BACKGROUND: Previous research has provided evidence that socioeconomic status has an impact on invasive treatments use after acute myocardial infarction. In this paper, we compare the socioeconomic inequality in the use of high-technology diagnosis and treatment after acute myocardial infarction between the US, Quebec and Belgium paying special attention to financial incentives and regulations as explanatory factors.

METHODS: We examined hospital-discharge abstracts for all patients older than 65 who were admitted to hospitals during the 1993-1998 period in the US, Quebec and Belgium with a primary diagnosis of acute myocardial infarction. Patients' income data were imputed from the median incomes of their residential area. For each country, we compared the risk-adjusted probability of undergoing each procedure between socioeconomic categories measured by the patient's area median income.

RESULTS: Our findings indicate that income-related inequality exists in the use of high-technology treatment and diagnosis techniques that is not justified by differences in patients' health characteristics. Those inequalities are largely explained, in the US and Quebec, by inequalities in distances to hospitals with on-site cardiac facilities. However, in both Belgium and the US, inequalities persist among patients admitted to hospitals with on-site cardiac facilities, rejecting the hospital location effect as the single explanation for inequalities. Meanwhile, inequality levels diverge across countries (higher in the US and in Belgium, extremely low in Quebec).

CONCLUSIONS: The findings support the hypothesis that income-related inequality in treatment for AMI exists and is likely to be affected by a country's system of health care.

Objective. To compare safety climate between diverse U.S. hospitals and Veterans Health Administration (VA) hospitals, and to explore the factors influencing climate in each setting.

Data Sources. Primary data from surveys of hospital personnel; secondary data from the American Hospital Association's 2004 Annual Survey of Hospitals.

Study Design. Cross-sectional study of 69 U.S. and 30 VA hospitals.

Data Collection. For each sample, hierarchical linear models used safety-climate scores as the dependent variable and respondent and facility characteristics as independent variables. Regression-based Oaxaca–Blinder decomposition examined differences in effects of model characteristics on safety climate between the U.S. and VA samples.

Principal Findings. The range in safety climate among U.S. and VA hospitals overlapped substantially. Characteristics of individuals influenced safety climate consistently across settings. Working in southern and urban facilities corresponded with worse safety climate among VA employees and better safety climate in the U.S. sample. Decomposition results predicted 1.4 percentage points better safety climate in U.S. than in VA hospitals: −0.77 attributable to sample-characteristic differences and 2.2 due to differential effects of sample characteristics.

Conclusions. Results suggest that safety climate is linked more to efforts of individual hospitals than to participation in a nationally integrated system or measured characteristics of workers and facilities.

Objective

To determine whether eligible extremely-low-birth-weight children (<1000g) were enrolled in the federally enacted, state-coordinated Early Intervention (EI) program intended to help children with developmental delay or disability regardless of parental income, and the factors associated with enrollment.

Methods

Retrospective analysis of 884 EI-eligible ELBW children born in South Carolina with birth weight 401 to 999g, gestation ≥24 weeks, and survival for the first 120 days of life. We created a linked data set with data from Early Intervention (1996–2001), Vital Records (1996–1998), death certificates, and Medicaid. Each child was followed from birth to 3 years old, the program eligibility period.

Results

A total of 54% of ELBW children were enrolled in EI at any time from birth to 36 months. Even among children ever enrolled in Medicaid (83% of all ELBW children), only 63% were enrolled in EI. Being born in a multiple gestational birth, having heavier birth weight (750 to 999g), and having ever enrolled in Medicaid were positively associated with EI enrollment. Among Medicaid patients for whom perinatal data were available, additional risk adjustment showed that EI enrollment was more likely with birth in level 3 hospitals, birth weight 750 to 999g, Neonatal Medical Index severity level V (most severe), and longer initial length of hospital stay.

Conclusions

Only about half of eligible ELBW children in South Carolina were enrolled—much lower than reported elsewhere. Efforts are needed to understand why eligible infants are not being enrolled and to develop strategies to remedy the situation.

Purpose. Mathematical and simulation models are increasingly used to plan for and evaluate health sector responses to disasters, yet no clear consensus exists regarding best practices for the design, conduct, and reporting of such models. The authors examined a large selection of published health sector disaster response models to generate a set of best practice guidelines for such models.

Methods. The authors reviewed a spectrum of published disaster response models addressing public health or health care delivery, focusing in particular on the type of disaster and response decisions considered, decision makers targeted, choice of outcomes evaluated, modeling methodology, and reporting format. They developed initial recommendations for best practices for creating and reporting such models and refined these guidelines after soliciting feedback from response modeling experts and from members of the Society for Medical Decision Making.

Results. The authors propose 6 recommendations for model construction and reporting, inspired by the most exemplary models: health sector disaster response models should address real-world problems, be designed for maximum usability by response planners, strike the appropriate balance between simplicity and complexity, include appropriate outcomes that extend beyond those considered in traditional cost-effectiveness analyses, and be designed to evaluate the many uncertainties inherent in disaster response. Finally, good model reporting is particularly critical for disaster response models.

Conclusions. Quantitative models are critical tools for planning effective health sector responses to disasters. The proposed recommendations can increase the applicability and interpretability of future models, thereby improving strategic, tactical, and operational aspects of preparedness planning and response.

The current focus of the health reform debate is rightfully beginning to shift to the need to transform the delivery system to contain the long run growth in costs. Although much of the debate still focuses on the role of a public plan, this ignores the need for fundamental change. None of the options on the table will transform the delivery system. If passed, the best the current proposals could do is to expand enrollment and perhaps contain federal costs, but on its own the public plan will be unable to make the delivery system more efficient.

To control health care costs, I propose a publicly chartered major risk pool, or MRP, that
will allow plans to pool risk, thereby eliminating the need for wasteful underwriting and
selective marketing costs. Participation in the MRP by both providers and insurers is
voluntary. It can be combined with any public option in an exchange implemented at the
federal or state level; it can even work without a public option. After a brief transition
period, the MRP requires no federal funds and will not be “on budget.” By allowing private plans to play a role in a transformed insurance and delivery system, the MRP can be politically attractive to a broader constituency than any of the current proposals.

The MRP addresses a key component of comprehensive health reform: restructuring the
delivery system. It is not a simple reinsurance pool that reimburses health plans for high costclaims. Instead, it creates a reformed payment system for both inpatient care and outpatient chronic care that will encourage efficiency and quality. The MRP will cover inpatient and similar short but expensive episodes, as well as chronic illness management. Its new payment approaches will achieve the efficiency goals promised by proposals for hospital medical staff-focused Accountable Care Organizations, but in an organizationally more plausible manner. Hospitals and physicians who focus on inpatient care and voluntarily form Care Delivery Teams will receive bundled episode-based payments, but the MRP will pay providers regardless of whether they belong to a Care Delivery Team, although at less attractive rates. Providers in these teams can use their bargaining power to charge the primary insurers more than the MRP pays. The MRP’s payments for monthly chronic illness management will give health plans and primary care physicians the incentives, flexibility, and information to more effectively compensate clinicians for the care they deliver and coordinate. By being publicly chartered, but independent of Congress, and by allowing options for all players, the MRP will be able to sidestep the ability of special interests to block change.

As pressure builds on the White House and Congress to deliver on their promise of health care reform, the idea of a government health insurance company to compete with for-profit and not-for-profit private companies is gaining political momentum. Advocates claim that this new company would be more efficient, honest, and successful in forcing lower reimbursement rates on physicians and hospitals. However, a close look at how the present health care system functions, what its major problems are, and what reforms are needed to solve them suggests that this new idea is not the answer. The three major problems of the current U.S. system are that 45 million to 50 million people have no health insurance, the cost of care is high and rapidly increasing, and there are gross lapses in the quality of care. There is no reason to think that a government insurance company would make a significant dent in any one of these problems, let alone all three. To do that would require real reform in the financing, organization, and delivery of care.

Background

Although the Accreditation Council for Graduate Medical Education (ACGME) limits the work hours of residents, concerns about fatigue persist. A new Institute of Medicine (IOM) report recommends, among other changes, improved adherence to the 2003 ACGME limits, naps during extended shifts, a 16-hour limit for shifts without naps, and reduced workloads.

Methods

We used published data to estimate labor costs associated with transferring excess work from residents to substitute providers, and we examined the effects of our assumptions in sensitivity analyses. Next, using a probability model to represent labor costs as well as mortality and costs associated with preventable adverse events, we determined the net costs to major teaching hospitals and cost-effectiveness across a range of hypothetical changes in the rate of preventable adverse events.

Results

Annual labor costs from implementing the IOM recommendations were estimated to be $1.6 billion (in 2006 U.S. dollars) across all ACGME-accredited programs ($1.1 billion to $2.5 billion in sensitivity analyses). From a 10% decrease to a 10% increase in preventable adverse events, net costs per admission ranged from $99 to $183 for major teaching hospitals and from $17 to $266 for society. With 2.5% to 11.3% decreases in preventable adverse events, costs to society per averted death ranged from $3.4 million to $0.

Conclusions

Implementing the four IOM recommendations would be costly, and their effectiveness is unknown. If highly effective, they could prevent patient harm at reduced or no cost from the societal perspective. However, net costs to teaching hospitals would remain high.

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform:

1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment.
2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions.
3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions.
4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange.
5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make deidentified information from this database on clinical interventions, patient outcomes, and costs available to researchers.
6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans.
7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage.
8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.