The relationship of hospital quality and cost per case in Hawaii.

One of the leading questions of our time is whether high-quality care leads to lower health care costs. Using data from Hawaii hospitals, this paper addresses the relationship of overall cost per case to a composite measure of the quality of inpatient care and a 30-day readmission rate. We found that low-cost hospitals tend to have the highest quality but the worst readmission performance.

Prevalence of heart disease and its risk factors related to age in Asians, Pacific Islanders, and Whites in Hawai'i.

Objective: To examine disparities in disease prevalence related to age and race/ethnicity. Study design. Retrospective observational study.

Heart failure patients receiving ACEIs/ARBs were less likely to be hospitalized or to use emergency care in the following year.

Angiotensin-converting enzyme inhibitors (ACEIs) have been shown to decrease morbidity and mortality in heart failure (HF) patients in randomized-controlled trials; observational studies have confirmed this benefit among patients discharged with HF. Investigating the benefit of ACEIs or angiotensin receptor blockers (ARBs) among general HF patients has important implications for quality-of-care measurement and quality initiatives. The objective of this study is to assess the impact of receipt of ACEIs/ARBs among patients with HF on hospitalization, emergency care, and healthcare cost during the following year.

Does pay for performance improve cardiovascular care in a "real-world" setting?

The objective was to investigate the impact of a pay-for-performance program (P4P) on quality care and outcomes among cardiovascular disease (CVD) patients. Claims data were used to identify CVD patients in a commercial plan in 1999-2006. Multivariate analyses were employed to examine the impact of P4P on quality care (lipid monitoring and treatment) and quality care on outcomes (new coronary events, hospitalizations, and lipid control).

Disparities in health, obesity and access to care among an insured population of Asian and Pacific Islander Americans in Hawai'i.

Objective: To examine differences in health status, obesity and access among Asian and Pacific Islander Americans in Hawai'i using data from a 2007 health plan survey, including Caucasians, Puerto Ricans, American Indian and Alaska Natives, Chinese, Filipinos, Japanese, Koreans, Native Hawai'ians, Samoans, and Other Pacific Islanders.

Methods: Data were collected through a stratified random sample of adult members of a health plan in Hawai'i (n = 119,563) who saw a physician in the past 12 months. Multivariable logistic and ordinary least squares regression analyses were used to examine racial/ethnic differences in health status, access, and obesity and the impact of obesity and access on health status, after controlling for age, gender, and education.

Impact of a pay-for-performance program on low performing physicians.

Studies have shown that the lowest performing physicians in pay-for-performance (P4P) programs improved the most; however, it is unclear whether this would occur without the P4P program or be sustained. The objective of this study is to investigate the impact of P4P in a Preferred Provider Organization (PPO) on low performing physicians over a 4-year period. We used administrative claims data from a PPO health plan in Hawaii, which implemented a P4P program, and a PPO plan in the South, which did not implement a P4P program.

The effect of a PPO pay-for-performance program on patients with diabetes.

Objectives: To investigate the effectiveness of a pay-for-performance program (P4P) to increase the receipt of quality care and to decrease hospitalization rates among patients with diabetes mellitus.

Study Design: Longitudinal study of patients with diabetes enrolled in a preferred provider organization (PPO) between January 1, 1999, and December 31, 2006.

Methods: We used multivariate analyses to assess the effect of seeing P4P-participating physicians on the receipt of quality care (ie, glycosylated hemoglobin and low-density lipoprotein cholesterol testing) and on hospitalization rates, controlling for patient characteristics.

Patient outcomes and evidence-based medicine in a preferred provider organization setting: a six-year evaluation of a physician pay-for-performance program.

Objective: To determine whether health plan members who saw physicians participating in a quality-based incentive program in a preferred provider organization (PPO) setting received recommended care over time compared with patients who saw physicians who did not participate in the incentive program, as per 11 evidence-based quality indicators.

Data Sources/study Setting: Administrative claims data for PPO members of a large nonprofit health plan in Hawaii collected over a 6-year period after the program was first implemented.

Study Design: An observational study allowing for multiple member records within and across years.

Follow-up services after an emergency department visit for substance abuse.

Objective: The recent introduction of substance abuse treatment measures to the Health Plan Employer and Data Information Set (HEDIS) highlights the importance of this area for managed care organizations (MCOs). Particularly challenging are members first diagnosed in an emergency department (ED).

Study Design: Retrospective claims analysis.

Health disparities in 30 indicators of recommended clinical care.

This article examines variations in clinical practice for 30 clinical indicators. Patients' age, gender, and morbidity and certain characteristics of their physicians affected whether they received recommended care. Recommended care increased with patient age for 13 significant clinical indicators and decreased with age for 7 others.

Antihypertensive adherence and drug class among Asian Pacific Americans.

Objective: Research on adherence has emphasized the need to consider patient ethnicity when developing adherence plans. The objective of this study is to identify predictors of adherence for specific groups, particularly Asian Americans and Pacific Islanders.

Methods: We examined the factors, including drug class, associated with antihypertensive adherence for 28,395 adults in Hawaii (July 1999-June 2003) using health plan administrative data.

Copayment level and compliance with antihypertensive medication: analysis and policy implications for managed care.

Objective: To measure the impact of medication copayment level and other predictors on compliance with antihypertensive medications, as measured by the medication possession ratio.

Study Design: Retrospective observational analysis.

Methods: We used claims data from a large managed care organization.

Variations in clinical practice among the Hawaiian islands.

State health surveys and hospital discharge data suggest aspects of health care may vary by island in the state of Hawai'i. This study further examines the issue comparing O'ahu, Maui, Hawai'i, and Kaua'i on 15 indicators of recommended clinical care using data from a large insurer in Hawaii. The Hawaiian Islands differed to a statistically significant extent on 14 of the 15 indicators.

Are physician reimbursement strategies associated with processes of care and patient satisfaction for patients with diabetes in managed care?

Objective: To examine associations between physician reimbursement incentives and diabetes care processes and explore potential confounding with physician organizational model.

Data Sources: Primary data collected during 2000-2001 in 10 managed care plans.

Study Design: Multilevel logistic regressions were used to estimate associations between reimbursement incentives and process measures, including the receipt of dilated eye exams, foot exams, influenza immunizations, advice to take aspirin, and assessments of glycemic control, proteinuria, and lipid profile.

Aligning financial incentives with quality of care in the hospital setting.

This article describes the structure, implementation, and early results of a performance-based hospital incentive program designed by a large nonprofit health plan. The Hospital Quality Service and Recognition program, developed by the Hawaii Medical Service Association, was launched in 2001 to reward high-quality medical care at the hospital level. This pay-for-performance program used administrative claims data, survey data, and hospital-reported information to assess hospital performance in risk-adjusted complications and risk-adjusted length of stay (LOS), patient satisfaction, and hospital processes of care measures.

Remote physiological monitoring: clinical, financial, and behavioral outcomes in a heart failure population.

This article reports on the outcomes associated with remote physiological monitoring (RPM) conducted as part of a heart failure disease management program. Claims data, medical records, data transmission records, and survey results for 91 individuals ages 50-92 (mean 74 years) successfully completing a heart failure RPM program were analyzed for time periods before, during, and after the monitoring intervention. The program was associated with significant reductions in per member per month costs and emergency room and hospital utilization.

A quality-driven physician compensation model: four-year follow-up study.

This case report describes a qualitative and preliminary quantitative assessment of a quality-based physician compensation program. The Hawaii Medical Service Association's Physician Quality and Service Recognition program offers an innovative and effective approach for improving delivery of high-quality and cost-effective care to patients enrolled in preferred provider organizations. Support for the program is demonstrated through increasing numbers of voluntarily participating physicians.

Alternate financial incentives in multi-tiered formulary systems to improve accountability for outcomes.

Background: Drug manufacturer rebates paid to health plans and pharmacy benefit management companies have come under increased public scrutiny. Over the past several years, numerous articles have appeared in the literature encouraging a shift to a more quality-based decision-making process for health plan drug formularies.

Objective: To propose a new basis for formulary placement decisions that would include consideration of health-plan-specific measures (clinical outcomes, total cost, adherence, and appropriateness of care) and align incentives for health plans, physicians, pharmacists, and pharmaceutical companies to promote high-quality care.

Prescription drugs: elderly enrollee reports of financial access, receipt of free samples, and discussion of generic equivalents related to type of coverage.

Objective: To compare elderly health plan enrollee's survey responses regarding access to prescription drugs, receipt of samples, and discussion of generic equivalents across healthcare delivery systems and to examine the extent to which member characteristics are related to responses.

Study Design: Cross-sectional, observational study.

Patients And Methods: Elderly enrollees (aged 65 and over) in the Preferred Provider Organization (PPO in = 10,2201) and Medicare cost contract (n = 14,635) of a single health insurer responded to a 2001 member satisfaction survey.