Research roundup: Value-based insurance; telemedicine in nursing homes; advance care planning

Feb 10 2014

Each week, KHN compiles a selection of recently released health policy studies and briefs.

Health Affairs: Use Of Telemedicine Can Reduce Hospitalizations Of Nursing Home Residents And Generate Savings For Medicare
Hospitalizations of nursing home residents are frequent and result in complications, morbidity, and Medicare expenditures of more than a billion dollars annually. The lack of a physician presence at many nursing homes during off hours might contribute to inappropriate hospitalizations. Findings from our controlled study of eleven nursing homes provide the first indications that switching from on-call to telemedicine physician coverage during off hours could reduce hospitalizations and therefore generate cost savings to Medicare in excess of the facility's investment in the service. But those savings were evident only at the study nursing homes that used the telemedicine service to a greater extent, compared to the other study facilities (Grabowski and O'Malley, 2/4).

JAMA Internal Medicine: Strategic Targeting Of Advance Care Planning Interventions
[T]he completion of an advance directive (AD) too far from or too close to the time of death can lead to end-of-life decisions that do not optimally reflect the patient's values, goals, and preferences: a poorly chosen target patient population that is unlikely to need an AD in the near future may lead to patients making unrealistic, hypothetical choices, while assessing preferences in the emergency department or hospital in the face of a calamity is notoriously inadequate. ... A key to optimal timing and strategic selection of target patients for an ACP program is prognostication, and we briefly highlight prognostication tools and studies that may point us toward high-value AD interventions (Billings and Bernacki 2/3).

Journal of General Internal Medicine: Specialty Use Among Patients With Treated Hypertension in a Patient-Centered Medical Home
Little is known about how delivery of primary care in the patient-centered medical home (PCMH) influences outpatient specialty care use. ... INTERVENTION: System-wide PCMH redesign implemented across 26 clinics in an integrated health care delivery system, beginning in January 2009.  ... Compared to baseline, the study population averaged 7 % fewer adjusted specialty visits during implementation and 4 % fewer adjusted specialty visits in the first post-implementation year. ... Results suggest that more comprehensive primary care in this PCMH redesign enabled primary care teams to deliver more hypertension care, and that many needs of low morbidity patients were within the scope of primary care practice. New approaches to care coordination between primary care teams and specialists should prioritize high morbidity, clinically complex patients (Liss et al., 2/2014).

The Kaiser Family Foundation: Medicaid Per Enrollee Spending: Variation Across States
To participate in Medicaid, states are required to meet federal core requirements; however, states have significant flexibility to expand beyond program minimums for benefits and coverage, to determine how care is delivered and to determine what and how providers are paid. As a result of this flexibility, there is significant variation in Medicaid programs across states. ... This brief examines variation in spending per enrollee across eligibility groups, across states and over time, as well as implications for program policy and financing. ... Proposals that would change the underlying financing structure of Medicaid by placing an overall cap on federal Medicaid spending or a limit on federal Medicaid spending per enrollee would have dramatically different results across states because of the current variation (Young, Rudowitz and Garfield, 2/3).

Robert Wood Johnson Foundation/Bailit Health Purchasing: Reducing Overuse and Misuse: State Strategies to Improve Quality and Cost of Health Care
Health care purchasers in several states have implemented well-established and successful initiatives to reduce misuse and overuse of care. In Washington state, such efforts have resulted in a 94 percent reduction in bariatric surgery spending and a $10 million reduction in enteral nutrition spending. This brief by Bailit Health Purchasing focuses on actions state purchasers can take with contracted plans, providers, and other engaged purchasers to reduce misuse and overuse of health care services. Such strategies include: ... Coordinating efforts with other large health care purchasers. ... Introducing evidence-based concepts into policies, regulations, and statutes (Burns, Dyer, and Bailit, 1/14).

The Heritage Foundation: CBO Confirms: Medicare Premium Support Means Savings For Taxpayers And Seniors
A major report by the Congressional Budget Office (CBO) confirms that premium support (a defined-contribution system of health-plan financing) would make the financially troubled Medicare program more sustainable. In a new competitive system of health plans, the CBO finds that private health plans can offer the same benefit and services as traditional Medicare fee-for-service plans-;at a lower cost to taxpayers. The CBO report also reveals that competition can drive lower beneficiaries' premiums and out-of-pocket costs. The CBO analysis affirms the potential of serious savings for Medicare beneficiaries and taxpayers alike (Moffit and Hederman, 2/3).

Substance Abuse and Mental Health Services Administration: Behavioral Health Barometer, 2013
This is the first edition of the Behavioral Health Barometer: United States, one of a series of State and national reports that provide a snapshot of the state of behavioral health in the Nation. This national report presents a set of substance use and mental health indicators as measured through data collection efforts sponsored by SAMHSA (the National Survey on Drug Use and Health and the National Survey of Substance Abuse Treatment Services), the Centers for Disease Control and Prevention (the Youth Risk Behavior Survey), and the National Institute on Drug Abuse (the Monitoring the Future survey). Also included are data on the use of mental health and substance use treatment services by Medicare enrollees, as reported by the Centers for Medicare & Medicaid Services (1/31). 

Here is a selection of news coverage of other recent research:

NPR's Shots blog: Are We Paying $8 Billion Too Much For Mammograms?
The question of how often women should get mammograms remains contested, with advisory panels and medical societies disagreeing on how early and how often they should be used to find breast cancer. But those discussions rarely mention cost. And the financial implications are huge. If women got screening mammograms every year starting at age 40, as the American Cancer Society , it would cost $10 billion a year, according to an published Monday in Annals of Internal Medicine. That's compared with $2 billion a year to screen women ages 50 to 69 every other year, or $3.5 billion to follow the recommendation of the U.S. Preventive Services Task Force (Shute, 2/4).

Modern Healthcare: Drug Adherence May Improve With Incentives, But Spending Reduction Might Not Offset Cost
Eliminating or lowering drug co-pays may improve patients' adherence to their medication regimens, but the reduction in overall health spending may not be enough to offset the cost. That was the experience of one insurer in a study published Monday in the policy journal Health Affairs. ... Blue Cross and Blue Shield of North Carolina paid an additional $6.4 million during a two-year period to cover the cost of higher drug use for patients with hypertension, diabetes, hyperlipidemia and congestive heart failure after the insurer lowered drug co-pays. That amounts to $139 to $173 annually for each member. But the $5.7 million drop in the cost of all other care did not offset the expense (Evans and Robeznieks, 2/3).

Politico Pro: Report Cites Medicare Policy Research Priorities
Health care policymakers are eager for more data to help them understand shifts in Medicare and how to move ahead in an environment shaped by ACA-inspired delivery system changes, changes in spending patterns and an aging population, according to a report released Monday by AcademyHealth. The report, "The AcademyHealth Listening Project: Improving the Evidence Base for Medicare Policymaking," surveyed people from the policymaker and research realms (Kenen, 2/3).

Medscape: Antibiotic Prescribing For Children May Be Leveling Off
A downward trend in outpatient antibiotic prescribing for children may have reached a plateau, according to an article published online February 2 in Pediatrics. In fact, in some areas, prescribing rates may have started inching back up. Louise Elaine Vaz, MD, from the Division of Infectious Diseases and Department of Laboratory Medicine, Boston Children's Hospital, Massachusetts, and colleagues analyzed pharmacy and outpatient claims from September 2000 to August 2010 for 3 regional US health plans (Hand, 2/4).