Value-Based Approaches for Emergency Care in a New Era.

Although emergency departments (EDs) play an integral role in the delivery of acute unscheduled care, they have not been fully integrated into broader health care reform efforts. Communication and coordination with the ambulatory environment remain limited, leaving ED care disconnected from patients' longitudinal care. In a value-based environment focused on improving quality, decreasing costs, enhancing population health, and improving the patient experience, this oversight represents a missed opportunity for emergency care.

Medical cost burdens among nonelderly adults with asthma.

Objectives: We used the 2003-2009 Medical Expenditure Panel Survey to evaluate average annual total and out-of-pocket expenditures by nonelderly adults with asthma.

Study Design: We divided patients diagnosed with asthma into 4 groups, based on whether or not they had had an asthma attack in the previous year (a crude marker for disease severity) and whether or not they reported using treatment for their asthma.

Methods: For each group we calculated total and out-of-pocket average annual spending for hospital inpatient, hospital outpatient, emergency department, and physician office care, as well as for prescription drugs.

Trends in the financial burden of medical care for nonelderly adults with diabetes, 2001 to 2009.

Objectives: To examine trends in out-of-pocket spending and the financial burden of care for persons with diabetes between 2001 and 2009, and to examine whether these trends are consistent with trends in access to prescription drugs and utilization of hospital services.

Study Design And Methods: Data are from the 2001 to 2009 Medical Expenditure Panel Survey (MEPS). The sample includes persons aged 18 to 64 years with diagnosed diabetes.

High physician concern about malpractice risk predicts more aggressive diagnostic testing in office-based practice.

Despite widespread agreement that physicians who practice defensive medicine drive up health care costs, the extent to which defensive medicine increases costs is unclear. The differences in findings to date stem in part from the use of two distinct approaches for assessing physicians' perceived malpractice risk. In this study we used an alternative strategy: We linked physicians' responses regarding their levels of malpractice concern as reported in the 2008 Health Tracking Physician Survey to Medicare Parts A and B claims for the patients they treated during the study period, 2007-09.

Care coordination agreements: barriers, facilitators, and lessons learned.

Background: With growing pressure to improve the quality and coordination of care, physicians feel a need to streamline their relationships with other practitioners around shared care for patients. Some physicians have developed written agreements that articulate the respective responsibilities of 2 or more parties for coordination of patient care, ie, care coordination agreements (CCAs).

Objectives: To describe how CCAs are formed and explore facilitators and barriers to adoption of effective CCAs, the extent to which CCAs may be replicable in different market contexts, and the implications for policies and programs that aim to improve the coordination of care.

Emergency preparedness and community coalitions: opportunities and challenges.

Being prepared for a natural disaster, infectious disease outbreak or other emergency where many injured or ill people need medical care while maintaining ongoing operations is a significant challenge for local health systems. Emergency preparedness requires coordination of diverse entities at the local, regional and national levels. Given the diversity of stakeholders, fragmentation of local health care systems and limited resources, developing and sustaining broad community coalitions focused on emergency preparedness is difficult.

Dispelling myths about emergency department use: majority of Medicaid visits are for urgent or more serious symptoms.

Contrary to conventional wisdom that Medicaid patients often use hospital emergency departments (EDs) for routine care, the majority of ED visits by nonelderly Medicaid patients are for symptoms suggesting urgent or more serious medical problems, according to a new national study by the Center for Studying Health System Change (HSC). About 10 percent of nonelderly Medicaid patient ED visits are for nonurgent symptoms, compared with about 7 percent for privately insured nonelderly people. Nonetheless, there are clearly opportunities to develop less-costly care options than emergency departments for both nonelderly Medicaid and privately insured patients.

After-hours care and its coordination with primary care in the U.S.

Background: Despite expectations that medical homes provide "24 × 7 coverage" there is little to guide primary care practices in developing sustainable models for accessible and coordinated after-hours care.

Objective: To identify and describe models of after-hours care in the U.S.

Comparative effectiveness of care coordination interventions in the emergency department: a systematic review.

Study Objective: To conduct a systematic review on the effectiveness of emergency department (ED)-based care coordination interventions.

Methods: We reviewed any randomized controlled trial or quasi-experimental study indexed in MEDLINE, CINAHL, Web of Science, Cochrane, or Scopus that evaluated the effectiveness of ED-based care coordination interventions. To be included, interventions had to incorporate information from previous visits, provide educational services on continuing care, provide post-ED treatment plans, or transfer information to continuing care providers.

Hospitals' geographic expansion in quest of well-insured patients: will the outcome be better care, more cost, or both?

The emphasis that hospitals place on cutting-edge technology and niche specialty services to attract physicians and patients has set the stage for health care's most recent competitive trend: an increased level of targeted, geographic service expansion to "capture" well-insured patients. We conducted interviews in twelve US communities in 2010 and found that many hospital systems--some with facilities in geographically undesirable areas--have expanded to compete for better-insured patients by building or buying facilities and physician practices in nearby, more affluent communities. Along with extending services to new markets, these hospital outposts often serve to pull well-insured patients to flagship facilities.

Americans' access to prescription drugs stabilizes, 2007-2010.

Despite the weak economy and more people lacking health insurance, the proportion of Americans reporting problems affording prescription drugs remained level between 2007 and 2010, with more than one in eight going without a prescribed drug in 2010, according to a new national study from the Center for Studying Health System Change (HSC). While remaining stable overall, access to prescription drugs improved for working-age, uninsured people, likely reflecting a decline in visits to health care providers, as well as changes in the composition of the uninsured population. Likewise, elderly people eligible for both Medicare and Medicaid saw a sharp drop in prescription drug access problems.

Association between quality of care and the sociodemographic composition of physicians' patient panels: a repeat cross-sectional analysis.

Background: Pay-for-performance programs could worsen health disparities if providers who care for disadvantaged patients face systematic barriers to providing high-quality care. Risk adjustment that includes sociodemographic factors could mitigate the financial incentive to avoid disadvantaged patients.

Objective: To test for associations between quality of care and the composition of a physician's patient panel.

Factors associated with frequent utilization of crisis substance use detoxification services.

Previous research suggests that some substance users have multiple crisis detoxification visits and never access rehabilitation care. This care-seeking pattern leads to poorer outcomes and higher costs. The authors aimed to identify predictors of repeat detoxification visits by analyzing state-level data routinely collected at the time of substances use services admission.

Administrative challenges to regionalization.

The ideal emergency care system delivers the right care to the right patient at the right time and yields appropriate patient outcomes at a sustainable overall cost. Transforming the current system of emergency care into the Institute of Medicine's vision of a coordinated, regionalized, and accountable emergency care system requires careful consideration of administrative challenges and barriers. Left unaddressed, certain processes, systems, and structures may prevent integration efforts or threaten long-term viability.

Research priorities for administrative challenges of integrated networks of care.

In 2006, the Institute of Medicine (IOM) advanced the concept of "coordinated, regionalized, and accountable emergency care systems" to address significant problems with the delivery of emergency medical care in the United States. Achieving this vision requires the thoughtful implementation of well-aligned, system-level structures and processes that enhance access to emergency care and improve patient outcomes at a sustainable cost. Currently, the delivery of emergency medical care is supported by numerous administrative systems, including economic; reimbursement; legal and regulatory structures; licensure, credentialing, and accreditation processes; medicolegal systems; and quality reporting mechanisms.

Where Americans get acute care: increasingly, it's not at their doctor's office.

Historically, general practitioners provided first-contact care in the United States. Today, however, only 42 percent of the 354 million annual visits for acute care--treatment for newly arising health problems--are made to patients' personal physicians. The rest are made to emergency departments (28 percent), specialists (20 percent), or outpatient departments (7 percent).

Physicians' fears of malpractice lawsuits are not assuaged by tort reforms.

Physicians contend that the threat of malpractice lawsuits forces them to practice defensive medicine, which in turn raises the cost of health care. This argument underlies efforts to change malpractice laws through legislative tort reform. We evaluated physicians' perceptions about malpractice claims in states where more objective indicators of malpractice risk, such as malpractice premiums, varied considerably.

Expectations outpace reality: physicians' use of care management tools for patients with chronic conditions.

Use of care management tools--such as group visits or patient registries--varies widely among primary care physicians whose practices care for patients with four common chronic conditions--asthma, diabetes, congestive heart failure and depression--according to a new national study by the Center for Studying Health System Change (HSC). For example, less than a third of these primary care physicians in 2008 reported their practices use nurse managers to coordinate care, and only four in 10 were in practices using registries to keep track of patients with chronic conditions. Physicians also used care management tools for patients with some chronic conditions but not others.

Substance use treatment barriers for patients with frequent hospital admissions.

Substance use (SU) disorders adversely impact health status and contribute to inappropriate health services use. This qualitative study sought to determine SU-related factors contributing to repeated hospitalizations and to identify opportunities for preventive interventions. Fifty Medicaid-insured inpatients identified by a validated statistical algorithm as being at high-risk for frequent hospitalizations were interviewed at an urban public hospital.

Medical homes: challenges in translating theory into practice.

The concept of the medical home has existed since the 1960s, but has recently become a focus for discussion and innovation in the health care system. The most prominent definitions of the medical home are those presented by the Patient-Centered Primary Care Collaborative, the National Committee for Quality Assurance, and the Commonwealth Fund. These definitions share: adoption of health information technology and decision support systems, modification of clinical practice patterns, and ensuring continuity of care.