Health plan pay-for-performance strategies.

Objective: To examine health plan strategies, planning, development, and implementation of pay-for-performance programs (financial incentives for hospitals and physicians tied to quality and efficiency) at the community level, focusing on differences across markets.

Study Design: A fifth round of site visits to 12 nationally representative metropolitan areas between January 2005 and June 2005, based on more than 1000 protocol-driven interviews with representatives from health plans, provider organizations, employers, and policy makers.

Methods: In each of 12 communities, we interviewed several executives from 35 health plans, including chief executive officers, marketing executives, and network contracting directors.

Consumer-directed health insurance products: local-market perspectives.

During the past few years, health plans have focused product development on consumer-driven health plans. This paper examines how these products are faring in twelve Community Tracking Study (CTS) communities. Although there has been a proliferation in the number and variety of consumer-directed plan options available, employers have taken a cautious approach.

An update on Medicare beneficiary access to physician services.

After declining markedly between 1997 and 2001, Medicare seniors' access to physician care stabilized between 2001 and 2003, according to a national study by the Center for Studying Health System Change (HSC). Access to care trends were parallel for Medicare seniors 65 and older and privately insured people between the ages of 55 and 64--the near-elderly--suggesting that health system developments were much more important influences on beneficiary access than any effects of Medicare's 2002 physician payment rate reduction. In addition, access to care for both Medicare seniors and privately insured near-elderly people was comparable in local health care markets where commercial insurance payment rates far exceed Medicare's.

Rhetoric vs. reality: employer views on consumer-driven health care.

Because of rising premiums, employers are investigating new health insurance approaches that maintain workers' broad choice of providers while raising awareness of health care costs through increased patient financial responsibility. Employers' knowledge of new health plan products, including consumer-driven health plans and tiered-provider networks, has grown considerably in recent years, according to findings from the Center for Studying Health System Change's (HSC) 2002-03 site visit to 12 nationally representative communities. But employers are concerned that consumer-driven health plans would take considerable effort to implement without much cost savings.

Employers shift rising health care costs to workers: no long-term solution in sight.

Despite concerns that an economic downturn would prompt employers to rein in rapidly rising health insurance premiums by radically reducing benefits, few have made dramatic benefit changes, according to findings from the Center for Studying Health System Change's (HSC) 2002-03 site visits to 12 nationally representative communities. Key employer changes focused on increasing patient cost sharing and revising family coverage policies. Few employers adopted innovative health benefit strategies or major design changes.

Patient cost-sharing innovations: promises and pitfalls.

Over the next decade, health plans and employers will refine patient cost sharing to encourage workers to seek more cost-effective care, according to a panel of market and health policy experts at a Center for Studying Health System Change (HSC) conference. Instead of using a single, large deductible, employers and health plans will likely vary patient cost sharing by choice of provider, site and type of service, so patients choosing less effective care options pay more. Employers also will try to limit financial hardships for low-income workers by, for example, varying cost sharing based on workers' income.

Patient cost sharing: how much is too much?

Responding to successive years of double-digit health insurance premium increases, employers continue to restructure health benefits to slow the rise in company costs by increasing patients' financial stake in their care. A new Center for Studying Health System Change (HSC) study examines how increased patient cost sharing through higher deductibles, copayments and coinsurance raises patients' out-of-pocket costs. Increased patient cost sharing creates more financial burdens for seriously ill and low-income workers.

Referral gridlock: primary care physicians and mental health services.

Background: Patients' barriers to mental health services are well documented and include social stigma, lack of adequate insurance coverage, and underdiagnosis by primary care physicians. Little is known, however, about challenges primary care physicians face arranging mental health referrals and hospitalizations.

Objective: To examine how practice setting and environment influence primary care physicians' ability to refer patients for medically necessary mental health services.

So much to do, so little time: physician capacity constraints, 1997-2001.

Signs of tightened physician capacity--or physicians' ability to provide services relative to demand--appeared between 1997 and 2001, according to a study by the Center for Studying Health System Change (HSC). Patients waited longer for appointments, and more physicians reported having inadequate time with patients. Despite signs of tightened physician capacity, the supply of physicians grew modestly, the proportion of physicians working with nurse practitioners and other caregivers increased and doctors spent more time in direct patient care.

Managing costs, managing benefits: employer decisions in local health care markets.

Objectives: To better understand employer health benefit decision making, how employer health benefits strategies evolve over time, and the impact of employer decisions on local health care systems.

Data Sources/study Setting: Data were collected as part of the Community Tracking Study (CTS), a longitudinal analysis of health system change in 12 randomly selected communities.

Study Design: This is an observational study with data collection over a six-year period.

Who do you trust? Americans' perspectives on health care, 1997-2001.

A turbulent backlash against managed care in the mid-1990s pitted consumers and health care providers against health plans in a struggle for control over medical decision making. New findings from the Center for Studying Health System Change (HSC) Community Tracking Study Household Survey indicate consumer confidence in the system and trust in physicians increased slightly between 1997 and 2001, perhaps as a result of changes in laws and loosening of health plan restrictions. Nevertheless, there is strong evidence of continued public concern about the influence of health plans on medical decision making.

The role of public employers in a changing health care market.

Public employers provide health insurance coverage to nearly 16 percent of all U.S. workers.

Growing physician access problems complicate Medicare payment debate.

Projected cuts in Medicare physician payments raise serious concerns that Medicare beneficiaries will lose access to needed physician services. A study by the Center for Studying Health System Change (HSC) shows growing physician access problems among Medicare and privately insured patients. Patients have the most difficulties obtaining care from specialists and in certain communities.

Obstacles to employers' pursuit of health care quality.

Large employers' roles in improving health care quality are shifting away from value-based purchasing toward direct efforts to improve health care delivery within local markets. Although most large employers adopted the tools required for value-based purchasing, inadequate information on quality has frustrated employers and limited their ability to make choices based on quality. More recent quality initiatives aimed at directly improving local health delivery systems may be limited to specific markets where the largest employers can exert substantial influence.

Employer-sponsored health insurance: pressing problems, incremental changes.

Despite large premium increases, employers made only modest changes to health benefits in the past two years. By increasing copayments and deductibles and changing their pharmacy benefits, employers shifted costs to those who use services. Employers recognize these changes as short-term fixes, but most have not developed strategies for the future.

Tax credits and purchasing pools: will this marriage work?

Bipartisan interest is growing in Congress for using federal tax credits to help low-income families buy health insurance. Regardless of the approach taken, tax credit policies must address risk selection issues to ensure coverage for the chronically ill. Proposals that link tax credits to purchasing pools would avoid risk selection by grouping risks similar to the way large employers do.

Stand-alone health insurance tax credits aren't enough.

Using health insurance tax credits to help reduce the ranks of the nearly 43 million uninsured Americans has attracted broad bipartisan support in Congress. But tax credits alone will not help many sick or older people obtain affordable coverage, according to an expert panel at an April 10, 2001, conference sponsored by the Center for Studying Health System Change (HSC). To make tax credits a viable option for eligible people, the individual insurance market would need significant reforms or a better way to spread risk-similar to large employers-over a large and varied population.

Minority physicians' experiences obtaining referrals to specialists and hospital admissions.

Context: Over the past 15 years, policy makers, healthcare providers, and researchers have focused their attention on understanding and reducing ethnic disparities in access to healthcare. Efforts to understand and reduce these disparities in access are driven by the wealth of studies that document significant differences in the health of ethnic minority groups in the United States.

Objective: To assess differences in access to medical care from African American, Hispanic, and white physicians' perspectives.

Are defined contributions a new direction for employer-sponsored coverage?

Defined contributions for health benefits are being promoted as the new silver bullet for employers to combat the rising costs of health care, the managed care backlash and the changing climate for employer liability. As interest in this concept grows, so does the number of proposed alternatives for implementing it. Originally called fixed contributions, defined contributions now also refer to cash transfers or vouchers, with reliance on the individual market for health insurance.

Does managed care enable more low income persons to identify a usual source of care? Implications for access to care.

Background: By requiring or encouraging enrollees to obtain a usual source of care, managed care programs hope to improve access to care without incurring higher costs.

Objectives: (1) To examine the effects of managed care on the likelihood of low-income persons having a usual source of care and a usual physician, and; (2) To examine the association between usual source of care and access.

Research Design: Cross-sectional survey of households conducted during 1996 and 1997.

Who has a choice of health plans?

Policy makers are concerned that consumers have no voice in the changing health care system. They debate, however, whether the consumers' voice should be heard through regulation, such as patient protections, or the marketplace. For market forces to work in the consumers' interest, consumers must have a choice of plans and detailed information on which to base their choice.

Monitoring the impact of the Medicare Fee Schedule on access to care for vulnerable populations.

Implementation of the Medicare Fee Schedule (MFS) introduced concerns about the potential for reduced access to care, especially for vulnerable populations. These analyses show differences in access before and after the MFS that cannot be explained by health status. In particular, those without private or public supplementary insurance, those with low incomes, African Americans, and the oldest old had lower utilization before the MFS.

Insurance aspects of DRG outlier payments.

As part of the prospective payment system, the government pays 'outlier' payments for especially long or expensive cases. These payments can be viewed as insurance for the hospital against excessive losses. They mitigate problems of access and underprovision of care for the sickest patients, and provide additional payments to the hospitals that take care of them, thereby making payments to hospitals more equitable.