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.

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.

Rationale: Timeliness is one of six important dimensions of health care quality recognized by the Institute of Medicine. Objectives: To evaluate timeliness of lung cancer care and identify institutional characteristics associated with timely care within the VA Health Care System. Methods: We used data from a VA nation-wide retrospective chart review and an independent audit of VA cancer programs to examine the association between time to first treatment and potentially explanatory institutional characteristics (e.g. volume of lung cancer patients) for 2,372 veterans diagnosed with lung cancer between 1/1/02 and 9/1/05 at 127 VA medical centers. We developed linear mixed effects models to control for clustering of patients within hospitals and stratified analyses by stage. Measurements and Main Results: Median time to treatment varied widely between (23 to 182 days) and within facilities. Median time to treatment was 90 days in stage I or II patients and 52 days in those with more advanced disease (p<0.0001). Factors associated with shorter times to treatment included a non-academic setting and the existence of a specialized diagnostic clinic (in patients with limited stage disease), performing a patient flow analysis (in patients with advanced disease), and leadership beliefs about providing timely care (in both groups). However, institutional characteristics explained <1% of the observed variation in treatment times. Conclusions: Time to lung cancer treatment in U.S. veterans is highly variable. The numerous institutional characteristics we examined explained relatively little of this variability, suggesting that patient, clinician, and/or unmeasured institutional characteristics may be more important determinants of timely care.

Understanding the factors that affect physicians' job satisfaction is important not only to physicians themselves, but also to patients, health system managers, and policy makers. Physicians represent the crucial resource in health-care delivery. In order to enhance efficiency and quality in health care, it is indispensable to analyse and consider the motivators of physicians. Physician job satisfaction has significant effects on productivity, the quality of care, and the supply of physicians.

The purpose of our study was to assess the associations between work-related monetary and non-monetary factors and physicians' work satisfaction as perceived by similar groups of physicians practicing at academic medical centres in Germany and the U.S.A., two countries that, in spite of differing health-care systems, simultaneously experience problems in maintaining their physician workforce. We used descriptive statistics, factor and correlation analyses to evaluate physicians' responses to a self-administered questionnaire.

Our study revealed that overall German physicians were less satisfied than U.S. physicians. With respect to particular work-related predictors of job satisfaction we found that similar factors contributed to job satisfaction in both countries. To improve physicians' satisfaction with working conditions, our results call for the implementation of policies that reduce the time burden on physicians to allow more time for interaction with patients and colleagues, increase monetary incentives, and enhance physicians' participation in the development of care management processes and in managerial decisions that affect patient care.

Objectives From 1994 to the year 2000 the government of Puerto Rico implemented a health care reform which included the mandatory enrollment of the entire Medicaid eligible population under Medicaid managed care (MMC) plans. This study assessed the effect of MMC on the use, initiation, utilization, and adequacy of prenatal care services over the reform period.

Methods Using the vital records of all infants born alive in Puerto Rico from the year 1995-2000, a series of bivariate and multivariate analyses were conducted to assess the effect of insurance status (traditional Medicaid, MMC, private insurance and uninsured) on prenatal care utilization patterns. In order to assess the potential influence of selection bias in generating the health insurance assignments, propensity scores (PS) were estimated and entered into the multivariate regressions.

Results MMC had a generally positive effect on the frequency and adequacy of prenatal care when compared with the experience of women covered by traditional Medicaid. However, the PS analyses suggested that self-selection may have generated part of the observed beneficial effects. Also, MMC reduced but did not eliminate the gap in the amount and adequacy of prenatal care received by pregnant women covered by Medicaid when compared to their counterparts covered by private insurance.

Conclusions The Puerto Rico Health Reform to implement MMC for pregnant women was associated with a general improvement in prenatal care utilization. However, continued progress will be necessary for women covered by Medicaid to reach prenatal care utilization levels experienced by privately insured women.

Fuchs argues that health reform must encompass the Four Cs in order to succeed: coverage, cost control, coordinated care and choice. While details are certainly important, Fuchs writes, Congress and the Obama Administration must remember that "God is in the essentials." Without the essentials, no reform plan can succeed.