Identify Strategies to Improve Access, Foster Appropriate Use, and Reduce Unnecessary Expenditures

Adequate access to health care services continues to be a challenge for many Americans. This is particularly true for the poor, the uninsured, members of minority groups, rural residents, and other priority populations. In addition, the changing organization and financing of care has raised new questions about access to a range of health services, including emergency and specialty care. At the same time, examples of inappropriate care, including overutilization and misuse of services, continue to be documented.

Through ongoing development of nationally representative and more specialized databases, the production of public-use data products, and research and analyses conducted by AHRQ staff and outside researchers, the Agency addresses critical policy issues pertaining to the access, cost and use of health care.

Research on Health Care Markets and Managed Care

We know that market dynamics and delivery-system organization affect outcomes, quality, access, cost and use. AHRQ continues to conduct and support studies, as well as develop databases and tools, that will enable decisionmakers to understand the key market and delivery-system variables and how changes in these variables affect health care.

Centers of Excellence—Market Forces Affecting Health Care Systems. AHRQ awarded $12.5 million in total funding over 5 years to establish three new centers of excellence to conduct research on how market forces are affecting the quality of health care, access to care, and health care costs. The magnitude and duration of these projects, along with the centers' plans to invite policymakers periodically to discuss findings and their implications, mark a new chapter in the way AHRQ examines how market forces are shaping our Nation's health care. The scientific evidence produced by these centers will help Federal and State policymakers better understand, monitor and anticipate the impact of changes.

Each center will carry out a number of inter-related research projects, some of which may be led by researchers at other institutions. The projects will include a special emphasis on market effects on rural and minority populations and on the influence of purchasers in local markets. The new AHRQ-funded centers of excellence are:

• Structuring Markets and Competition in Health Care. Harvard Medical School, Boston, MA. (In collaboration with Boston University, Boston, Mass. and the University of Puerto Rico, San Juan, PR). The projects that will be researched include:
  • The impact of market forces on the performance of health plan network hospitals.
  • Market-based reforms and quality of care.
  • Mental health carve-outs and cost shifting.
  • Selection and risk adjustment in private employer plans.
  • Managed care penetration in rural settings.
• Quality Measures and Managed Care Markets. University of California, San Francisco, San Francisco, CA (In collaboration with the University of Michigan, Ann Arbor, MI). The projects that will be researched include:
  • Health plan performance and employer choice of plan.
  • Health plan quality and market forces.
  • Market incentives and health plan advertising strategies.
  • Market changes and minorities.
  • National and community perspectives.
• Health Care Markets and Vulnerable Populations. RAND, Santa Monica, CA (in collaboration with the University of Rochester, Rochester, NY). The projects that will be researched include:
  • Health care markets and the quality of hospital care for vulnerable populations.
  • Market competition and safety-net hospitals.
  • Health care markets, the safety net, and access to care for the uninsured.

Integrated Delivery System Research Network (IDSRN). The Integrated Delivery System Research Network (IDSRN) is a new model of field-based research designed by AHRQ to link the Nation's top researchers with some of the largest health care systems for conducting fast-track research on cutting-edge issues in health care. The network creates, supports, and disseminates scientific evidence about what works and what does not work in terms of data and measurement systems and organizational "best practices" related to care delivery and research diffusion. It also provides a cadre of delivery-affiliated researchers and sites to test ways to adapt and apply existing knowledge.

As a group, the IDSRN provides health services in a wide variety of organizational care settings to over 34 million Americans, including the privately insured, Medicare and Medicaid patients, the uninsured, ethnic and racial minorities, and rural and inner-city residents.

In Fiscal Year 2000, AHRQ funded 10 IDSRNs for a total of approximately $2.4 million. Project timelines range from 9 months to 2 1/2 years. The IDSRN projects are grouped into two categories—those that will inform the development of the nation's data and measurement capacity, and those that will inform 'best practices' of how to structure health care organizations. Examples of projects for informing the development of data and management capacity are below.

• Build Capacity to Study Racial/Ethnic Disparities in Access, Use, and Outcomes. The USQA Center for Healthcare Research, a subsidiary of Aetna Healthcare in Atlanta, will examine the current capacity of health plans to study racial/ethnic disparities using managed care organization databases, and it will identify potential strategies for improving such capacity.
• Evaluate the Potential of Private-Sector Data to Augment Public-Sector Data for Use in Annual Report on the State of Quality in the United States. Minneapolis' Center for Healthcare Policy and Evaluation, an independent research institute affiliated with UnitedHealth Group, will evaluate the feasibility of using data from private health care organizations in developing AHRQ's annual National Quality Report. The report, scheduled for publication first in Fiscal Year 2003, will provide a comprehensive picture of the quality of the Nation's health care system. Examples of projects for expanding understanding of "best practices" are below.
• Assess Variations in the Management of Cardiovascular Disease. The United HealthGroup-affiliated Center for Healthcare Policy and Evaluation will assess socioeconomic, racial and ethnic, and gender variations in the management of cardiovascular disease within and across different settings and models of care.
• Track and Evaluate How a Clinical Practice Guideline Is Implemented by a Health Plan. The Kaiser Foundation Research Institute of Oakland, CA, will evaluate the implementation of a clinical practice guideline within an integrated delivery system, which will involve AHRQ priority populations.
• Understand Barriers to the Use of Information Technology Within Delivery Systems. The Research Triangle Institute will conduct a project to increase understanding of barriers that undermine the diffusion of information technology within integrated delivery systems so that strategies can be tailored to overcome them.

Select for a complete list of IDSRN Prodjects.

Research Grants Related to Cost, Use and Access

Adequate access to health care services continues to be a challenge for many Americans. This is particularly so for the poor, the uninsured, members of minority groups, rural residents, and other priority populations. In addition, the changing organization and financing of care has raised new questions about access to a range of health services, including emergency and specialty care. At the same time, examples of inappropriate use of care, including overutilization and misuse of services, continue to be documented.

In Fiscal Year 2000, AHRQ released a program announcement (PA) that expressed AHRQ's interest in extramural grants to identify strategies to improve access, foster appropriate use, and reduce unnecessary expenditures. This area focuses on issues pertaining to:

• The types of health care services Americans use.
• The cost of these services and sources of payment.
• Determinants of access to care.
• Whether particular approaches to health care delivery and financing, or characteristics of the health care market, alter behaviors in ways that improve access and promote cost-effective use of health care resources.

Select for examples of grants funded in Fiscal Year 2000 related to cost, use, and access.

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A Selection of Fiscal Year 2000 Grants Related to Cost, Use and Access

• Care Management by Nurse Practitioner/Hospitalist Team. This grant will compare the effectiveness of care management by a hospitalist MD/acute care nurse practitioner multidisciplinary care management team to conventional approaches to hospital care delivery for acutely ill general medicine inpatients.

  The primary hypotheses are that patients in the experimental unit will have shorter hospital stays, lower resource use during hospitalization and 6 months post-discharge, lower costs during hospitalization and 6 months post-discharge, lower readmission rates post discharge, higher patient satisfaction at discharge and 30 days post-discharge, and higher health related quality of life between admission and 30 days post discharge (University of California, Los Angeles).

• Health Plan Responses to Medicare HMO Premium Payments. This grant will examine how Medicare Health Maintenance organizations (HMOs) have reacted to the new Medicare formula being used to set HMO capitation rates in 1998 and 1999. In 1998, 45 HMOs cancelled their Medicare contracts, while 54 others reduced the market areas in which they offer services. At the same time, more than 30 new plans applied to enter; many plans lowered premiums and changed benefits; and overall Medicare HMO enrollment grew by 8 percent.

  This study will take advantage of this setting to study HMO behavior and its differential response to Medicare payment policy (Boston University).

• Patient-centered Care and Health Care Costs. Preliminary studies indicate that patient-centered care, characterized by incorporating the patient's experience of illness, the psychosocial context and shared decisionmaking, may reduce utilization while improving health status and satisfaction, especially among patients who present with unexplained somatic symptoms. These patients are common, incur high illness burden and cost, and are often dissatisfied with care.

  This grant will examine the relationship between measures of physicians' patient-centeredness and health care costs (total, inpatient, outpatient, testing and medication); health status and satisfaction; and will characterize features of patient-physician communication that contribute to lower health care costs (University of Rochester).

• Efficacy/Reliability of Telemedicine in Routine Pediatric Practice. Limited access and escalating costs of health care persist despite decades of attention to these problems. Telemedicine, conceived as an integrated system of health-care delivery that employs telecommunications and computer technology as a substitute for in-person contact between provider and patient, has previously been used mostly as a tool to address geographic barriers that prevail in rural areas.

  The specific aim of this study is to assess the reliability and efficacy of telemedicine for common, acute complaints of children presenting to the emergency department or primary care office setting (University of Rochester).

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HIV Data Coordinating Center (DCC)

In Fiscal Year 1999 and 2000, AHRQ and sister agencies (HRSA, SAMHSA, and the Office of AIDS Research at NIH) provided support to develop the first phase of the HIV Resource Utilization Data Coordinating Center (DCC). In Fiscal Year 2001, based on the promising results of the first phase, support from these agencies has continued, and plans have been made to expand the scope of this project.

The goal of this project is to provide timely and relevant information to policymakers about the resources utilized to treat persons with HIV disease. It is important to obtain timely data because quickly occurring therapeutic advances, the shifting epidemiology of HIV infection, and the rapid diffusion of managed care are having a major effect on patterns of health care resource utilization for HIV disease. More than $7 billion spent each year by Medicaid, Medicare, the Department of Veterans Affairs, and the Ryan White CARE Act to treat people with HIV disease. Information is needed by Federal and State policymakers to ensure that all persons with HIV disease have access to appropriate health care services.

The mechanism developed to address these issues is a multi-site HIV provider network, which is linked by a centralized data coordinating center. The Data Coordinating Center (DCC) receives data from a large number of HIV providers around the nation in order to provide valid and reliable information about the determinants of resource utilization by persons with HIV disease. The Data Coordinating Center has the capability to receive, consolidate, analyze, and disseminate information about the care provided to persons with HIV disease, eventually operating in a continuous data receipt mode.

The initial phase of this project has succeeded in enrolling a set of HIV care providers in different regions of the U.S. and in establishing procedures for transferring data on HIV-related resource utilization and relevant clinical parameters to the Coordinating Center. Last year, data on over 10,000 HIV-infected patients for calendar year 1999 were transferred to the Coordinating Center, which is currently summarizing them. Analyses of data for a six-month period in 1998 have also been completed. During Fiscal Year 2001, DCC activities are continuing. Data on HIV-related medical resource utilization will be collected for calendar year 2000.

HIV/DCC Preliminary Data. Preliminary data analyses from the HIV DCC indicate that there are serious disparities among those with HIV disease in their ability to receive expensive new drug therapies. DCC data indicate that individuals with HIV disease who are African-American, covered by Medicaid insurance, and who are women are less likely to receive new and expensive drug therapies such as protease inhibitor.

In particular, DCC data collected in the first, pilot year of the DCC from 6,560 patients show that white patients are more likely than African-American or Hispanic patients to receive these new drugs (55%, 48% and 44%, respectively—select for chart), that patients with Medicaid are less likely than privately insured patients (43% vs 61%) to receive protease inhibitors, and that female patients are less likely to be prescribed protease inhibitors than male patients (45% versus 54%).

Healthcare Cost and Utilization Project (HCUP)

The Healthcare Cost and Utilization Project (HCUP) is a public-private partnership to build a multi-State health care data system and companion set of software tools and other resources. The growing family of HCUP databases include 26 State inpatient databases, 13 State ambulatory surgery databases, pilot state emergency department databases, and the National Inpatient Sample (NIS).

In Fiscal Year 2000 and 2001, AHRQ initiated a number of HCUP expansions and enhancements guided by input from key stakeholders—State HCUP partners, hospital associations and other private data organizations, policymakers and researchers—gleaned during meetings convened by AHRQ to specifically to solicit feedback and from other forms of informal and formal outreach with users.

Fiscal Year 2000 and 2001 HCUP accomplishments include:

• Increased the number of States participating in HCUP; now over half (26) of all States are HCUP partners, an increase of roughly 20 percent over the previous fiscal year. New State partners were selected based on the diversity—in terms of geographic representation and population ethnicity—they bring to the project, along with data quality performance and their ability to facilitate timely processing of data.

• Expanded HCUP beyond inpatient hospital settings. HCUP now includes hospital-based ambulatory surgery databases from 13 States with 2 additional States to be added in the remainder of Fiscal Year 2001, and pilot emergency department databases from 5 States in 2000 with four to be added by the end of this fiscal year.

• Developed a multi-pronged effort to make HCUP data more available to the public. A centerpiece of this effort, HCUPnet, is an online query system that provides users easy access to State and National statistics on hospital utilization patterns. Menu-driven HCUP answers questions about conditions treated and procedures performed in hospitals for the population as a whole, as well as for subsets such as children and the elderly. HCUPnet is accessed by a wide array of users including researchers, journalists, state and local health officials, clinicians, and advocacy groups to track and compare trends at the state and national levels. About 4,000 visits are logged each month on HCUPnet.

  A second key component of AHRQ's effort to facilitate researchers' access to HCUP data is the creation of a central distribution center for the State-level databases. Prior to the creation of the central distribution center, researchers interested in State level data had no option but to pursue the labor-intensive approach of contacting each State on an individual basis and follow state-specific application protocols; now researchers can go one-stop shopping.

  In tandem with these efforts to make HCUP data more accessible, efforts are also underway to make the documentation specifications for the databases available electronically to researchers through the Agency's Web site. Use of HCUP by the extramural research community has grown, with nearly 200 State-level databases distributed in the past year, and 190 copies of the National Inpatient Sample distributed.

• Used HCUP data for its congressionally mandated annual reports—the National Quality Report and National Disparities Report.

• Completed a study on the feasibility of creating a database specifically tailored for analyses of children's hospitalization patterns, in response to the growing interests among policymakers and researchers in studying pediatric care.

  Many pediatric conditions for which children are hospitalized are rare, which historically has made analyses difficult, even with the large sample size of the NIS. A kid's inpatient database (KID) is now in development, and efforts are underway to obtain the necessary approval from the HCUP States to make the new available through the central distribution center.

• Undertook a comprehensive assessment of the sampling and weighting strategy for the Nationwide Inpatient Sample (NIS) database to determine if and how its capacity to generate national estimates might be improved. As a result, the subsequent NIS was redesigned and an analysis of the re-design implications was prepared for the research community.

• Began an assessment of the feasibility and utility of constructing a national database from the state ambulatory surgery databases.

• Launched an HCUP fact book series, which is disseminated as bound publications as well as through the AHRQ Web site. The fact book series has been well-received; the first fact book, excerpted here, was downloaded nearly 40,000 times in the first 6 months it was posted on the Agency's Web site. The fact book presents data on reasons Americans are hospitalized, how long they stay in the hospital, the procedures they undergo, and the charges for their stays. This in-depth profile of inpatient care answers many key questions about how specific conditions are treated in hospitals and the resulting outcomes. It contributes to the evidence base needed to develop effective strategies for improving the quality and value of health care. Select for an example of the information provided in the HCUP fact book (specifically related to children).

Excerpts from Hospitalization in the United States, 1997

• The most common reasons for hospital admission in the United States are births (3.8 million), followed by coronary atherosclerosis (1.4 million), pneumonia (1.2 million), congestive heart failure (1.0 million) and heart attack (746,000).
• The most expensive were as follows: respiratory distress syndrome (infant) ($68,000), spinal cord injury ($53,000), prematurity and low birthweight ($50,000), heart valve disorders ($48,000), and leukemia ($44,000). The figures are average charges for the entire stay.
• Overall, patients stayed in the hospital an average of five days. But stays involving premature birth, with problems such as low birthweight averaged 22 days. Stays because of infant respiratory distress syndrome average 25 days, and patients with spinal cord injuries remained hospitalized an average of 16 days.
• Over one-third of all hospital patients are initially seen in the emergency department before being admitted. This figure includes 40 percent of all hospitalized children and 55 percent of the very old (80 and older). The number one cause of hospital admission through the emergency room was pneumonia.

  Half of the other top 10 conditions for the admission of emergency room patients involved heart conditions. The other leading conditions for admission through the emergency department were stroke, chronic obstructive lung disease (emphysema or chronic bronchitis), asthma and blood infection (septicemia).

Medical Expenditure Panel Survey (MEPS)

The Medical Expenditure Panel Survey (MEPS) is an ongoing, annual (1996 to present) nationally representative survey of health care use, expenditures, sources of payment, and insurance coverage for the U.S. civilian noninstitutionalized population. The 1996 MEPS also included a national survey of nursing homes and their residents.

This survey is AHRQ's main source to:

• Collect and examine comprehensive data that estimate the level and distribution of health care use and expenditures.
• Monitor the dynamics of the health care delivery and insurance systems.
• Assess health care policy implications.

Select for more details about MEPS.

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