2011 Potpourri XXXII

An article in the Archives of Internal Medicine reports on a test of  the care transitions intervention in a real world setting.  The care transitions program is a four week intervention that follows hospitalization and includes a transitions coach and tools to help with self-management skills.  A randomized clinical trial had shown benefits for the intervention in preventing readmissions.  This study was a prospective cohort study of Medicare fee-for-service beneficiaries.  Those patients who received the intervention had a 12.8%  30 day readmission rate versus a 20% rate for those who did not.  Given the looming CMS readmission penalties, finding interventions that work is critical for hospitals.   (Archives Article)

A New England Journal of Medicine Perspective discusses a renowned health system’s efforts to avoid a repeat of a rare complication that had led to a serious adverse health consequence and a malpractice suit.  The precipitating event was failure to give a patient who had her spleen removed a pneumonia vaccine.  In trying to understand how the EMR and other data didn’t pinpoint the potential problem, it became apparent that there are many problems in getting the right data into an EMR and even more problems in getting known items of care delivered to the patient.  Coordinating across providers is difficult.  The system spent a fair amount of money addressing the issue in hindsight by paying residents to review charts and update them to indicate patients needing the vaccine.  This was for a rare event.  Just shows how hard it will be to systematically get all care delivered as it should be.   (NEJM Perspective)

A paper published under the auspices of the National Bureau of Economic Research looks at the impact of design and question phrasing on the answers received in subjective survey questions about respondents’ health.  The paper finds that when such questions are asked after a series of specific health questions, different answers are given than when they are asked before.  Since subjective perceptions of health are often used in predictive algorithms, understanding how design and phrasing may affect the answers is important.  This kind of research is important to ensure that factors that may lead to subjective data not fully reflecting reality is taken into account in designing surveys and in interpreting the results.   (NBER Paper)

An opinion piece by John Goodman in the Wall Street Journal suggests three simple ways that Medicare could save money.  The underlying premise is that Medicare’s attempt to fix prices for every possible health service has been very flawed and has created serious distortions in the supply of physician skills and incentives to over-deliver high paid services.  The first suggested response is to allow beneficiaries to access private walk-in emergency and convenience clinics, most of which charge less than Medicare typically pays for their services, so Medicare and the beneficiaries would save money.  The second is to allow beneficiaries to use the numerous internet and phone services which have become widely available to address common medical issues, which again are typically cheaper than Medicare’s fixed payment.  Finally, concierge arrangements should be encouraged and Medicare should pay part of the fee.  Too much sense for this administration to ever endorse.   (WSJ OpEd)

A research study looks at whether patients who primarily use community health centers have lower overall health spending than those who use the private provider community.  The study occurred in North Carolina and found that overall, community health center users with the same demographic and health status as a group of non-users had 62% less spending.  The difference was about $3437 in total spending and $1211 in ambulatory care.  The research describes several factors which may be responsible for the difference, including salaried staff, enabling services that encourage access and use and sliding scale fee structure.  This is a reform worth pursuing–continuing to build and pump money into community health centers, particularly in areas with limited access to primary care–and then requiring that Medicaid recipients must use these centers, to lower costs for the Medicaid program.  (Comm. Ctr. Paper)

Another NEJM Perspective discusses using behavioral economics in designing employee health benefits.  The reform law allows expanded use of differential cost-sharing for those employees engaging in healthy or unhealthy behaviors.  While the authors raise certain “fairness” issues that frankly make no sense whatsoever, they also point to behavioral economics principles that can maximize the effectiveness of these programs.  They include using frequent, smaller rewards or penalties as opposed to one-time large ones; the reward or penalty should be separate from other financial events, so don’t do it through a paycheck or by a premium adjustment and consider whether a penalty program which may seem fairer is better or a reward program that makes employees feel better about the employer.   (NEJM Perspective)