Evaluating community deliberations about health research priorities

CONTEXT

Engaging underrepresented communities in health research priority setting could make the scientific agenda more equitable and more responsive to their needs.

OBJECTIVE

Evaluate democratic deliberations engaging minority and underserved communities in setting health research priorities.

METHODS

Participants from underrepresented communities throughout Michigan (47 groups, n = 519) engaged in structured deliberations about health research priorities in professionally facilitated groups. We evaluated some aspects of the structure, process, and outcomes of deliberations, including representation, equality of participation, participants' views of deliberations, and the impact of group deliberations on individual participants' knowledge, attitudes, and points of view. Follow-up interviews elicited richer descriptions of these and also explored later effects on deliberators.

RESULTS

Deliberators (age 18-88 years) overrepresented minority groups. Participation in discussions was well distributed. Deliberators improved their knowledge about disparities, but not about health research. Participants, on average, supported using their group's decision to inform decision makers and would trust a process like this to inform funding decisions. Views of deliberations were the strongest predictor of these outcomes. Follow-up interviews revealed deliberators were particularly struck by their experience hearing and understanding other points of view, sometimes surprised at the group's ability to reach agreement, and occasionally activated to volunteer or advocate.

CONCLUSIONS

Deliberations using a structured group exercise to engage minority and underserved community members in setting health research priorities met some important criteria for a fair, credible process that could inform policy. Deliberations appeared to change some opinions, improved some knowledge, and were judged by participants worth using to inform policymakers.

GAD1 (2q31.1), which encodes glutamic acid decarboxylase (GAD67), is associated with childhood-onset schizophrenia and cortical gray matter volume loss

Postmortem brain studies have shown deficits in the cortical gamma-aminobutyric acid (GABA) system in schizophrenic individuals. Expression studies have shown a decrease in the major GABA-synthesizing enzyme (glutamic acid decarboxylase (GAD67) mRNA levels in neurons in dorsolateral prefrontal cortex in schizophrenics relative to controls. In the present study, SNPs in and around the GAD1 gene, which encodes the protein GAD67, were tested on a rare, severely ill group of children and adolescents with childhood-onset schizophrenia (COS) (n=72), in a family-based association analysis. Compared to adult-onset samples, the COS sample has evidence for more salient familial, and perhaps genetic, risk factors for schizophrenia, as well as evidence for frontal cortical hypofunction, and greater decline in cortical gray matter volume on anatomic brain MRI scans during adolescence. We performed family-based TDT and haplotype association analyses of the clinical phenotype, as well as association analyses with endophenotypes using the QTDT program. Three adjacent SNPs in the 5' upstream region of GAD1 showed a positive pairwise association with illness in these families (P=0.022-0.057). Significant transmission distortion of 4-SNP haplotypes was also observed (P=0.003-0.008). Quantitative trait TDT analyses showed an intriguing association between several SNPs and increased rate of frontal gray matter loss. These observations, when taken together with the positive results reported recently in two independent adult-onset schizophrenia pedigree samples, suggest that the gene encoding GAD67 may be a common risk factor for schizophrenia.

Differences by race in the rates of procedures performed in hospitals for Medicare beneficiaries

This study analyzes administrative data from the Medicare program to compare differences by race in the use of 17 major procedures performed in the hospital. In both 1986 and 1992, black beneficiaries were less likely than white beneficiaries to have received these procedures while hospitalized. The largest differences were seen for "referral-sensitive surgeries" such as percutaneous transluminal coronary angioplasty, coronary artery bypass graft surgery, total knee replacement, and total hip replacement. These differences by race suggest that there are barriers to these services. In contrast, black beneficiaries were found to have substantially higher rates than white beneficiaries in the use of four procedures performed in the hospital: amputation of part of the lower limb, surgical debridement, arteriovenostomy, and bilateral orchiectomy. The types of procedures for which black beneficiaries have higher rates raise questions about whether there is a need for more comprehensive and continuous ambulatory care for the underlying health conditions associated with these procedures.

Medicare beneficiaries: adverse outcomes after hospitalization for eight procedures

Rehospitalization following surgery is widely recognized as an important outcome measure. The purpose of this study was to identify rehospitalizations for adverse events following 8 procedures, using diagnosis and procedure codes contained in Medicare claims files. Adverse events were broadly defined as: 1) complications; 2) failure of the procedure to achieve its therapeutic goal; and 3) untoward events associated with the natural history of the disease being treated with the procedure. Expert panels identified specific diagnosis and procedure codes that might indicate an adverse event if they appeared on the Medicare record of a rehospitalization. Among patients undergoing percutaneous transluminal coronary angioplasty, almost 36% were rehospitalized for an adverse event within a year of surgery; among patients undergoing coronary artery bypass graft surgery, 20% were rehospitalized for an adverse event. Following the other 6 procedures (cholecystectomy, partial excision of the large intestine, total knee replacement, total hip replacement, replacement of the head of the femur, and reduction of fracture of the femur) between 4% and 9% of patients were rehospitalized for an adverse event. Findings from this exploratory study indicate that rehospitalizations for adverse events appear to be a useful outcome measure for the cardiac procedures; they appear to be less useful for the other procedures, at least at the individual hospital or small area level, because of their relative rarity. Future studies should investigate procedures associated with more frequent rehospitalizations, and medical admissions, which often tend to be associated with higher rehospitalization levels.

Physician payment reform under Medicare: monitoring utilization and access

The Omnibus Budget Reconciliation Act (OBRA) of 1989 brought about significant changes in physician payment policy under Medicare. A major component of physician payment reform was the implementation on January 1, 1992, of the Medicare fee schedule (MFS). The Secretary of Health and Human Services is required to monitor and report annually on the impact of the changes in physician payment on access to and utilization of health care services. This article provides an overview of the 1993 Report to Congress. First, the article discusses the changes made in physician payment policy as well as the complexities involved in assessing the effects of the MFS. Next, the article discusses the approaches that were implemented in the Health Care Financing Administration (HCFA) to generate timely data to monitor and evaluate the impact of physician payment reform on Medicare beneficiaries. Last, the article describes six analyses that were designed to provide differing perspectives for understanding the impact of the OBRA 1989 physician payment changes on access and utilization. Some of the most salient results of these analyses are presented, including preliminary data from the first year during which the MFS was in effect.

A longitudinal perspective on patterns of Medicare payments

To provide insight into the stream of Medicare payments over time, a sixteen-year longitudinal study examines three age cohorts of beneficiaries, looking separately at beneficiaries who died during the study period and those who survived. The common wisdom that a small minority of the population accounts for a large majority of health care expenditures is tempered when health care use is examined over an extended period of time. By putting high average costs in the final years of life in the context of a cohort's total lifetime experience, the study shows a leveling of spending over time, resulting in a lower concentration of health care resources on a small fraction of the population.

U.S. initiatives and approaches for outcomes and effectiveness research

This paper provides an overview of the new Federal initiative underway to promote research in outcomes and effectiveness of services provided in the U.S. It discusses the factors that stimulated the U.S. government ot undertake this initiative and summarizes past research and current efforts to advance knowledge about utilization and outcomes of care. A focal point of this initiative is to take advantage of information in large, administrative data bases to monitor the use, costs and outcomes of medical services. As part of this initiative, the Federal Government for the first time assembled detailed data, by geographic area and by demographic groups, on the hospitalization, mortality and rehospitalization experience of the entire Medicare population. The paper describes this project and illustrates uses of these data.

Trends in Medicare use of post-hospital care

The introduction of Medicare's hospital prospective payment system has raised concerns about availability of and access to needed health care services after beneficiaries are discharged from the hospital. In this article, Medicare coverage of skilled nursing facility, home health agency, and inpatient hospital rehabilitation services is discussed and recent trends in the use of these services are explored. In addition, an overview is provided of two major studies currently sponsored by the Federal Government to examine availability and other issues related to post-hospital care.

Longitudinal patterns of enrollment and expenditures for a Medicaid cohort

This article is based on 4 years of data for a cohort of Medicaid enrollees in California and Georgia to determine patterns of enrollment and expenditures. The analyses were developed from the statistical system known as Tape-to-Tape, which is based on Medicaid enrollment and claims files from these and other States. The composition of the cohort changed over times as a result of the differential rates of turnover for subgroups of the Medicaid population. Longitudinal expenditure patterns also varied by health service and eligibility group. These Medicaid expenditure patterns differed from those observed previously in Medicare studies, undoubtedly reflecting differences in service coverage under Medicare and Medicaid.

Nursing home costs for those dually entitled to Medicare and Medicaid

The focus of this article is the impact of nursing home care on total Medicare and Medicaid expenditures for the aged population entitled to both programs. To determine these costs for 1981, data in the Health Care Financing Administration's Medicare Statistical System were linked, for the first time, to data in the Medicaid system for four States. Also examined are expenditure patterns for survivors and decedents using nursing home services. Results indicate that the two most significant factors influencing costs or the dually entitled elderly are the use of nursing home services and the costs of care in the last months of life. An unexpected finding was that of the 73 percent who neither died nor were in a nursing home, per capita expenditures were remarkedly constant across all age groups.

Twenty years of Medicare and Medicaid: covered populations, use of benefits, and program expenditures

Marian Gornick is Director, Division of Beneficiary Studies, in the Office of Research, Health Care Financing Administration. She has been involved in research studies relating to Medicare and Medicaid since the programs were first implemented.

Jay N. Greenberg is on the faculty of the Heller Graduate School, Brandeis University. Dr. Greenberg serves as the Associate Director for Research of the school's Health Policy Center.

Paul W. Eggers is Chief, Program Evaluation Branch, in the Office of Research, Health Care Financing Administration (HCFA). Dr. Eggers’ research activities involve the evaluation of the impact of HCFA programs on the beneficiaries.

Allen Dobson is Director, Office of Research, Health Care Financing Administration. Dr. Dobson is responsible for directing the planning and development of the Agency's research agenda.

The dually entitled elderly Medicare and Medicaid population living in the community

This study shows that the elderly living in the community and covered by Medicare and Medicaid have a higher proportion of older persons, of minority races, and of women and are in poorer health than other aged persons covered only by Medicare. The noninstitutionalized poor elderly population use more health care services (especially inpatient hospital care) and have much higher per capita health care expenses compared to those covered by Medicaid. There were also large disparities in education and income. The study indicates that the Medicare program provides substantially more financial protection for all elderly persons living in the community than for the total elderly population.

Options for change under Medicare: impact of a cap on catastrophic illness expense

This study analyzes the total deductibles and coinsurance Medicare beneficiaries accrued in 1980. The study shows that Part B services accounted for 70 percent of all liability and Part A for 30 percent. Only 21 percent of enrollees exceeded $270 in liability from Part A and Part B combined. In 1980, if every enrollee had paid a surcharge of about $70, all liability over $270 could have been capped--without any additional program outlays. Similarly, projections for 1984 indicate that a surcharge of $98 could cap all liability over $800. For Part B alone, a surcharge of $113 could cover all liability over $200.

A study of the "crossover population": aged persons entitled to both Medicare and Medicaid

This study focused on persons 65 years of age and over who were dually entitled to Medicare and Medicaid in 1978. The paper examines their age, sex, and race characteristics, and their Medicare utilization and mortality rates in comparison to persons eligible for Medicare only. The study showed that the group entitled to both Medicare and Medicaid was relatively much older than those with Medicare only, with a mean age of 76.6 years compared to 73.6 years. In the group entitled to both Medicare and Medicaid, the proportion of persons of minority races was four times as great as the proportion in the remaining population. Nevertheless, nearly three out of four persons entitled to both programs were white. In the group with dual eligibility, 71 percent were women, compared to only 59 percent in the Medicare-only population. Thus, the dually covered group may be characterized as being relatively older than other Medicare enrollees, largely composed of white persons and women, and as having a higher proportion of minority persons than the general population. The study showed that a much higher proportion of dually entitled persons were users of the Medicare program than were persons eligible for Medicare only. On a per-enrollee basis, reimbursement was substantially higher for those dually eligible. The study also found differences in the diagnostic conditions of the dually entitled. The data indicate (after being standardized for age) that the death rate was 50 percent higher for the dually entitled. This difference in mortality is partly attributable to the relatively high mortality rates for the medically needy; nonetheless, the mortality rate for the dually entitled who also received cash assistance was 20 percent higher than those for other Medicare enrollees. The excess mortality among this group was notably higher for the age group 65-69, with a 50 percent excess mortality, and for the age group 70-79, the excess mortality was 30 percent. Thus, the dually entitled, in general, experience higher mortality rates than those with Medicare only, and that fact very likely explains to a large extent the higher utilization rates found for the dually entitled in this study. The paper concludes by raising some possible consequences of either Medicare or Medicaid coverage being altered or tightened.

Trends and regional variations in hospital use under Medicare

Large regional differences have long been noted in hospital admission rates, in average length of stay, and in the days of care rate for Medicare beneficiaries. This paper provides an overview of national trends in the use of inpatient hospital services by Medicare beneficiaries and reviews past work on geographic differences in hospital use. It reassesses Medicare program experience and provides some new views on the subject. Perhaps the most surprising finding from this re-examination of regional differences in hospital use is that the number of days of care per capita in one area can differ substantially from that of another area while the per capita costs of care can be nearly equal. The major conclusion from this study is that no one utilization statistic is adequate for supplying information for the many current policy issues. Rather, there is a continuing need to understand national trends and regional differences in hospital utilization and to study the disparities by area in Medicare per capita spending for program benefits.

Analysis of services received under Medicare by specialty of physician

This paper examines use of physicians' services by Medicare beneficiaries according to the specialty of the physician providing care. The major objectives of this study were to determine which types of physicians are most frequently used, the average charge per service by specialty, the mix of physicians (by specialty) that patients saw during the year, and the amount Medicare reimburses in relation to total physician income. Data were studied for the total Medicare population and by age, sex, race, and geographic area. Claims data for 1975 and 1977 were used from the Part B Bill Summary System. This system collects information from bills from a 5 percent sample of Medicare enrollees. Major findings from this study indicate: (1) Physicians in general practice and internal medicine provided about the same number of services and each far outranked all other types of physicians in numbers of Medicare beneficiaries with reimbursed services. (2) There were marked differences by census region in the use of certain specialists, particularly pathologists, podiatrists, dermatologists, and the specialty group otology, laryngology, rhinology. (3) Average charges per service varied considerably by specialty. Internists' charges averaged 35 percent higher per service than charges by general practitioners. Charges submitted by the surgical specialties far outranked all others and showed the greatest increase during the period under study. (4) Of the total persons with reimbursement physicians' services in 1977, 85 percent saw a primary care physician during the year, while the remaining 15 percent received services from specialists only. (5) Of the total reimbursements made by Medicare, internists received 20 percent, general practitioners received 14 percent, and general surgeons 12 percent. Medicare's payments were estimated to be 21 percent of total gross income for internists, 20 percent for anesthesiologists, and 18 percent for surgical specialties.

Physicians' charges under Medicare: assignment rates and beneficiary liability

Under Medicare's Part B program, the physician decides whether to accept assignment of claims. When assignment is accepted, the physician agrees to accept as full payment Medicare's allowed charge. Physicians' acceptance of assignment is of considerable importance in relieving the beneficiaries of the burden of the costs of medical care services. This factor and the beneficiaries' liabilities for premiums, the annual deductible, and coinsurance are analyzed in considerable detail in this report. Data from physicians' claims for services in 1975 show that 45.8 percent of the services and 47.2 percent of the charges were assigned for the aged. There were wide variations in the rate of acceptance of assignment by physician specialty, and by age, race, and residence of beneficiaries. Total beneficiary liability from the deductible, coinsurance, and from unassigned claims amounted to 37.7 percent of total physicians' charges due. When the premium which the beneficiary pays for Part B is included, beneficiary liability rises to 69.2 percent of total physicians' charges due.

Factors affecting differences in Medicare reimbursements for physicians' services

Under Medicare's Part B program, wide variations are found in average reimbursements for physicians' services by demographic and geographic characteristics of the beneficiaries. Average reimbursements per beneficiary enrolled in the program depend upon the percentage of enrolled persons who exceed the deductible and receive reimbursements, the average allowed charge per service, and the number of services used. This study analyzes differences in average reimbursements per beneficiary for physicians' services in 1975 and discusses allowed charges and use factors that affect average reimbursements. Differences in the level of allowed charges and their impact on meeting the annual deductible are also discussed. The study indicates that average reimbursements per beneficiary are likely to continue to vary significantly year after year under the present Part B cost-sharing and reimbursement mechanisms.

Medicare patients: geographic differences in hospital discharge rates and multiple stays

Marked regional variations are found in patterns of use of short-stay hospitals by Medicare patients. Variations found in the rate of hospitalization, as measured by the number of discharges per 1,000 enrollees, and on the upward trend in that rate are the focus here. The data indicate that reductions in length of stay are offset by the rising number of admissions. An examination of multiple stays--a major factor in the number of discharges--shows that States with high rates of discharges have high percentages of patients with multiple stays. Furthermore, in these States the percentage of multiple stays is high, no matter what the diagnosis. In other States, the rate is low for all diagnoses. These findings suggest that options exist for the provision of care for the same or similar conditions and that geographic patterns appear in the use of those options. An urgent need exists for research to establish the variables affecting utilization and to explore ways of changing some of the patterns of delivering services.