Performance Improvement 2008. Goal 1 - Improve the Safety, Quality, Affordability and Accessibility of Health CARE Including Behavioral Health CARE and Long Term CARE



This Strategic Goal targets the need for people to be able to obtain and maintain affordable health care coverage, receive efficient high-quality health care services, and access appropriate information for informed choices.[2]

Broaden Health Insurance and Long-Term Care Coverage.

Researchers examining where individuals obtained their health care found that although non-group (individually purchased) insurance is less common than employer-provided insurance, increasing such coverage through tax credits is one potential approach to health care reform. Most non-elderly persons who have health insurance obtain it through their employment or through a family member´s employment, and the poor sometimes are covered through public programs. However, about 17 million persons under age 65 in 2006 had coverage through an individually purchased private policy.

Investigators compared individual health insurance with other private insurance obtained through employers. Various State and Federal Health Insurance Portability and Accountability Act regulations affect who purchases non-group policies and the premiums they pay. The most important regulation appeared to be "guaranteed renewability," whereby individual premiums may not be increased solely because changes occur in the individual´s health status.

An inquiry to determine whether States have reduced the number of uninsured low-income children found that nationally, the percentage of uninsured low-income children decreased between 2002 and 2005 although no State had a statistically significant change in its percentage of uninsured low-income children.

A striking finding in an exploration of the long-term care choices made by claimants who have private insurance, was the low level of nursing facility use. Although nearly half of all individuals chose to use residential care, most chose to enter assisted living rather than nursing facilities. Those who chose nursing homes were significantly more physically disabled than those who used home care or assisted living.

Increase Health Care Service Availability and Accessibility.

Staff examined the historical and projected trends in Medicaid enrollment and spending and concluded that increases in the number of people eligible for and receiving benefits in the Medicaid program will play a large part in determining future spending. The increases will be disproportionately larger for eligibility categories that have higher per capita spending: the aged, and disabled. The rate of increase in Medicaid spending will likely exceed the rate of increase in overall health care spending.

Examining what information resources individuals used when seeking nursing home care, researchers found that consumers did not generally avail themselves of the large quantities of quality information available to help them make a decision. They often did not have the time to access the information or were not aware the information existed. A study of the nursing home chain sector found that it was smaller and focused differently than it was ten years ago. Government financing remained vital, with corporate structure heavily influenced by factors such as litigation, State reimbursement, and geography.

Researchers in another project estimated that the 89,334 beneficiaries enrolled in a Preferred Provider Organization (PPO) demonstration cost the Medicare program more than for non-demonstration beneficiaries. The estimated additional cost of $41 million – $457 per enrollee – was 9.3 percent more than it would have been without the PPO demonstration.

In a review of the results of the Medicare Modernization Act, it appears that the availability of Medicare Advantage plans substantially improved, with lowered premiums and beneficiary cost sharing, and improved drug benefits. Access to Medicare private fee-for-service plans increased considerably in all parts of the country, including the rural areas.

Another study examined whether selected Medicare durable medical equipment, prosthetics, orthotics, and supply (DMEPOS) suppliers physically existed and conducted business at their listed addresses. The study found that of 169 DMEPOS suppliers, ten did not exist at their business address, yet billed Medicare almost $400,000 during the two months after researchers determined that the suppliers were absent. In total, 10 percent of the suppliers did not exist or were closed.

Improve Health Care Quality, Safety, Cost and Value.

Researchers asked how health care outcomes vary in different Medicare post acute settings for patients who suffered strokes. They found that patients who were sent to an inpatient rehabilitation facility and then to a skilled nursing facility had the same outcomes as patients who were sent directly to a skilled nursing facility but the cost was three times greater for those who first went to a rehabilitation facility. Patients using (clinic/hospital based) outpatient therapy received more therapy services and experienced better outcomes than patients receiving services only at home.

A study of how Medicare beneficiaries in long-term care facilities used prescription drugs compared to community residents treated at the same time found that beneficiaries in the community used 12 percent fewer prescription drugs.

An inquiry regarding the scope of the health care fraud problem and the value of using electronic health records to help reduce fraud determined that fraudulent claims are between 3 and 10 percent of total claim dollars, or approximately $60-$200 billion per year. Electronic health records are perceived as part of the solution to this problem. Research was also conducted to determine how widely electronic health records have been adopted in the United States. There was no evidence confirming the existence of a digital divide in health care practice; physicians treating fewer Medicaid patients used electronic health records more than doctors with a larger share of practice revenue from the insurance program. Work was performed to develop a standardized definition of electronic health record adoption and was applied to previous studies to establish a nationwide baseline rate of electronic health record adoption.

Investigators examined the impact of the Medicare Replacement Drug Demonstration on physicians and patient access to care and patient outcomes. Unexpectedly, the demonstration did not provide new access to drug therapy to most participants and Medicare spending increased over the 16-month program.

A survey of how patients and their caregivers view medical device recalls and safety information revealed that the term "recall" elicits many different emotions --- from anxiety, anger, and distrust; to more benign feelings of "cautious" and "need more information." Participants with implanted devices, other than implantable cardioverter-defibrillators (pacemakers), were the most upset by the recall discussion and the least likely to know the manufacturer of their device or be confident their doctor would contact them about a recall.

An inquiry into the current and future market for quality indicators found that 114 national entities used such indicators and that quality indicators produced by the Department of Health and Human Services fill a unique niche in the quality indicators´ market. There are no other sources of hospital care quality indicators that represent both a national standard and are also publicly available, transparent, and based on administrative data.

A review of how often Quality Improvement Organizations identify and respond to quality-of-care concerns found that these organizations recommended corrective actions in about 4,500 of the over 300,000 cases initially selected for review during the study period, i.e., 1.5 percent of cases reviewed.

Studies of several programs provided alerts that costs and services might require local or broader program management or policy intervention. An analysis of survey data in one area concluded that Medicare carriers (insurance agents) overstated co-payments for mental health services for beneficiaries with Alzheimer's disease and related disorders. In another study, it was found that 31 percent of Medicaid payments for pediatric dental services resulted in improper payments. A third exploration concluded that 64 percent of payments for surgical removal of dead or unhealthy tissue from wounds in 2004 did not meet Medicare program requirements, resulting in improper payments. In a fourth important alert to program staff and the public, a study found that States cited health deficiencies for almost half the hospices surveyed and for a quarter of hospices investigated for complaints; many related to patient care. Finally, unannounced visits to suppliers of Medicare durable medical equipment, prosthetics, orthotics, and supplies in one area found that almost a third of suppliers did not, as required, maintain a physical facility or were not open and staffed during unannounced site visits.

An examination of Medicaid payments and services made for evacuees of Hurricanes Katrina and Rita for outpatient and medical services and for prescription drugs found that a greater percentage of evacuees than non-evacuees received medical services and prescription drugs but that the average total payment evacuees received was less.

Recruit, Develop, and Retain a Competent Health Care Workforce.

Researchers explored practice profiling criteria that may allow health care organizations to identify efficient qualified physicians. The best practice profiling methodology, criteria used in contracting including financial profiling, and bonus arrangements for high quality physicians. The use of physician quality and economic profiling by payers and employers in evaluating physicians for staff appointment, reappointment or selective contracting has been suggested as an industry practice that would modernize Medicare payment practices.

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