, changes in beneficiary choice, and growth in MA plans available to employer groups. The brief notes that the number of Medicare beneficiaries in MA plans continues to grow, to 8.2 million at the end of 2007, up from 5.4 million in March 2005. In the first four months of 2008, enrollment increased by more than 800,000. Private fee-for-service plans account for more than half of this new growth. About one in five Medicare beneficiaries (19 percent) is enrolled in an MA plan. In addition, four main players—UnitedHealthcare, Humana, Kaiser, and Blue Cross Blue Shield—accounted for more than half of enrollment at the end of 2007.

"Engaging Consumers: What Can Be Learned from Public Health Consumer Education Programs?" Margaret Gerteis, Matthew Hodges, and James Mulligan, March 2008. The Medicare Payment Advisory Commission recognizes the importance of engaging consumers in the movement to promote greater quality and efficiency in the healthcare system. In this project, MedPAC contracted with Mathematica to explore what can be learned from other public health campaigns in other arenas about strategies for engaging consumers and influencing their behavior.

"Report to Congress on the Evaluation of Medicare Disease Management Programs." Arnold Chen, Randall Brown, Dominick Esposito, Jennifer Schore, and Rachel Shapiro, February 2008. Before Medicare Part D, Congress authorized the Medicare disease management demonstration to evaluate whether disease management programs—in conjunction with a comprehensive prescription drug benefit—could improve health outcomes and reduce Medicare expenditures. The demonstration targeted fee-for-service Medicare beneficiaries with advanced congestive heart failure, diabetes, or coronary artery disease. This congressionally mandated study found that, based on the population-based random assignment design, none of the three demonstration programs had impacts on key outcomes of Medicare Part A and B expenditures and service use.

"Third Report to Congress on the Evaluation of the Medicare Coordinated Care Demonstration." Deborah Peikes, Randall Brown, Arnold Chen, and Jennifer Schore, January 2008. This report evaluates whether disease management, in conjunction with comprehensive prescription drug benefits, improve health outcomes and reduce costs.

"Health Plans' Use of Physician Resource Use and Quality Measures." Timothy Lake, Margaret Colby, and Stephanie Peterson, October 2007. In recent years, health plans have developed measures of health service resource use to assess efficiency of care physicians and other providers deliver primarily relying on tools commonly known as "episode groupers." This report investigates the use of episode grouper-based measures in the private sector in four health markets around the country: Austin, Boston, Cleveland, and Seattle. Health plans included in the study have multiple years of technical experience implementing physician resource use and quality measures; however, most are still in the early stages of determining the best ways to use these measures in their local markets. The report includes lessons for future quality measurement efforts in Medicare and other programs.

"Cash and Counseling: Improving the Lives of Medicaid Beneficiaries Who Need Personal Care or Home- and Community-Based Services." Randall Brown, Barbara Lepidus Carlson, Stacy Dale, Leslie Foster, Barbara Phillips, and Jennifer Schore, August 2007. To address the needs of Medicaid beneficiaries who are elderly or disabled and desire greater control over their personal care, the federal government has encouraged states to offer consumer-directed options. One of the most innovative and flexible consumer-directed-care models is Cash and Counseling, recently tested in a demonstration program in Arkansas, Florida, and New Jersey. The program gives consumers a monthly allowance that they may use to hire workers and to purchase care-related services and goods. This report summarizes findings from five years of research on how each of the three demonstration states implemented its program, and on how the programs have affected consumers who participated, consumers’ paid and unpaid caregivers, and costs to Medicaid. The findings from the randomized trial study design show that the program had overwhelmingly positive effects on consumers of all ages and their caregivers. However, in each state, total Medicaid expenditures were higher under the program than what they would have been in its absence, for different reasons. States interested in offering a Cash and Counseling program or similar consumer-directed options may benefit from the report’s discussion of lessons learned about how to control costs. Executive Summary

"Making Pay-for-Performance Work in Medicaid.” Suzanne Felt-Lisk, Gilbert Gimm, and Stephanie Peterson, Health Affairs, Web Exclusive, June 2007. This article examines five Medicaid-focused health plans that implemented new financial incentives for physicians to improve the timeliness of well-baby care. By contrasting the experiences of plans with better and worse outcome trends, the authors identify key program features, including strong communication with providers and placing enough dollars at stake to compensate providers for the effort required to obtain the desired outcomes. The article also highlights barriers to improvement that future Medicaid pay-for-performance efforts should consider.

"Hospital Response to Public Reporting of Quality Indicators." Mary Laschober, Myles Maxfield, Suzanne Felt-Lisk, and David J. Miranda, Health Care Financing Review, spring 2007. Senior hospital executives responding to a 2005 national telephone survey report that Hospital Compare and other public reports on hospital quality measures have helped to focus hospital leadership attention on quality matters. This article notes that the executives also report increased investment in quality improvement projects and in people and systems to improve documentation of care. In addition, more consideration is given to best practices guidelines and internal sharing of quality measure results among hospital staff. Large, Joint Commission on Accreditation of Healthcare Organizations (JCAHO) accredited hospitals appear to be responding to public reporting efforts more consistently than small, non-JCAHO accredited hospitals.

"Testing Consumers' Comprehension of Quality Measures Using Alternative Reporting Formats." Margaret Gerteis, Jessie S. Gerteis, David Newman, and Christopher Koepke, Health Care Financing Review, spring 2007. The Centers for Medicare & Medicaid Services has publicly reported nursing home quality measures since 2002, but research has shown that many users do not understand the measures. This article reports on efforts to develop and test seven alternative reporting templates to improve comprehension. Less than one-half of respondents accurately interpreted bar graphs. Respondents made fewest errors on templates using words to characterize performance as better, average, or worse.

"State Health Care Expenditures: Experience from 2005." Maryland Health Care Commission, February 2007. This publication tracks trends in state health care expenditures to inform policy deliberations among health care experts, professionals, executives, and legislators.

"Improving Health Care Quality Reporting: Lessons from the California HealthCare Foundation." Beth Stevens, Tim Lake, and Erin Fries Taylor, January 2007. The California HealthCare Foundation has devoted substantial resources to promoting public reporting on the quality of California hospitals, physician groups, and nursing homes. Mathematica conducted an evaluation of the foundation's work from 1998 through 2005, identifying lessons from its experience in fostering quality information and exploring avenues for future foundation involvement in the field. This brief looks at the measurement and reporting activities funded and how they changed over time; factors that contribute to the evolution of quality strategies; and the role that regional, state, and local foundations can play in the development of accurate and useful quality measurement and reporting systems.

"Pay for Performance: Are Hospitals Ready and Willing?" Suzanne Felt-Lisk and Mary Laschober, November 2006. Public and private payers are developing hospital care pay for performance (P4P) initiatives as part of a broader national movement to improve the quality and cost-effectiveness of health care services. These initiatives augment or reduce payments to a hospital on the basis of its performance on a predefined set of quality measures. This issue brief is based on Mathematica’s study that examined hospital public reporting of quality information. The study included a nationally representative survey of acute care hospitals in 2005 that asked about their participation in P4P programs and views on future quality initiatives. Researchers found that only about 20 percent of hospitals had participated in a P4P program but nearly all support moving ahead with a P4P strategy that would encompass most U.S. acute care hospitals.

"Estimating the Proportion of Health-Related Websites Disclosing Information That Can Be Used to Assess Their Quality." Margaret Gerteis, Anna Katz, Davene Wright, Frank Potter, and Margo Rosenbach, May 2006. Widespread and growing use of the internet as a medium for disseminating and gathering information has raised concerns about users' ability to assess the quality of the health and medical information presented on websites. The Office of Disease Prevention and Health Promotion has identified six types of information that should be publicly disclosed to users of health-related websites: identity, purpose, content and content development, privacy, user feedback/evaluation, and content updating. This report details Mathematica's efforts to develop, test, and implement a methodology for estimating the proportion of health websites that disclose information consistent with the identified criteria. Researchers found a lack of consistency in how or where websites disclosed information relating to the criteria. Of the six criteria, privacy was met most often, followed by user feedback/evaluation. The lowest levels of compliance were found in content/content development and content updating criteria.

"Translating Research to Action: Improving Physician Access in Public Insurance." Marsha Gold, Sylvia Kuo, and Erin Fries Taylor, Journal of Ambulatory Care Management, January-March 2006. Policymakers struggle with how to ensure adequate access to physician services in public programs such as Medicaid and SCHIP. The authors synthesize research on this topic and provide a framework that policymakers can use to identify and measure barriers to access, determining where and why problems exist and how to intervene. They also discuss important factors in translating research for use by policymakers.

"Using Quality Information for Health-Care Decisions and Quality Improvement." Tim Lake, Chris Kvam, and Marsha Gold, May 2005. Health care quality measurement and reporting have grown rapidly during the past decade and now enjoy wide support. The CAHPS surveys, funded by the Agency for Healthcare Research and Quality since 1995, have been a key part of the effort to generate scientifically sound measures of consumer perspectives on health care access and quality. This report reviews research on incentives for and barriers to quality reporting, and takes stock of what CAHPS has accomplished to date, noting that it has made a standardized instrument available for assessing consumer experiences with health care, and that consumers, purchasers, and health plans find the information it generates useful.

"Monitoring Medicare+Choice: What Have We Learned? Findings and Operational Lessons for Medicare Advantage." Marsha Gold, Lori Achman, Jessica Mittler, and Beth Stevens, August 2004. The role of private health plans in Medicare expanded substantially in 2004 under the Medicare Modernization Act, which builds on plan experience under Medicare+Choice, created in 1997 to offer more managed care choices for beneficiaries and recently renamed Medicare Advantage. Although sponsors originally hoped Medicare+Choice would lead to a greater role for private plans in Medicare, this report notes that the program is widely viewed as a failure, with plans leaving and beneficiaries having fewer, less attractive choices when the program ended in 2003 than they did when it began. As private plans continue to be a focal point for changing Medicare in the future, the researchers note that policymakers need a better understanding of the dynamics of the system to facilitate a successful transition in this latest effort.

"Geographic Variation in Medicare Per Capita Spending: Should Policy-Makers Be Concerned?" Policy Brief No. 6. Claudia H. Williams and Marsha Gold, July 2004. Examines the following: Does Medicare spending vary geographically? How much of the variation is due to differences in population mix and prices across areas? What explains the remaining variation? Do people in higher spending areas get better care?

"Elimination of Medicare's Waiting Period for Seriously Disabled Adults: Impact on Coverage and Costs." Stacy Berg Dale and James M. Verdier, July 2003. Over 1.2 million seriously disabled Americans under age 65—including as many as 400,000 without health insurance—are currently in the two-year waiting period for Medicare coverage, according to this new report. Eliminating this waiting period would provide stable health insurance to a vulnerable group of adults who are unable to work. Some disabled adults in the waiting period also qualify for state Medicaid programs. Dropping the two-year Medicare wait would save cash-strapped states an estimated $1.8 billion a year in Medicaid costs.

"Effects of Selected Cost-Containment Efforts: 1971-1993." Marsha Gold, Karyen Chu, Suzanne Felt, Mary Harrington, and Timothy Lake, Health Care Financing Review, spring 1993. This article reviews the literature on four types of supply-side price controls for health care, and although it looks at an older time period, the same issues persist today.

Equity

"Beyond Affordability: The Impact of Nonfinancial Barriers on Access for Uninsured Adults in Three Diverse Communities." Jeffrey T. Kullgren and Catherine G. McLaughlin. Journal of Community Health, 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, 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.

"Differences in Prevalence, Treatment, and Outcomes of Asthma Among a Diverse Population of Children With Equal Access to Care: Findings From a Study in the Military Health System." Kate A. Stewart, Patricia C. Higgins, Catherine G. McLaughlin, Thomas V. Williams, Elder Granger, and Thomas W. Croghan. Archives of Pediatric and Adolescent Medicine, June 2010. The authors analyzed data from 822,900 children age 2 through 17 who were continuously enrolled throughout 2007 in TRICARE Prime, a Department of Defense health maintenance organization-type plan. Asthma prevalence, treatment patterns and outcomes were assessed among children age 2 to 4, 5 to 10 and 11 to 17. Racial and ethnic differences were apparent in several measures and age groups. Black and Hispanic children were more likely to be diagnosed with asthma at all ages. Black children of all ages and Hispanic children age 5 to 10 were more likely to have potentially avoidable hospitalizations or emergency department visits related to asthma.

"Racial/Ethnic and Socioeconomic Disparities in Access to Care and Quality of Care for U.S. Health Center Patients Compared with Non-Health Center Patients." Leiyu Shi, Jenna Tsai, Patricia Collins Higgins, and Lydie A. Lebrun, Journal of Ambulatory Care Management, October/December 2009. This study compares racial/ethnic and socioeconomic disparities in access to care and quality of care for U.S. health center patients and non-health center patients. Data for the study came from the 2002 Community Health Center User Survey and the 2003 National Healthcare Disparities Report. Results show that health center patients experience fewer racial/ethnic and socioeconomic disparities in access to care and quality of care, compared with non-health center patients nationally.

"The Effects of State Policy Decisions on the Employment and Earnings of Medicaid Buy-In Participants in 2006." Henry T. Ireys, Gilbert Gimm, and Su Liu, Journal of Disability Policy Studies, December 2009. This article examines the Medicaid Buy-In program, so named because workers with disabilities “buy into” Medicaid coverage with monthly premiums. In 2006, over 97,000 individuals were enrolled in 32 state Buy-In programs. States have taken different pathways toward the program’s dual objectives: expanding Medicaid coverage to vulnerable populations and promoting employment of working-age adults with disabilities. Analyses indicate that some states appear to have accomplished both objectives, whereas other states have emphasized one over the other. In addition, certain program features (such as higher earned-income limits) contribute to both larger percentages of Buy-In participants who are employed and higher earnings of employed participants.

"Implementation of Mental Health Parity: Lessons from California." Margo L. Rosenbach, Timothy K. Lake, Susan R. Williams, and Jeffrey A. Buck, Psychiatric Services, December 2009. Reprinted with permission from Psychiatric Services (copyright 2009). In 2000, California legislated parity coverage for mental health care. This article reviews the experiences of state health plans, providers, and consumers between 2000 and 2005 in implementing parity and discusses implications for the 2008 federal parity law. California’s experiences suggest that federal policymakers should consider monitoring health plan performance related to access and quality, in addition to monitoring coverage and costs; examining the breadth of diagnoses covered by health plans; and mounting a campaign to educate consumers about their insurance benefits.

"State Variation in Out-of-Home Medicaid Mental Health Services for Children and Youth: An Examination of Residential Treatment and Inpatient Hospital Services." Jonathan Brown, Brenda Natzke, Henry Ireys, Mathew Gillingham, and Morris Hamilton, Administration and Policy in Mental Health and Mental Health Services Research, August 2009. Using Medicaid data from 2003, this article describes the demographics and diagnoses of youth under 22 receiving mental health services in general and psychiatric hospitals, psychiatric residential treatment facilities, and other residential treatment settings. The research found that treatment stays and costs in these facilities varied considerably from state to state, findings which may call for more research on state service systems and Medicaid policies.

"Measuring Racial and Ethnic Disparities in Health Care: Efforts to Improve Data Collection." Patricia Collins Higgins and Erin Fries Taylor, May 2009. Disparities in the quality of health care contribute to higher rates of disease, disability, and mortality in racial and ethnic minority groups. A new policy brief examines recent federal and state activities aimed at strengthening the collection of health-related data on race, ethnicity, and primary language. It highlights three states—California, Massachusetts, and New Jersey—that implemented laws or regulations guiding data collection activities by hospitals, health plans, and government agencies.

"Reducing Racial and Ethnic Disparities in Health Care: Partnerships Between Employers and Health Plans." Patricia Collins Higgins, Melanie Au, and Erin Fries Taylor, July 2009. Health plans and employers rarely work together to address racial and ethnic health care disparities in the workforce. However, these collaborations can strengthen programs to reduce disparities. This policy brief draws on interviews with large employers, health plan representatives, government officials, and national experts to assess health plan/employer partnerships addressing disparities. The brief also looks at barriers that prevent partnerships from forming and discusses strategies to encourage increased involvement of employers. Educating employers and employees on the causes and consequences of disparities, promoting the business case for disparities reduction, and creating more national leadership around these issues may elevate disparities reduction as a priority.

"Availability of Data to Measure Disparities in Leading Health Indicators at the State and Local Levels." Marsha Gold, Allison Hedley Dodd, and Melissa Neuman, Journal of Public Health Management Practice, November 2008. Healthy People 2010 identifies the elimination of health disparities as a critical national goal. This article analyzes the availability of state and local data to support this goal. Researchers assessed data availability for the 10 leading health indicators, comprising a set of 26 measures, and based their analysis on a mid-2007 review of federal and state websites. They conclude that some relevant state-level disparities data exist, major gaps remain, local estimates are limited, and some states make better use of data than others. Federal leadership and support are critical to states’ abilities to address the Healthy People 2010’s disparities goal.

"State Efforts to Address the Healthy People 2010 Goal to Eliminate Health Disparities: Two Case Studies." Leslie Jackson Conwell, Melissa Neuman, and Marsha Gold, September 2008. Healthy People 2010 identified eliminating health disparities as one of two overarching goals for the U.S., along with increasing quality and years of healthy life. This report examines North Carolina and Washington, two states that are making notable use of data to address disparities. Washington’s initiative is in the early stages, while North Carolina’s has existed since the early 1990s. Case studies in this report illustrate how data are being used to identify health disparities and develop initiatives to eliminate them.

"Participants in the Medicaid Buy-In Program, 2000-2004: Characteristics, Earnings, and Medical Expenditures." Su Liu, Henry T. Ireys, and Craig Thornton, Journal of Disability Policy Studies, September 2008, subscription required. The Medicaid Buy-In program, a state Medicaid option since the late 1990s, is designed to encourage adults with disabilities to work by allowing them to buy into Medicaid when their earnings exceed standard Medicaid eligibility limits. This article describes enrollment, expenditures, and earnings for Buy-In participants in 27 states between 2000 and 2004. Younger participants receiving no federal income support when they enroll in the Buy-In program have higher earnings, compared with older participants receiving Social Security Disability Insurance payments. The innovative process used in this study to link data from multiple agencies could be adapted for exploring other policy issues related to employment of individuals with disabilities.

"Evidence of Trends, Risk Factors, and Intervention Strategies." A report from the Healthy Start National Evaluation 2006: Racial and Ethnic Disparities in Infant Mortality. So Sasigent O'Neil, Melanie Besculides, and Margo Rosenbach, June 2008. Experts believe that eliminating racial and ethnic disparities in birth outcomes is key to continued reduction in infant mortality in the United States. Healthy Start, a national initiative begun in 1991, is the largest program addressing disparities in birth outcomes. This paper provides an evidence base to support Healthy Start’s targeted interventions. It reviews risk factors that include prenatal care, folic acid use, periodontal care, infant sleeping position, breastfeeding, well-child care, interconceptional care, maternal smoking, alcohol and other drug use, adolescent pregnancy, perinatal depression, stress, domestic violence, and maternal birthweight.

"Do We Know If Medicare Advantage Special Needs Plans Are Special?" James Verdier, Marsha Gold, and Sarah Davis, January 2008. Special needs plans (SNPs) are a type of Medicare Advantage managed care plan that serves individuals who have chronic or disabling conditions, are covered under both Medicare and Medicaid, or are institutionalized. Enrollment in SNPs has nearly doubled in the past year to almost 1.1 million, and many expect continued enrollment growth in both existing plans and in the nearly 300 new plans approved for 2008. This report describes the history of these plans, how they fit into the larger Medicare Advantage marketplace, and how to assess whether SNPs are performing differently from other Medicare Advantage plans.

"Receiving Advice About Child Mental Health From a Primary Care Provider: African American and Hispanic Parent Attitudes." Jonathan D. Brown, Lawrence S. Wissow, Ciara Zachary, and Benjamin Cook, Medical Care, November 2007. African American and Hispanic youth with mental health problems are less likely than their Caucasian counterparts to receive mental health services. Primary care providers are often the source of mental health care for children and may play a role in reducing disparities. This research investigated parent attitudes associated with receiving advice about child mental health in primary care and whether attitudes differed according to race and ethnicity during 773 visits to 54 providers in 13 clinics. Hispanics were more likely than non-Hispanics to agree that primary care providers should treat child mental health and were more willing to allow their child to receive medications or visit a therapist for a mental health problem if recommended by the provider. African American parents were significantly less willing than Caucasians and Hispanics to allow their child to receive medications for mental health but did not differ in their willingness to visit a therapist. These findings suggest that African American parents are generally as willing as Caucasian parents to have their child’s mental health needs addressed in primary care and that primary care may be a particularly good point of intervention for Hispanic youth with mental health problems.

"Lessons from Local Access Initiatives: Contributions and Challenges." Karen Minyard, Deborah Chollet, Laurie Felland, Lindsey Lonergan, Chris Parker, Tina Anderson-Smith, Claudia Lacson, and Jaclyn Wong, August 2007. Community health initiatives—locally crafted responses to health care access problems—have been steadfast in their efforts to connect uninsured and medically indigent people to health care services and health insurance. These programs assist in outreach, coordinate and integrate care, and help clients use limited resources efficiently. This report offers five case studies of community health initiatives that seek to improve access and coverage for those most likely to be uninsured: low-income, nonelderly adults. Executive Summary

“Evaluation of a Learning Collaborative’s Process and Effectiveness to Reduce Health Care Disparities Among Minority Populations.” Marsha Gold, Erin Fries Taylor, Katherine Gruene Segersten, Patrick Doreian,  Jennifer Coughlan, Debra Lipson, December 2006. This report uses social network analysis to study the relationships among organizations participating in a large-scale, public-private collaboration among major health plans to reduce racial and ethnic disparities in health care.

More than Ramps: Improving Health Care Quality for People with Disabilities. Lisa Iezzoni and Bonnie O’Day, New York: Oxford University Press, 2006. What are the challenges that adults with disabilities face when seeking health care? The authors, both living with disabilities, write from first-hand experience. The first part of the book is devoted to a discussion of health insurance and social policies affecting people with disabilities; the second describes challenges people with disabilities face when accessing health care; and the third posits specific suggestions for successfully overcoming those challenges. The book also has four appendices including lists of internet resources, descriptions of surveys that provided data for the book and suggestions for improving accessibility of health care services. The book is a mixture of literature review and narrations by people with disabilities describing particular challenges they have faced. One reviewer calls it "important reading for any person working in a health care environment" or any person interacting with people with disabilities.

"Racial Disparities in Prescription Drug Use Among Dually Eligible Beneficiaries." Jennifer Schore, Randall Brown, and Bridget Lavin, Health Care Financing Review, winter 2003-2004. Well-documented racial disparities in use of medical services raise concerns about such disparities in other aspects of health care. This article compares the difference in Medicaid pharmacy use between black and white dually eligible Medicare beneficiaries, finding that black beneficiaries have significantly fewer prescriptions filled and lower pharmacy costs in 8 of the 10 states examined, despite having higher physician costs. The study findings suggest that simply providing a Medicare prescription drug benefit will not eliminate observed racial disparities in prescription drug use. However, well-designed, well-implemented, and culturally sensitive disease management programs may help reduce disparities.

"How Seniors Learn." Beth Stevens, 2003. The learning capacity of older adults has direct, practical implications for professionals trying to educate older people and their families about health care services and benefits, especially in Medicare. This issue brief discusses how older people learn and explores research from the field of cognitive aging. It also offers tips for adapting educational programs and materials to build on clients' cognitive strengths and compensate for some of the losses that can occur with aging.

"Developing Culturally Appropriate Medicare Education Materials." Beth Stevens, Donna Yee, and Jose Ortiz, 2001. Cultural differences are some of the most subtle, yet critical, factors affecting how people with Medicare understand their benefits, rights, and choices. This brief explores the lessons learned from an effort to develop and test Medicare education materials suitable for audiences of varying cultural backgrounds, noting that more than translation is needed for materials to be effective.

Transition

"Basing Health Care on Empirical Evidence" Reforming Health Care Issue Brief #3. Jill Bernstein, Deborah Chollet, and Stephanie Peterson, May 2010. Federal reform embraces the development of evidence-based practice as a way to control health care costs and improve quality. This brief reviews initiatives under way to develop evidence of comparative effectiveness and put it into practice.

"Evaluating System Change: A Planning Guide." Methods brief. Margaret B. Hargreaves, April 2010. This methods brief provides guidance on planning effective evaluations of system change interventions. It begins with a general overview of systems theory and then outlines a three-part process for designing system change evaluations. This three-part process aligns (1) the dynamics of the targeted system or situation, (2) the dynamics of the system change intervention, and (3) the intended purpose(s) and methods of the evaluation. Incorporating systems theory and dynamics into evaluation planning can improve an evaluation’s design by capturing system conditions, dynamics, and points of influence that affect the operation and impact of a system change intervention. The goal is to provide an introduction to system change evaluation planning and design and to encourage funders, program planners, managers, and evaluators to seek out more information and apply systems methods in their own evaluation work.

"Toward Understanding EHR Use in Small Physician Practices." Suzanne Felt-Lisk, Lorraine Johnson, Christopher Fleming, Rachel Shapiro, and Brenda Natzke, Health Care Financing Review, fall 2009. This article presents insights into the use of electronic health records (EHRs) by small physician practices participating in a Centers for Medicare & Medicaid Services pay-for-performance demonstration. Site visits to four states revealed slow movement toward improved EHR use. Factors facilitating use of EHRs include customization of products and being owned by a larger organization. Factors limiting use include system limitations, cost, and lack of strong incentives to improve. Many practices also increased use of medical assistants after implementing EHRs.

"Health Information Exchange: The Role of Safety-Net Providers." Trends in Health Informatics, Issue Brief #5. Suzanne Felt-Lisk, Melanie Au, and Patricia Higgins, June 2009. Health information technology has great potential for improving health care through Health Information Exchange (HIE), the exchange of health-related information electronically across providers, with strong privacy, confidentiality, and security protections. If safety-net providers are to keep pace with other providers, organizations responsible for funding and facilitating expansion of HIE need a solid understanding of safety-net providers’ needs. A new brief reviews lessons learned from a 13-member panel convened to discuss barriers and catalysts safety-net providers face in integrating HIE.

"Cash and Counseling: Improving the Lives of Medicaid Beneficiaries Who Need Personal Care or Home- and Community-Based Services." Randall Brown, Barbara Lepidus Carlson, Stacy Dale, Leslie Foster, Barbara Phillips, and Jennifer Schore, August 2007. To address the needs of Medicaid beneficiaries who are elderly or disabled and desire greater control over their personal care, the federal government has encouraged states to offer consumer-directed options. One of the most innovative and flexible consumer-directed-care models is Cash and Counseling, recently tested in a demonstration program in Arkansas, Florida, and New Jersey. The program gives consumers a monthly allowance that they may use to hire workers and to purchase care-related services and goods. This report summarizes findings from five years of research on how each of the three demonstration states implemented its program, and on how the programs have affected consumers who participated, consumers’ paid and unpaid caregivers, and costs to Medicaid. The findings from the randomized trial study design show that the program had overwhelmingly positive effects on consumers of all ages and their caregivers. However, in each state, total Medicaid expenditures were higher under the program than what they would have been in its absence, for different reasons. States interested in offering a Cash and Counseling program or similar consumer-directed options may benefit from the report’s discussion of lessons learned about how to control costs. Executive Summary

"Personal Health Records: What Do Underserved Consumers Want?" Trends in Health Informatics, Issue Brief #4. Lorenzo Moreno, Stephanie Peterson, Ann Bagchi, and Raquel af Ursin, May 2007. Growing use of clinical electronic medical records has also sparked interest in personal health records (PHRs). PHRs have the potential to help individuals take a more active role in their health care by allowing them to access and coordinate personal health information and share it with those who need it. The federal government is exploring whether PHRs can be used to address the information needs of medically underserved populations, most of them minorities, who face economic, cultural, or linguistic barriers to health care. This issue brief describes features of existing publicly available PHRs. It also assesses whether these features match the needs and preferences of underserved individuals, who often have low health and computer literacy, as reported in focus group discussions with residents in a medically underserved area in New Jersey.

"Moving Research into Practice: Lessons from the US Agency for Healthcare Research and Quality's IDSRN Program." Marsha Gold and Erin Fries Taylor, Implementation Science, March 2007. Applied research aims to provide answers to "real world" questions. Whether that research is used in the real world to encourage innovation and change, however, has typically not been a major research focus. The U.S. Agency for Healthcare Research and Quality’s Integrated Delivery Systems Research Network (IDSRN) was established to encourage implementation of research into practice. This article looks at IDSRN’s success in generating research findings that could be applied in practice. Factors important to success were responsiveness of project work to delivery system needs, ongoing funding to support multiple project phases, and development of applied products or tools that helped users see their operational relevance. Factors impeding success include limited project funding, competing demands on potential research users, and failure to reach the appropriate audience.

"Informed Participation in TennCare by People with Disabilities." Steven C. Hill and Judith Wooldridge, Journal of Health Care for the Poor and Underserved, November 2006. Informed consumer participation in health care is increasingly important, but people with disabilities face barriers to making health care decisions. Using a unique survey, we examine informed health care choices by nonelderly people with diverse disabilities, including mental retardation, mental illness, visual and hearing impairments, and difficulty communicating, in TennCare, Tennessee's Medicaid managed care program. Most people with disabilities chose their plans and providers, felt they had enough information to choose a plan, and rated information from their providers as good to excellent. A minority did not know they could choose their plans and providers and reported poor or fair communication with providers. Adults with mental retardation were less likely than other adults with disabilities to seek information. Adults with serious difficulty communicating were less satisfied than others with information from providers. Medicare, Medicaid, health plans, and providers should tailor information dissemination to the diverse needs of people with disabilities.

"Evaluation of the Local Initiative Rewarding Results Collaborative Demonstrations." Suzanne Felt-Lisk, Gilbert Gimm, and Stephanie Peterson, October 2006. The evaluation of the Local Initiative Rewarding Results demonstration is unique among national research projects focused on pay-for-performance in its focus on the Medicaid environment. The five California Medicaid health plans that implemented incentives under the demonstration targeted two HEDIS measures for improvement of great importance to the Medicaid population—adolescent well-care visits and well-baby visits by age 15 months. The health plans used various combinations of financial and non-financial incentives to encourage improvement. This final evaluation report draws on quantitative and qualitative data, concluding that while there is some evidence for the effectiveness of the financial incentives the plans implemented for well-baby care, any large effect from the incentives was limited to one of the five plans. The greatest contribution of the demonstration may be that it has generated lessons learned and hypotheses for the next generation of plan incentive programs and research.

“When the Funding Stops: Do Grantees of the Local Initiative Funding Partners Program Sustain Themselves?" (Evaluation and Program Planning, May 2006.) Reviews the experiences of coalitions formed to help expand health coverage for low-income children, noting that most were able to sustain themselves after foundation funding ended. States inherited knowledgeable and skilled advocates that helped form networks to continue the grantees’ work.

"New Hospital Information Technology: Is It Helping to Improve Quality?" Trends in Health Care Quality, Issue Brief #3. Suzanne Felt-Lisk, May 2006. Although health information technology (IT) is at the center of efforts to improve the nation’s health care system by enhancing patient safety and reducing inefficiencies, little evidence exists to link IT to quality improvements and efficiency gains. This new issue brief reports on how six types of information technology have affected hospital quality, based on interviews with senior hospital executives. The findings suggest that IT has been an important factor in enhancing quality, particularly in terms of more timely clinical information, diagnosis, and treatment.

"Expectations of Sustainability: What Do CKF Grantees and State Officials Predict Will Happen Once RWJF Funding Ends?" Covering Kids and Families Evaluation, Highlight Memo #21, Beth Stevens and Sheila D. Hoag, December 2005. This memo looks at efforts to sustain new community social services programs after initial funding ends.

“Crossing the Quality Chasm via Transformational Change.” Myles Maxfield, Meredith Lee, Sarah Davis, and Lindsay Harris, October 2005. This publication reports on case studies of six hospitals transitioning to new systems.

"Implementing Telemedicine Services for Low-Income Seniors: Potential Strategies." Trends in Health Informatics, Issue Brief #2. Lorenzo Moreno and Arnold Chen, September 2005. This four-page brief suggests key factors for policymakers and funders of telemedicine interventions to consider as they move forward in developing initiatives for groups with little education and limited experience with technology. Home-based telemedicine is emerging as a powerful tool that may improve access to health care for people who live in medically underserved or remote rural areas, or who have limited personal mobility. In particular, a growing number of health care organizations are using telemedicine to serve Medicare beneficiaries with chronic conditions, such as congestive heart failure, depression, and diabetes, who are separated geographically from health care providers.

"SSI Enrollees' Health Care in TennCare." Steven C. Hill and Judith Wooldridge, Journal of Health Care for the Poor and Underserved, May 2003. How well does Tennessee's Medicaid managed care program meet the needs of blind or disabled SSI enrollees? People with disabilities have extensive health care needs and greater barriers to accessing care, so reducing their service use may decrease their health and independence. On the other hand, managed care may enhance care coordination. The authors conclude that SSI enrollees in TennCare had mixed experiences. Their access to care and satisfaction were similar to or slightly worse than that of other TennCare enrollees. A significant minority had unmet needs for care, and lack of care coordination was a problem for some.