Health Policy Research

Reports

• "Enrollment, Employment, and Earnings in the Medicaid Buy-In Program, 2011." Matthew Kehn, May 2013. This report, prepared for CMS, is the last in a series of annual reports on participation in the Medicaid Buy-In program. It provides updates on both national- and state-level trends in enrollment, employment, and earnings among the 35 reporting Medicaid Infrastructure Grant (MIG) states with a Buy-In program in 2011. Additionally, it addresses recent changes to state program rules and policies, and identifies factors that have affected recent Buy-In program enrollment, as reported by the states in an annual questionnaire.
• "Chartbook: Medicaid Pharmacy Benefit Use and Reimbursement in 2009." Ann D. Bagchi, James Verdier, and Dominick Esposito, December 2012. This chartbook presents highlights and key comparisons from the statistical compendium on Medicaid pharmacy benefit use and reimbursement in 2009 that Mathematica prepared for CMS. Mathematica has prepared similar compendiums and chartbooks for 1999 and for each year from 2001 to 2009. The 2009 compendium was prepared for 42 states and the District of Columbia, because 8 states did not submit complete data to CMS for 2009.
• "Independent Evaluation of the Ninth Scope of Work, QIO Program. Volume I: Findings." Arnold Chen, Andrew Clarkwest, Sarah Croake, Suzanne Felt-Lisk, Myles Maxfield, Lauren Smith, Suzanne Witmer, Jelena Zurovac, Jennifer Lucado, Lauren McGivern, Kathy Paez, and Claudia Schur, November 2011. The Centers for Medicare & Medicaid Services (CMS) operates the Quality Improvement Organization (QIO) Program to ensure and improve the quality of health care for Medicare beneficiaries. This report presents the results of an independent evaluation of the ninth scope of work, QIO Program, conducted by Mathematica during 2008–2011. Using innovative quasi-experimental methods, the evaluation found that QIO’s work led to improvement in 4 of the 12 targeted measures of quality evaluated. In addition, more than three-fourths of the hospitals and nursing homes in a national survey with QIO contacts said the contacts themselves or resources the QIO staff provided led to changes that improved patient care.
• "Sustainability, Partnerships, and Teamwork in Health IT Implementation: Essential Findings from the Transforming Healthcare Quality Through IT Grants." Suzanne Felt-Lisk, Grace Ferry, Rebecca Roper, Melanie Au, James Walker, J.B. Jones, and Virginia Lerch, December 2012. This report presents findings from the Agency for Healthcare Research and Quality’s Transforming Healthcare Quality Through IT program on aspects of sustainability, partnerships, and effective teamwork in grantees’ health IT implementation. Seventy percent of grantees sustained or increased use of at least some of the health IT that was a focus of their project. When purchasing a health IT product, grantees stressed the importance of checking product ratings and quality of technical support. Nearly all partnerships built or enhanced through IT grants continued to work together in part or in whole after the end of the grant period. In most projects, users were involved in process redesign before implementation and conducted competency-based training as part of implementation.
• "Medicare Health Plans and Dually Eligible Beneficiaries: Industry Perspectives on the Current and Future Market." Marsha Gold, Winnie Wang, and Gretchen Jacobson, March 2013. With federal and state governments pursuing efforts to better coordinate care and reduce costs for people dually eligible for both Medicare and Medicaid, this brief examines how insurers serving these markets view the opportunities and challenges. Based on interviews with senior executives at 13 large firms that contract with the Medicare and Medicaid programs, the brief finds almost all of the insurers expect dually eligible beneficiaries will become more important to their business over time.
• "Helping You Take Care of Yourself Men of Color Prostate Health Workshops." Laura Ruttner, Irina Cheban, and So O'Neil, March 2013. This report describes the knowledge gain among participants of the Massachusetts Department of Public Health Helping You Take Care of Yourself prostate health workshops. Using scores on pre- and post-tests administered immediately before and after the workshops, findings indicated that knowledge increased among workshop participants on average and that they were generally satisfied with the workshops.
• "CHIPRA Mandated Evaluation of Express Lane Eligibility: First Year Findings." Sheila Hoag, Sean Orzol, Margaret Colby, Adam Swinburn, Fredric Blavin, Genevieve M. Kenney, and Michael Huntress, December 2012. This report describes the nine programs approved for Express Lane Eligibility (ELE) as of April 2012. The report found that states have implemented diverse ELE programs, and ELE has benefited applicants in some states by reducing documentation requirements and expediting eligibility determination. Administrative savings or costs varied widely; however, states using ELE to process large numbers of children were better able to generate net savings quickly than states not using ELE.
• "Medicaid Analytic eXtract 2008 Encounter Data Chartbook." Rosemary Borck, Ashley Zlatinov, and Susan Williams, February 2013. This chartbook uses Medicaid Analytic eXtract (MAX) 2008 data to describe the service utilization of Medicaid enrollees in managed care plans. The chartbook extends the analysis of the previous MAX chartbooks, which focused on the service utilization of Medicaid enrollees covered on a fee-for-service basis. This chartbook also supplements recent MAX issue briefs that focused on the quality and completeness of encounter data. This chartbook provides valuable information for the Centers for Medicare & Medicaid Services and researchers on the availability of and uses for encounter data in MAX data. Appendix tables.
• "Social Security Numbers in Medicaid Records: Reporting and Validity, 2009." John L. Czajka and Shinu Verghese, January 2013. This report presents findings from a validation study of Social Security numbers (SSNs) in Medicaid Statistical Information System (MSIS) records for the fourth quarter of federal fiscal year 2009. The study produced results for the nation and the states on how often SSNs were reported in MSIS records and how often the reported SSNs passed a validation test at the U.S. Census Bureau, based on data obtained from the Social Security Administration.

Journal Articles

• "Meeting Meaningful Use Criteria and Managing Patient Populations: A National Survey of Practicing Physicians." Catherine M. DesRoches, Anne-Marie Audet, Michale Painter, and Karen Donelan. Annals of Internal Medicine, June 2013 (subscription required). More than 40 percent of the nation’s physicians have access to a basic electronic health record (EHR) system; however, implementation of advanced functions for patient management and care coordination is not widespread, according to a study led by Mathematica and the Mongan Institute for Health Policy at Massachusetts General Hospital. Furthermore, when these tools are available, physicians report they are complicated and difficult to use. Many EHR functions, such as electronic data exchange, will be required for physicians to meet the meaningful use criteria of the Centers for Medicare & Medicaid Services (CMS) for EHRs. CMS established these criteria to ensure that physicians use EHRs to improve patient care; physicians participating in the meaningful use program receive financial incentives when they meet the criteria.
• "Paying the Doctor: Evidence-Based Decisions at the Point-of-Care and the Role of Fee-for-Service Incentives." Eugene C. Rich, Timothy K. Lake, Christal Stone Valenzano, and Myles M. Maxfield. Journal of Comparative Effectiveness Research, May 2013. This article dvelops a framework for understanding how financial and nonfinancial incentives can complicate point-of-care decision making by physicians, leading to the over- or under-use of health care services. The analysis highlights contributing factors that promote and impede evidence-based decision making, using examples from the “Choosing Wisely” program. The authors discuss how the existing fee-for-service payment system can contribute to the problems of over- and under-testing, diagnosis, and treatment.
• "Paying More Wisely: Effects of Payment Reforms on Evidence-Based Clinical Decision-Making." Timothy K. Lake, Eugene C. Rich, Christal Stone Valenzano, and Myles M. Maxfield. Journal of Comparative Effectiveness Research, May 2013. This article reviews the recent research, policy, and conceptual literature on the effects of payment policy reforms on evidence-based clinical decision making by physicians at the point of care. Payment reforms include recalibration of existing fee structures in fee-for-service, pay-for-quality, episode-based bundled payments and global payments. The authors review the advantages and disadvantages of these reforms in terms of their effects on physicians’ and patients’ use of evidence in clinical decisions related to the diagnosis, testing, treatment, and management of disease. They conclude with a recommended pathway for improving payment incentives to better support evidence-based decision making.
• "Perspectives of Physicians and Nurse Practitioners on Primary Care Practice." Karen Donelan, Catherine M. DesRoches, Robert S. Dittus, and Peter Buerhaus. The New England Journal of Medicine, May 2013 (subscription required). A study finds that, although primary care physicians and nurse practitioners mostly agree that nurse practitioners should be able to practice to the full extent of their education and training, they strongly disagree about proposed changes to the scope of nurse practitioners' responsibilities. The survey—led by investigators from Massachusetts General Hospital, the Institute for Medicine and Public Health at Vanderbilt University Medical Center, and Mathematica—revealed points of disagreement on appropriate leadership roles for nurse practitioners, reimbursement levels, and overall quality of services.
• "National and State Trends in Enrollment and Spending for Dual Eligibles Under Age 65 in Medicaid Managed Care." Jenna Libersky, Allison Hedley Dodd, and Shinu Verghese. Disability and Health Journal, April 2013 (subscription required). This article uses 2005 and 2008 Medicaid Analytic eXtract (MAX) data to present spending and enrollment trends for adults with disabilities who are dually eligible for Medicare and Medicaid. Nationwide, the proportion of adult duals in managed care increased from 2005 to 2008, with the expansion of prepaid health plans (PHPs), particularly behavioral health PHPs, driving the increase. Although overall use of managed care has increased, there has been little expansion in the use of comprehensive managed care among adult dual eligible beneficiaries, particularly when compared with their Medicaid-only disabled adult peers. This imbalance suggests room to remove barriers preventing dually eligible adults, from enrolling in comprehensive, integrated managed care.
• "Assessing the Usability of MAX 2008 Encounter Data for Comprehensive Managed Care." Vivian L.H. Byrd and Allison Hedley Dodd. Medicare & Medicaid Research Review, March 2013. This article summarizes the availability, completeness, quality, and usability of the encounter data in the MAX file, derived from CMS’s Medicaid Statistical Information System, for enrollees in comprehensive managed care plans. It also gives specific information by state. Most states that have comprehensive managed care plans reported data to the other services, inpatient, and prescription drug files in 2008. Of these data, the majority are usable.
• "Primum Non Nocere: Reconciling Patient-Centered Outcomes with Evidence-Based Care." Eugene C. Rich. Journal of Comparative Effectiveness Research, March 2013. This “Methods to Policy” piece discusses opportunities and challenges in reconciling increased demands for evidence to be “patient-centered” with the realities of highly diverse patient circumstances, preferences, and clinical situations.
• "Systems Model of Physician Professionalism in Practice." Barrett T. Kitch, Catherine DesRoches, Cara Lesser, Amy Cunningham, and Eric G. Campbell. Journal of Evaluation in Clinical Practice, February 2013. This article found that characteristics of organizations such as hospitals, group practices, and physician organizations can help foster a consistent systems model of physician professionalism.
• "Mental Health Communications Skills Training for Medical Assistants in Pediatric Primary Care." Jonathan D. Brown, Lawrence S. Wissow, Benjamin L. Cook, Shaina Longway, Emily Caffery, and Chris Pefaure. The Journal of Behavioral Health Services & Research, January 2013. This article provides findings from a training pilot to enhance the ability of medical assistants (MAs) to have therapeutic encounters with Latino families who have mental health concerns in pediatric primary care. The study found that MAs were able to master most of the skills taught during the training, which improved their ability to have patient-centered encounters with families during standardized patient visits. Parents interviewed one and six months following the training were more than twice as willing as parents interviewed one month before the training to discuss mental health concerns with MAs, and they had better perceptions of their interactions with MAs.
• "Parents' Preferences for Enhanced Access to the Pediatric Medical Home: A Qualitative Study." Joseph S. Zickafoose, Lisa R. DeCamp, Dana J. Sambuco, and Lisa A. Prosser. The Journal of Ambulatory Care Management, January/March 2013 (subscription required). In this study 20 parents were interviewed about experiences accessing primary care for their children, priorities for enhanced access, and willingness to make trade-offs. Parents had strong preferences for certain services, such as same-day sick care appointments, and were willing to make trade-offs for high-priority services. The authors concluded that primary care practices and medical home programs should educate families about trade-offs needed to implement new services and engage families in setting priorities for medical home implementation.
• "How to Provide and Pay for Long-Term Care of an Aging Population is an International Concern." Marsha Gold. Israel Journal of Health Policy Research, January 2013. As populations age, most industrialized nations are seeking to review their long-term care programs and better allocate better limited public resources to meet expanding needs. This commentary piece examines critical questions that define the way individual nations provide for the long-term care needs of their aging populations.
• "The Effects of Mental Health Parity on Spending and Utilization for Bipolar, Major Depression, and Adjustment Disorders." Alisa B. Busch, Frank Yoon, Colleen L. Barry, Vanessa Azzone, Sharon-Lise T. Normand, Howard H. Goldman, and Haiden A. Huskamp. The American Journal of Psychiatry, February 2013 (subscription required). This study counters concerns that benefit expansion under parity would increase spending. The study finds that mental health parity provisions implemented in the Federal Employees Health Benefits program resulted in reductions in total out-of-pocket spending for patients with more-severe behavioral health conditions, while the level of services they received remained largely unchanged.  The study also found, however, that individuals with less-severe but acute mental health conditions received fewer services, suggesting that health plans were selectively managing benefits.
• "Enhancing the Primary Care Team to Provide Redesigned Care: The Roles of Practice Facilitators and Care Managers." Erin Fries Taylor, Rachel M. Machta, David S. Meyers, Janice Genevro, and Deborah N. Peikes. Annals of Family Medicine, January/February 2013 (subscription required). This article co-authored with the Agency for Healthcare Research and Quality, examines the distinct and complementary roles practice facilitators and care managers play in redesigning and improving primary care delivery. Practice facilitators coordinate practice quality improvement and redesign efforts, helping build capacity for activities that improve quality and safety and the implementation of evidence-based practices. Care managers coordinate patient care and help patients navigate the system, improving access and communicating across the care team.
• "Matching Study Designs to Disability-Related Comparative Effectiveness Research Questions." Jeffrey Ballou, Eugene Rich, and Matthew Kehn. Journal of Comparative Effectiveness Research, January 2013. This article presents methodological and design issues for researchers to consider when addressing disability-related comparative effectiveness research questions.

Issue Briefs

• "Outreach to Low-Income Families During the First Year of HeA PA." Health-E-App Public Access: A New Online Path to Children's Health Care Coverage in California, Research Brief #3. Maggie Colby, May 2013. This is the third brief in a series about the first year of California’s Health-e-App Public Access (HeA PA) enrollment system, introduced in December 2010. Available in English and Spanish, HeA PA was a self-service online application for the Healthy Families Program and a screening tool for Medi-Cal for families. This brief describes the ways that California made families aware of HeA PA, including a formal outreach campaign during the second half of 2011, and evaluates the outreach strategies’ effectiveness in attracting eligible applicants.
• "Analysis of the Variation in Efficiency of Medicare Advantage Plans." Research Brief. Marsha Gold and Maria Cupples Hudson, April 2013. The Affordable Care Act has altered payment policy for private Medicare Advantage (MA) plans, with the goal of lowering costs to bring them closer to the costs of traditional Medicare. Using new information on 2009 MA costs, an issue brief compares plans’ estimates of per capita costs for providing Parts A and B benefits to their enrollees, on a risk-adjusted basis, against government data on the same costs for traditional Medicare program beneficiaries in the same county. On average, risk-adjusted MA plan costs were 4 percent higher than traditional Medicare costs (104 percent). Among plan types, only HMOs had lower average costs than traditional Medicare. The wide variation in costs for MA plans relative to those for traditional Medicare suggests room for greater efficiency in care delivery.
• "Trends and Patterns in the Use of Prescription Drugs Among Medicaid Beneficiaries: 1999 to 2009." MAX Medicaid Policy Brief #17. James M. Verdier and Ashley Zlatinov, March 2013. This brief presents noteworthy trends and patterns in the use and costs of prescription drugs for Medicaid beneficiaries from 1999 to 2009. It builds on previous annual tables and chartbooks, and describes trends in drug usage and costs. The brief emphasizes trends for beneficiaries with disabilities and chronic illnesses, whose drug use is much more extensive than that of children and nondisabled adults.
• "Medicare Part D Prescription Drug Coverage for Medicare-Medicaid Enrollees in the Capitated Financial Alignment Demonstration." Technical Assistance Brief. James M. Verdier, March 2013. This technical assistance brief, prepared for the Integrated Care Resource Center, provides basic information for states participating in the Centers for Medicare & Medicaid Services’ capitated Financial Alignment Demonstration covering Medicare-Medicaid enrollees. Although not a comprehensive overview of the Medicare Part D prescription drug benefit, it covers beneficiary enrollment, drug payment, drug coverage, and drug utilization. It also reviews how the Medication Therapy Management Program works.
• "Health-E-App Public Access: A New Online Path to Children's Health Care Coverage in California. Applicant Characteristics and Experiences." Study of Health-e-App Public Access Research Brief #2. Adam Dunn and Leslie Foster, February 2013. This is the second brief in a series about the first year of California’s Health-e-App Public Access (HeA PA) self-service, public health benefits enrollment system, following its introduction in December 2010. It describes HeA PA applicants and their experiences with the tool. Findings suggest that tools like HeA PA are a good option for people who have convenient access to high-speed internet service and do not need extensive in-person help when applying for coverage.
• "Toward a More Perfect Union: Creating Synergy Between the Money Follows the Person and Managed Long-Term Services and Supports Programs." The National Evaluation of the Money Follows the Person (MFP) Demonstration Grant Program, Reports from the Field #11. Debra J. Lipson and Christal Stone Valenzano, February 2013. This report examines how five states have structured the interface between Money Follows the Person (MFP) demonstration grants and Managed Long-Term Services and Support (MLTSS) programs to promote transitions from institutional care to home- and community-based settings. It describes how eligibility rules for each program affect the overlap between enrollees, how Medicaid payment rates to contracted managed care organizations (MCOs) promote transitions, how MFP and MCO staff divide responsibility for transition planning, and how states track quality of care and performance indicators for MFP participants enrolled in MLTSS plans.
• "How Are CHIPRA Demonstration States Approaching Practice-Level Quality Measurement and What Are They Learning?" The National Evaluation of the CHIPRA Quality Demonstration Grant Program Evaluation Highlight No. 1. Grace A. Ferry, Henry T. Ireys, Leslie Foster, Kelly J. Devers, and Lauren Smith, January 2013. This Evaluation Highlight discusses the early accomplishments, challenges, and lessons learned from the following four states pursuing practice-level quality measurement: Maine, Massachusetts, North Carolina, and Pennsylvania. It describes the states’ efforts to select meaningful measures, adapt health plan and state-level measures for practice-level reporting, and use technology to collect measurement data. The analysis draws on semi-structured interviews with demonstration staff, providers, and stakeholders and semi-annual reports the states submitted to the Centers for Medicare & Medicaid Services.
• "Using the MAX-NHANES Merged Data to Evaluate the Association of Obesity and Medicaid Costs." MAX Medicaid Policy Brief #16. Allison Hedley Dodd and Philip M. Gleason, January 2013. This brief presents the results of the first study conducted using the newly merged Medicaid Analytic eXtract (MAX) and National Health and Nutrition Examination Survey (NHANES) data. The study evaluated the association between Medicaid costs and obesity among adults in 1999–2004. Although the estimated costs were higher for obese adults than for non-obese adults, the combination of a small sample size for NHANES data, wide variation in costs among Medicaid enrollees, and the necessity of controlling for state variation yielded an unstable model with imprecisely estimated relationships. The results demonstrate the hazard of using a small national survey (NHANES) with a state-based data system (MAX) to perform cost analyses, particularly when the range of realistic costs is large.

Working Papers

• "The ACA, Health Care Costs, and Disparities in Employer-Sponsored Health Insurance." Nan L. Maxwell, March 2013. This working paper examines the potential changes in the disparities in employer-sponsored health insurance (ESI) and other benefits between low- and high-wage workers under health reform. The analysis suggests that potential changes firms make in compensation could decrease disparities between low- and high-skilled workers in the quality of ESI and increase the disparities in the offering of benefits other than ESI, if the legislation does not slow rising health care costs.
• "Perceptions of Electronic Health Records and Their Effect on the Quality of Care: Results from a Survey of Patients in Four States." Jelena Zurovac, Stacy Dale, and Martha Kovac, November 2012. Using data from patients surveyed after primary care provider visits, this working paper found patients had favorable perceptions of electronic health records (EHRs). Patients believed that EHRs improved the quality of care, and most were not concerned with confidentiality of records. Adopters' patients rated the quality of care higher than nonadopters' patients did. There was also no detrimental effect of EHR use on patient–provider communication and no relationship between the way in which physicians interacted with the computer and patients' perceptions of care.
• "Paying Wisely: Reforming Incentives to Promote Evidence-Based Decisions at the Point of Care." Eugene C. Rich, Tim Lake, and Christal Stone Valenzano, October 2012. This white paper describes how current financial incentives in the fee-for-service (FFS) system can lead to the over- and underuse of services at the point of care by physicians and other clinicians. It explores prominent payment reform models and concludes that no single approach consistently rewards evidence-based care. The paper also suggests that more targeted use of these models—grounded in recalibrated FFS—might be the most effective way to neutralize incentives and facilitate evidence-based decision making at the point of care.
• "Rewarding Physicians for Their Patients' Health Outcomes: What Can Medicare Learn from Education's Value-Added Models?" Greg Peterson and Eric Schone, June 2012. This working paper examines how value-added models of performance measurement used in education can apply to health care when measuring and rewarding physician performance, particularly in the Medicare system. The paper finds that value-added models used to measure teacher effects on student test scores may have useful applications in Medicare because the models provide opportunities to identify impacts on outcomes while controlling for factors that are beyond physicians' control, such as severity of illness or adherence to a treatment plan. The working paper also identifies limitations and challenges associated with value-added measures and discusses potential approaches to address these challenges.
• "RDD Unplugged: Findings from a Household Survey Using a Cell Overlap Design." John Hall, Barbara Lepidus Carlson, and Karen CyBulski, December 2011. This working paper presents methodological findings from the latest round of the Health Tracking Household Survey, which added a cell phone sample to the existing landline sample of random telephone numbers to increase the coverage of the U.S. population.
• "An Assessment of the Effectiveness of Anti-Poverty Programs in the United States." Yonatan Ben-Shalom, Robert A. Moffitt, and John Karl Scholz, May 2011. This paper assesses the effectiveness of means-tested and social insurance programs in the United States. The U.S. benefit system has a major impact on poverty rates, reducing the percentage of the poor in 2004 from 29 to 13.5 percent. The system reduces poverty the most for persons with disabilities and the elderly and least for several groups among the nonelderly and nondisabled. While there are significant behavioral side effects of many programs, their aggregate impact is very small and does not affect the magnitude of the aggregate poverty impact of the system.

Other

• Book Examines Health Reform and Employer-Based Insurance
  "The Health and Wealth of a Nation: Employer-Based Health Insurance and the Affordable Care Act," a new monograph by senior researcher Nan L. Maxwell, examines how firms behaved with respect to employment-based health insurance before Affordable Care Act deliberations and uses that behavior to predict the changes that might occur when the legislative requirements become fully implemented.