Expanding comprehensive pregnancy care for Emergency Medicaid recipients: a cost-effectiveness analysis

BACKGROUND

Emergency Medicaid is a restricted benefits program for individuals who have low-income status and who are immigrants.

OBJECTIVE

This study aimed to compare the cost-effectiveness of 2 strategies of pregnancy coverage for Emergency Medicaid recipients: the federal minimum of covering the delivery only vs extended coverage to 60 days after delivery.

STUDY DESIGN

A decision analytical Markov model was developed to evaluate the outcomes and costs of these policies, and the results in a theoretical cohort of 100,000 postpartum Emergency Medicaid recipients were considered. The payor perspective was adopted. Health outcomes and cost-effectiveness over a 1- and 3-year time horizon were investigated. All probabilities, utilities, and costs were obtained from the literature. Our primary outcome was the incremental cost-effectiveness ratio of the competing strategies.

RESULTS

Extending Emergency Medicaid to 60 days after delivery was determined to be a cost-saving strategy. Providing postpartum and contraceptive care resulted in 33,900 additional people receiving effective contraception in the first year and prevented 7290 additional unintended pregnancies. Over 1 year, it resulted in a gain of 1566 quality-adjusted life year at a cost of $10,903 per quality-adjusted life year. By 3 years of policy change, greater improvements were observed in all outcomes, and the expansion of Emergency Medicaid became cost saving and the dominant strategy.

CONCLUSION

The inclusion of postpartum care and contraception for immigrant women who have low-income status resulted in lower costs and improved health outcomes.

Thematic Analysis of Challenges of Care Coordination for Underinsured and Uninsured Cancer Survivors With Chronic Conditions

IMPORTANCE

Although a majority of underinsured and uninsured patients with cancer have multiple comorbidities, many lack consistent connections with a primary care team to manage chronic conditions during and after cancer treatment. This presents a major challenge to delivering high-quality comprehensive and coordinated care.

OBJECTIVE

To describe challenges and opportunities for coordinating care in an integrated safety-net system for patients with both cancer and other chronic conditions.

DESIGN, SETTING, AND PARTICIPANTS

This multimodal qualitative study was conducted from May 2016 to July 2019 at a county-funded, vertically integrated safety-net health system including ambulatory oncology, urgent care, primary care, and specialty care. Participants were 93 health system stakeholders (clinicians, leaders, clinical, and administrative staff) strategically and snowball sampled for semistructured interviews and observation during meetings and daily processes of care. Data collection and analysis were conducted iteratively using a grounded theory approach, followed by systematic thematic analysis to organize data, review, and interpret comprehensive findings. Data were analyzed from March 2019 to March 2020.

MAIN OUTCOMES AND MEASURES

Multilevel factors associated with experiences of coordinating care for patients with cancer and chronic conditions among oncology and primary care stakeholders.

RESULTS

Among interviews and observation of 93 health system stakeholders, system-level factors identified as being associated with care coordination included challenges to accessing primary care, lack of communication between oncology and primary care clinicians, and leadership awareness of care coordination challenges. Clinician-level factors included unclear role delineation and lack of clinician knowledge and preparedness to manage the effects of cancer and chronic conditions.

CONCLUSIONS AND RELEVANCE

Primary care may play a critical role in delivering coordinated care for patients with cancer and chronic diseases. This study's findings suggest a need for care delivery strategies that bridge oncology and primary care by enhancing communication, better delineating roles and responsibilities across care teams, and improving clinician knowledge and preparedness to care for patients with cancer and chronic conditions. Expanding timely access to primary care is also key, albeit challenging in resource-limited safety-net settings.

Between-Community Low-Income Status and Inclusion in Mandatory Bundled Payments in Medicare's Comprehensive Care for Joint Replacement Model

This cohort study examines whether communities in Medicare’s Comprehensive Care for Joint Replacement (CJR) Model are representative of others nationwide with respect to residents’ socioeconomic status.

Can vertically integrated health systems provide greater value: The case of hospitals under the comprehensive care for joint replacement model?

OBJECTIVE

We aim to assess whether system providers perform better than nonsystem providers under an alternative payment model that incentivizes high-quality, cost-efficient care. We posit that the payment environment and the incentives it provides can affect the relative performance of vertically integrated health systems. To examine this potential influence, we compare system and nonsystem hospitals participating in Medicare's Comprehensive Care for Joint Replacement (CJR) model.

DATA SOURCES

We used hospital cost and quality data from the Centers for Medicare & Medicaid Services linked to data from the Agency for Healthcare Research and Quality's Compendium of US Health Systems and hospital characteristics from secondary sources. The data include 706 hospitals in 67 metropolitan areas.

STUDY DESIGN

We estimated regressions that compared system and nonsystem hospitals' 2017 cost and quality performance providing lower joint replacements among hospitals required to participate in CJR.

PRINCIPAL FINDINGS

Among CJR hospitals, system hospitals that provided comprehensive services in their local market had 5.8 percent ($1612) lower episode costs (P = .01) than nonsystem hospitals. System hospitals that did not provide such services had 3.5 percent ($967) lower episode costs (P = .14). Quality differences between system hospitals and nonsystem hospitals were mostly small and statistically insignificant.

CONCLUSIONS

When operating under alternative payment model incentives, vertical integration may enable hospitals to lower costs with similar quality scores.

Bridging the gap: an economic case study of the impact and cost effectiveness of comprehensive healthcare intermediaries in rural Mexico

BACKGROUND

In rural settings where patients face significant structural barriers to accessing healthcare services, the formal existence of government-provided health coverage does not necessarily translate to meaningful care delivery. This paper analyses the effectiveness of an innovative approach to overcome these barriers, the Right to Health Care programme offered by Compañeros en Salud in Chiapas, Mexico. This programme provides comprehensive free coverage of all additional direct and indirect medical costs as well as accompaniment through the medical system. Over 550 patients had participated from 2013 until November 2018.

METHODS

Focusing on ten of the most frequently treated conditions, including hernias, cataracts and congenital heart defects, we performed a retrospective case study analysis of the quality-adjusted life years (QALYs) gained from treatment and the cost per QALY for 69 patients. This analysis used disability weights and uncertainty intervals from the Global Burden of Disease study and organisational micro-costing data for each patient. Each patient was compared to their own hypothetical counterfactual health outcome had they not received the secondary and tertiary care required for the specific condition. A mixed methods approach is used to establish this counterfactual baseline, drawing on pre-intervention observations, qualitative interviews and established literature precedent.

RESULTS

The programme was found to deliver an average of 14.4 additional QALYs (95% uncertainty interval 12.4-15.8) without time discounting. The mean cost per QALY over these conditions was $388 USD (95% UI $262-588) at purchasing power parity.

CONCLUSIONS

These numbers compare favourably with studies of other health services and international cost per QALY guidelines. They reflect the on-treatment effect for the ten conditions analysed and are presented as a case study indicative of the promise of healthcare intermediaries rather than a definitive assessment of cost-effectiveness. Nonetheless, these results show the potential feasibility and cost effectiveness of a more comprehensive approach to healthcare provision in a resource-limited rural setting.

TRIAL REGISTRATION

This study involves economic analysis of a programme facilitating access to public healthcare services. Thus, there was no associated clinical trial to be registered.

Association of Organizational Factors and Physician Practices' Participation in Alternative Payment Models

Importance

Consolidation among physician practices and between hospitals and physician practices has accelerated in the past decade, resulting in higher prices in commercial markets. The resulting integration of health care across clinicians and participation in alternative payment models (APMs), which aim to improve quality while constraining spending, are cited as reasons for consolidation, but little is known about the association between integration and APM participation.

Objective

To examine the association of organizational characteristics, ownership, and integration with intensity of participation in APMs among physician practices.

Design, Setting, and Participants

A cross-sectional descriptive study, adjusted for sampling and nonresponse weights, was conducted in US physician practice respondents to the National Survey of Healthcare Organizations and Systems conducted between June 16, 2017, and August 17, 2018; of 2333 responses received (response rate, 46.9%) and after exclusion of ineligible and incomplete responses, the number of practices included in the analysis was 2061. Data analysis was performed from April 1, 2019, to August 31, 2019.

Exposures

Self-reported physician practice characteristics, including ownership, integration (clinical, cultural, financial, and functional), care delivery capabilities, activities, and environmental factors.

Main Outcomes and Measures

Participation in APMs: (1) bundled payments, (2) comprehensive primary care and medical home programs, (3) pay-for-performance programs, (4) capitated contracts with commercial health plans, and (5) accountable care organization contracts.

Results

A total of 49.2% of the 2061 practices included reported participating in 3 or more APMs; most participated in pay-for-performance and accountable care organization models. Covariate-adjusted analyses suggested that operating within a health care system (odds ratio [OR] for medical group: 2.35; 95% CI, 1.70-3.25; P < .001; simple health system: 1.46; 95% CI, 1.08-1.97; P = .02; and complex health system: 1.76; 95% CI, 1.25-2.47; P = .001 relative to independent practices), greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater APM participation.

Conclusions and Relevance

Greater APM participation appears to be supported by integration and system ownership.

Effect of Comprehensive Care Coordination on Medicaid Expenditures Compared With Usual Care Among Children and Youth With Chronic Disease: A Randomized Clinical Trial

IMPORTANCE

Medicaid spending on children and young adults with chronic disease could be decreased through care coordination programs by reducing unnecessary hospital and emergency care.

OBJECTIVE

To assess whether a comprehensive care coordination program reduces Medicaid expenditures by decreasing hospital and emergency department (ED) utilization.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial included 6259 children and young adults with chronic disease who received public insurance through Illinois Medicaid. In April 2016, eligible youth were randomized to receive comprehensive care coordination through the Coordinated Healthcare for Complex Kids (CHECK) program (n = 3126) or usual care (n = 3119) to measure the effect of the CHECK program on Medicaid expenditures and health care utilization using a difference-in-differences (DID) approach. Data were collected from May 1, 2014, to April 30, 2017, and analyzed in May 2018.

INTERVENTIONS

Care coordination, mental health care, education, and social support were provided to CHECK participants and their family members. Services were tailored based on family and participant need.

MAIN OUTCOMES AND MEASURES

Mean annual Medicaid expenditures, mean annual health care utilization by category (ED and inpatient), and chronic disease type and risk level.

RESULTS

A total of 6259 participants (mean [SD] age, 11.3 [6.4] years; 2918 [46.6%] female; 2594 [41.4%] with medium and high risk) were randomized. Following the exclusion of 14 outliers, 6245 participants were analyzed. The mean (SD) annual Medicaid expenditure before the intervention was $1633 ($4006) for the intervention group and $1703 ($4466) for the usual care group, which decreased to a mean (SD) of $1341 ($3004) and $1413 ($3785), respectively, after the intervention (DID, -$1; 95% CI, -$199 to $196; P = .99). The mean (SD) inpatient utilization before the intervention was 63.0 (344.4) per 1000 person-years (PYs) for the intervention group and 69.3 (370.9) per 1000 PYs for the usual care group, which decreased to 43.5 (297.2) per 1000 PYs and 47.8 (304.9) per 1000 PYs, respectively, after the intervention (DID, 2.0; 95% CI, -17.9 to 21.8; P = .85). Among participants with asthma, those in the intervention group had a greater mean (SD) decrease in ED utilization compared with usual care, but the difference was not significant (-225.9 [65.3] vs -104.5 [80.0] visits per 1000 PY; DID, -121.5; 95% CI, -268.9 to 26.0; P = .11). Similarly, enrolled participants with sickle cell disease had a smaller but not significant mean (SD) increase in ED utilization compared with usual care (583.3 [839.0] vs 3761.9 [4611.2] visits per 1000 PYs; DID, -3178.6; 95% CI, -10 724.3 to 4367.2; P = .41).

CONCLUSIONS AND RELEVANCE

Overall Medicaid expenditures and health care utilization (hospital and ED) decreased similarly for both CHECK participants and the usual care group.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04057521.

Care Transformation Collaborative of Rhode Island: Building a Strong Foundation for Comprehensive, High-Quality Affordable Care

As the Patient Centered Medical Home (PCMH) model has evolved nationally and in Rhode Island, there has been increased recognition that PCMH has not been sufficient to achieve desired cost and quality goals. In this article, we describe the evolving concept of "comprehensive primary care" in Rhode Island, which includes addressing the behavioral health and social determinants of health (SDOH) needs of patients. These needs are identified through systematic screening and dedicated care management and care coordination for patients who present with complex needs.

Program of All-Inclusive Care for the Elderly (PACE): Integrating Health and Social Care Since 1973

According to the Centers for Medicare & Medicaid Services (CMS), the future of older adult care in the United States has arrived in a provider-sponsored health plan model that integrates medical, behavioral, and social care for frail elders. This approach gives the provider complete control over patient outcomes and total cost of care and enables participants to live safely in the community - rather than a nursing home - for an extra four years, on average. This article reviews the Program of All-inclusive Care for the Elderly (PACE) model, whose roots go back to the 1970s in California, and offers case studies on two PACE-RI participants with chronic healthcare needs. In both examples, the patients reduced hospitalizations and increased mental and physical health, all while alleviating caregiver stress. With the older population slated to double by 2060, the time has come to expand PACE to more people. A few years ago, the acting administrator of the Centers for Medicare & Medicaid Services (CMS) said he was "glimpsing into our future" when he visited a provider-sponsored health plan that integrated medical, behavioral, and social care for frail elders, allowing them to remain in the community rather than live in a nursing home.[1] This approach to aging services successfully braided Medicare and Medicaid funding and gave the provider complete control over patient outcomes and total cost of care over a significant period - the key elements to delivering "value-based care." What is noteworthy is that this program of the "future" has been in Rhode Island since 2005 and in other parts of the country since 1973! It helps its medically complex participants live at home for an extra four years on average and retain a much higher quality of life, all while controlling associated costs for the government through capitated payment arrangements.[5] The program is called PACE - short for Program of All-inclusive Care for the Elderly - and it is a comprehensive and community-based model of care that coordinates medical, behavioral, and social services for individuals ages fifty-five and older who have high care needs but can remain safely in the community. PACE is currently offered in 31 states.[2] The model is backed by the National PACE Association and serves 50,000 seniors in 126 sponsoring organizations at 260 PACE centers across the country. While PACE has already had some success at scaling its integrated services, emerging demographics and heightened outreach poise the program for significant growth.

The (cost-)effectiveness of preventive, integrated care for community-dwelling frail older people: A systematic review

Integrated care is increasingly promoted as an effective and cost-effective way to organise care for community-dwelling frail older people with complex problems but the question remains whether high expectations are justified. Our study aims to systematically review the empirical evidence for the effectiveness and cost-effectiveness of preventive, integrated care for community-dwelling frail older people and close attention is paid to the elements and levels of integration of the interventions. We searched nine databases for eligible studies until May 2016 with a comparison group and reporting at least one outcome regarding effectiveness or cost-effectiveness. We identified 2,998 unique records and, after exclusions, selected 46 studies on 29 interventions. We assessed the quality of the included studies with the Effective Practice and Organization of Care risk-of-bias tool. The interventions were described following Rainbow Model of Integrated Care framework by Valentijn. Our systematic review reveals that the majority of the reported outcomes in the studies on preventive, integrated care show no effects. In terms of health outcomes, effectiveness is demonstrated most often for seldom-reported outcomes such as well-being. Outcomes regarding informal caregivers and professionals are rarely considered and negligible. Most promising are the care process outcomes that did improve for preventive, integrated care interventions as compared to usual care. Healthcare utilisation was the most reported outcome but we found mixed results. Evidence for cost-effectiveness is limited. High expectations should be tempered given this limited and fragmented evidence for the effectiveness and cost-effectiveness of preventive, integrated care for frail older people. Future research should focus on unravelling the heterogeneity of frailty and on exploring what outcomes among frail older people may realistically be expected.

Value of Comprehensive HCV Treatment among Vulnerable, High-Risk Populations

OBJECTIVES

The objective of this study was to explore the trade-offs society and payers make when expanding treatment access to patients with chronic hepatitis C virus (HCV) infection in early stages of disease as well as to vulnerable, high-risk populations, such as people who inject drugs (PWID) and HIV-infected men who have sex with men (MSM-HIV).

METHODS

A discrete time Markov model simulated HCV progression and treatment over 20 years. Population cohorts were defined by behaviors that influence the risk of HCV exposure: PWID, MSM-HIV, an overlap cohort of individuals who are both PWID and MSM-HIV, and all other adults. Six different treatment scenarios were modeled, with varying degrees of access to treatment at different fibrosis stages and to different risk cohorts. Benefits were measured as quality-adjusted life-years and a $150,000/quality-adjusted life-year valuation was used to assess social benefits.

RESULTS

Compared with limiting treatment to METAVIR fibrosis stages F3 or F4 and excluding PWID, expanding treatment to patients in all fibrosis stages and including PWID reduces cumulative new infections by 55% over a 20-year horizon and reduces the prevalence of HCV by 93%. We find that treating all HCV-infected individuals is cost saving and net social benefits are over $500 billion greater compared with limiting treatment. Including PWID in treatment access saves 12,900 to 41,200 lives.

CONCLUSIONS

Increased access to treatment brings substantial value to society and over the long-term reduces costs for payers, as the benefits accrued from long-term reduction in prevalent and incident cases, mortality, and medical costs outweigh the cost of treatment.

Primary or specialist medical care: Which is more equitable? A policy brief

BACKGROUND

Equity in health and equitable access to healthcare has been at the core of health policy in India. The key policy challenge has been how to make that possible? Various health insurance schemes such as the Rashtriya Swasthya Bima Yojana and Arogyasri seek to improve poor people's access to specialist medical care in the public and private sectors. On the other hand, access to primary medical care has been left to the supply side interventions.

METHODS

We did a focused review of evidence on equity aspects of primary medical care versus specialist medical care. We selected relevant publications from the Cochrane Library, PubMed and Google Scholar searches and articles snowballing out of them.

RESULTS

Higher primary care physician-to-population ratio is invariably associated with better health outcomes. Primary care may partly protect the poor from adverse effects of income inequality on health status. On the other hand, populations do not necessarily benefit from an overabundance of specialists in a geographical area.

CONCLUSIONS

Three key policy lessons emerge from this review. First, states should strengthen primary medical care by upgrading health centres. Second, a family health protection plan should be introduced as a demand side intervention to deliver primary care through health centres, non-profit and for-profit clinics. Third, postgraduate courses in family medicine should be introduced for a balanced development of the specialty of primary care pari passu other specialties.

Medicare Program; Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR). Final rule

This final rule implements three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation (CR) Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement model under section 1115A of the Social Security Act. Acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-forservice beneficiaries receiving services during acute myocardial infarction, coronary artery bypass graft, and surgical hip/femur fracture treatment episodes. All related care within 90 days of hospital discharge will be included in the episode of care. We believe these models will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.

Comprehensive Corporate Social Responsibility Health Programs: Providing Quality, Affordable and Accessible Healthcare for Financially - Chal- lenged Patients (Private Tertiary Hospital Setting)

In 2012 the Manila Doctors Hospital became the first hospital in the Philippines to launch and commit to a Social Vision. Since then, this Social Vision has served as a guide for good governance and a blueprint for its Corporate Social Responsibility (CSR) programs focusing on health, environment and gender. The goal of the Manila Doctors comprehensive CSR health program is to render the fundamental right to health care available to marginalized patients. Through our CSR programs, more than 20,000 financially challenged patients gain access to quality medical services annually. This directly contributed to the country's health development agenda 2016-2020 of achieving the health related SDG Targets of Financial Risk Protection, Better Health Outcomes and Responsiveness.

Donor Agencies' Involvement in Reproductive Health: Saying One Thing and Doing Another?

The debates about what services constitute reproductive health, how these services should be organized, managed, and delivered, and what the role of donor agencies' support should be mirror the long-standing debates on how best to implement primary health care. After briefly reviewing the development of the discourse on primary health care and reproductive health, the authors present results of qualitative research in Ghana, Kenya, and Zambia that indicate a range of factors influencing and explaining the way donors operate in these countries and consider the implications of these results for the delivery of comprehensive reproductive health services. These findings are compared with South Africa, a country with limited donor activity. In the light of the complex interplay of factors, the authors suggest that donors' words and actions frequently do not correlate. Conclusions are drawn as to the potential for donor support for integrated reproductive health service delivery in sub-Saharan Africa, drawing on the research to provide lessons and a reappraisal of the role of donors in health sector aid.

Comprehensive Care for Joint Replacement (CJR) Bundle Expense in Perioperative Pain Management

The implementaion of the Comprehensive Care for Joint Replacement (CJR) model has necessitated value-focused care for a 90-day period. Pain management in joint arthroplasty therefore represents a focused opportunity to achieve lasting change in the delivery of care. To be successful, orthopedic surgeons must integrate approaches that take into account administration route and therapy duration, and various combinations thereof, to achieve improved longer term outcomes for joint arthroplasty patients. In addition, pain management choices must be based on value and not on simple costs, as patient satisfaction scores affect CJR repayments. While the postdischarge time period poses the highest risk, improved collaboration with post-acute care providers, such as hospitalists, pharmacists, and rehabilitation facilities will be crucial to addressing patient comorbidities and ensuring optimal outcomes post-surgery. Furthermore, multimodal pain management strategies associated with optimal pain control and shorter hospital stays are valuable in achieving improved outcome and financial metrics.

Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. Final rule

This final rule implements a new Medicare Part A and B payment model under section 1115A of the Social Security Act, called the Comprehensive Care for Joint Replacement (CJR) model, in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for lower extremity joint replacement (LEJR) or reattachment of a lower extremity. All related care within 90 days of hospital discharge from the joint replacement procedure will be included in the episode of care. We believe this model will further our goals in improving the efficiency and quality of care for Medicare beneficiaries with these common medical procedures.

Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial

BACKGROUND

Most patients with hip fractures are characterised by older age (>70 years), frailty, and functional deterioration, and their long-term outcomes are poor with increased costs. We compared the effectiveness and cost-effectiveness of giving these patients comprehensive geriatric care in a dedicated geriatric ward versus the usual orthopaedic care.

METHODS

We did a prospective, single-centre, randomised, parallel-group, controlled trial. Between April 18, 2008, and Dec 30, 2010, we randomly assigned home-dwelling patients with hip-fractures aged 70 years or older who were able to walk 10 m before their fracture, to either comprehensive geriatric care or orthopaedic care in the emergency department, to achieve the required sample of 400 patients. Randomisation was achieved via a web-based, computer-generated, block method with unknown block sizes. The primary outcome, analysed by intention to treat, was mobility measured with the Short Physical Performance Battery (SPPB) 4 months after surgery for the fracture. The type of treatment was not concealed from the patients or staff delivering the care, and assessors were only partly masked to the treatment during follow-up. This trial is registered with ClinicalTrials.gov, number NCT00667914.

FINDINGS

We assessed 1077 patients for eligibility, and excluded 680, mainly for not meeting the inclusion criteria such as living in a nursing home or being aged less than 70 years. Of the remaining patients, we randomly assigned 198 to comprehensive geriatric care and 199 to orthopaedic care. At 4 months, 174 patients remained in the comprehensive geriatric care group and 170 in the orthopaedic care group; the main reason for dropout was death. Mean SPPB scores at 4 months were 5·12 (SE 0·20) for comprehensive geriatric care and 4·38 (SE 0·20) for orthopaedic care (between-group difference 0·74, 95% CI 0·18-1·30, p=0·010).

INTERPRETATION

Immediate admission of patients aged 70 years or more with a hip fracture to comprehensive geriatric care in a dedicated ward improved mobility at 4 months, compared with the usual orthopaedic care. The results suggest that the treatment of older patients with hip fractures should be organised as orthogeriatric care.

FUNDING

Norwegian Research Council, Central Norway Regional Health Authority, St Olav Hospital Trust and Fund for Research and Innovation, Liaison Committee between Central Norway Regional Health Authority and the Norwegian University of Science and Technology, the Department of Neuroscience at the Norwegian University of Science and Technology, Foundation for Scientific and Industrial Research at the Norwegian Institute of Technology (SINTEF), and the Municipality of Trondheim.

What are FQHCs and how do they affect dental services?

Federally Qualified Health Centers serve, on a "cost-to-provide-care basis," low-income and other patients who cannot use private pay facilities. This is a safety-net care system that is much more comprehensive and less expensive than emergency room visits. The existence of an FQHC in a community partially removes the pressure on fee-for-service providers to make arrangements for treating dentally disadvantaged individuals. Increases in federal spending for dental services have recently outpaced declines in out-of-pocket private pay spending and sluggish improvements in insurance coverage.

Financial planning on a comprehensive scale

Hospitals and health systems that wish to explore the shift to comprehensive care management should: Assess the investments in infrastructure necessary to support comprehensive care management, Gauge the financial implications and set quality and financial goals, Monitor performance using metrics such as patient satisfaction, avoidable admissions, out-of-group referrals, and average length of stay.

What the comprehensive economics of blindness and visual impairment can help us understand

Since the year 2000, the amount written about the economics of blindness and visual impairment has increased substantially. In some cases, the studies listed under this heading are calculations of the costs related to vision impairment and blindness at a national or global level; in other cases the studies examine the cost-effectiveness of strategies to prevent or modify visual impairment or blindness that are intended to be applied as a guide to treatment recommendations and coverage decisions. In each case the references are just examples of many that could be cited. These important studies have helped advocates, policy makers, practitioners, educators, and others interested in eye and vision health to understand the magnitude of the impact that visual impairment and blindness have on the world, regions, nations, and individuals and the tradeoffs that need to be made to limit the impact. However, these studies only begin to tap into the insights that economic logic might offer to those interested in this field. This paper presents multiple case studies that demonstrate that the economics of blindness and visual impairment encompasses much more than simply measures of the burden of the condition. Case studies demonstrating the usefulness of economic insight include analysis of the prevention of conditions that lead to impairment, decisions about refractive error and presbyopia, decisions about disease and injury treatment, decisions about behavior among those with uncorrectable impairment, and decisions about how to regulate the market all have important economic inputs.

Commentary: health care payment reform and academic medicine: threat or opportunity?

Discussion of the flaws of the current fee-for-service health care reimbursement model has become commonplace. Health care costs cannot be reduced without moving away from a system that rewards providers for providing more services regardless of need, effectiveness, or quality. What alternatives are likely under health care reform, and how will they impact the challenged finances of academic medical centers? Bundled payment methodologies, in which all providers rendering services to a patient during an episode of care split a global fee, are gaining popularity. Also under discussion are concepts like the advanced medical home, which would establish primary care practices as a regular source of care for patients, and the accountable care organization, under which providers supply all the health care services needed by a patient population for a defined time period in exchange for a share of the savings resulting from enhanced coordination of care and better patient outcomes or a per-member-per-month payment. The move away from fee-for-service reimbursement will create financial challenges for academic medicine because of the threat to clinical revenue. Yet academic health centers, because they are in many cases integrated health care organizations, may be aptly positioned to benefit from models that emphasize coordinated care. The author also has included a series of recommendations for how academic medicine can prepare for the implementation of new payment models to help ease the transition away from fee-for-service reimbursement.

Undertreatment of menopausal symptoms and novel options for comprehensive management

OBJECTIVE

There is currently a gap in treatment options for menopausal symptoms and a need for comprehensive therapies that are safe and effective for postmenopausal women. This review discusses challenges in the management of menopausal symptoms and the effect of the Women's Health Initiative (WHI) study findings on current treatment patterns. It also examines present and future therapies.

RESEARCH DESIGN AND METHODS

A literature search was conducted using Medline, the Cochrane Database, and the National Heart Lung and Blood Institute WHI website with the following search terms: primary care, menopause, vasomotor symptoms, hormone therapy, osteoporosis, and vaginal atrophy. Searches were limited to articles published between 1995 and 2009.

RESULTS

Comprehensive therapies that target several aspects of menopause, such as vasomotor symptoms and chronic disease prevention, are currently hormone based. These hormone-based approaches are considered more effective than currently available nonhormonal therapies for the relief of menopausal symptoms. However, hormone therapy is not recommended for women at high risk for venous thromboembolic events, cardiovascular disease, and/or breast cancer. A need exists for novel therapies that mitigate menopausal symptoms, provide protection from osteoporosis, and encourage patient compliance without promoting cancer, heart disease, or stroke. Emerging modalities and strategies, such as the tissue selective estrogen complex (TSEC), Org 50081, MF101, and desvenlafaxine, may provide improved options for postmenopausal women.

CONCLUSIONS

Several new menopausal therapies that may help to address the ongoing unmet need for safe and effective therapies for postmenopausal women are currently in development. In particular, the TSEC, which provides the benefits of both a selective estrogen receptor modulator and conjugated estrogens with an improved tolerability profile, may offer advantages over currently available treatment options. Limitations of this review include the narrow search criteria and limited search period.

Benefits of a comprehensive, publicly funded prenatal care and obstetrics program

OBJECTIVE

To demonstrate the effectiveness of a comprehensive, multispecialty, interdisciplinary team approach to prenatal and obstetric care for previously medically underserved patients.

STUDY DESIGN

A retrospective chart review analysis was performed on a total of 1,800 charts pertaining to 600 patients divided evenly between a publicly funded, comprehensive prenatal care program and that same institution's private faculty practice. For each of the 600 patients data were extracted from prenatal, intrapartum and postpartum records. Data were analyzed using Fisher's exact test, the chi2 test and the Mann-Whitney test. In addition, for certain parameters, the data from the publicly funded program were compared to national data.

RESULTS

In the publicly funded group, more patients initiated prenatal care at a later date (p < 0.0001), had a significantly higher rate of illegal substance use (p < 0.0007), utilized home care services more frequently (p < 0.0001) and averaged a somewhat longer hospital stay for mother and neonate (p < 0.0019, p < 0.0001, respectively). However, there was no significant difference between the 2 groups or between the publicly funded group and the national averages for most antepartum, intrapartum and postpartum complications or for maternal or fetal morbidity or mortality. The publicly funded group averaged a higher rate of breast-feeding.

CONCLUSION

Despite belonging to a higher risk population, there were no statistically significant differences in maternal or neonatal outcomes between the publicly funded group and the private faculty practice group or between the publicly funded group and national data. This suggests that a comprehensive, multispecialty, interdisciplinary team approach to prenatal and obstetric care is an effective program to provide to patients who have previously been medically underserved.

The economic analyses of the UK prospective diabetes study

An economic analysis was not initially included in the study design of the UK Prospective Diabetes Study (UKPDS). However, data were collected throughout the study on hospital drugs and medications used and these were supplemented near the end of the study by cross-sectional surveys of non-inpatient healthcare use and quality of life. Evaluations of tight vs. less tight blood pressure control, intensive vs. less conventional blood glucose control and metformin showed that each was highly cost-effective and that all could be provided at modest total cost. Further analyses showed that amputations and stroke had particularly severe consequences for quality of life, and that amputations and non-fatal MI had high cost consequences. Finally, patient-level data were used to construct a diabetes outcomes model, which estimates the probability of longer-term complications from patient-specific risk factors and can be used in populations at different stages of diabetes progression. The economic analyses arising from the UKPDS have provided new evidence to clinicians, policymakers and researchers on the consequences of diabetes and the cost-effectiveness of interventions, thereby assisting the development of treatment guidelines and improved standards of care. The analyses also illustrated a number of methodological innovations. Finally, the UKPDS Outcomes Model is gaining widespread acceptance as a validated tool for long-term economic and clinical prediction in diabetes.

The impact of 'comprehensive geriatric assessment (CGA)' implementation on the effectiveness and cost (CEA) of healthcare in an acute geriatric ward

AIM

to investigate the cost effectiveness of CGA in an acute geriatric ward.

METHODS

a non-randomized controlled trial was carried out at Dr. Cipto Mangunkusumo General Hospital from January to December 2005. The inclusion criteria were elderly patients with geriatric syndrome. Exclusion criteria were advanced malignancy, APACHE II score > 34,in-hospital mortality in the first 24 hours, move to another ward before completing CGA management, the presence of dementia. After patients were allocated into CGA and non-CGA group, effectiveness was assessed using ADL/WHO Unescap score, days of hospitalization, proportion of re-hospitalization, survival, quality of life score (EQ5D),patients and nurses satisfaction score. Cost effectiveness analysis was done using TreeAge-Pro 2004 software program.

RESULTS

the length of hospitalization was shorter in the CGA group than in non-CGA group (10.99 [0.79] days vs.20.16 [2.62] days; p=0.00). At the end of treatment, mean of ADL score changes was significantly higher in CGA group than non-CGA group. Mean of WHO-Unescap score changes in CGA group was higher than non-CGA group (0.71[0.04]vs 0.61 [0.04]; p=0.09). EQ5D-VAS score was also higher in CGA group (0.79[0,01] vs 0.75[0.01]; p=0,01). Survival proportion in CGA group was lower than non-CGA group(80.37% vs 86.92%; p>0.05). Rehospitalization proportion was higher in non-CGA group than in CGA group (21.5%vs 11.21%; p 0.04). Patient's satisfaction level was higher in CGA group (193.38 [1.25] vs 177.47 [3.04]; p=0.00).Nurse satisfaction level was also higher in CGA group than non-CGA group but not statistically significant (225.06[7.08] vs 220.06[8.26]; p=0.65).Mean of healthcare cost in non-CGA group was higher than in CGA group (Rp. 9,746,426.00 [1,180,331] vs Rp 4,760,965.00 [338,089]). Cost effectiveness analysis indicated that CGA was superior to conventional approach because for each point score of QALD's, total cost was lower in geriatric acute care unit than in conventional ward(Rp 418,199.00 vs Rp 628,695.00). Moreover, QALD's in CGA group was better than in non-CGA group (24.1 vs 22.8; p= 0.03).

CONCLUSION

the CGA approach is more cost effective compared to conventional approach. Quality adjusted life days are better in CGA group than in non-CGA group although survival is not statistically different. In CGA group, length of hospitalization was shorter, functional status and patient satisfaction is better in general. Working satisfaction of nurses in CGA group was not lower than in non CGA group.

Insurance expansions: do they hurt those they are designed to help?

Seeking to redress health disparities across income and race, many policy-makers mandate health insurance benefits, presuming that equalized benefits will help equalize use of beneficial health services. This paper tests that presumption by measuring health care use by a diverse population with comprehensive health insurance. Focusing on use of mental health care and pharmaceuticals, it finds that even when insurance benefits and access are constant, whites and those with high incomes consume more of these benefits than other people do. This suggests that privileged classes extract more health care services even when everyone pays equal premiums for equal insurance coverage.

Children and youth with special healthcare needs: there is no place like (a medical) home

PURPOSE OF REVIEW

This review highlights the importance, components, and outcomes of the medical home for children and youth with special healthcare needs. Relevant work supporting the medical home concept for this vulnerable group is highlighted for healthcare providers.

RECENT FINDINGS

Developing a medical home model is garnering support from many national organizations and agencies. Having a medical home for children and youth with special healthcare needs is associated with favorable impacts on healthcare utilization and family-centered care. Achieving family-centered care is associated with increases in satisfaction and linkages to specialists, decreases in school absences and unmet medical needs. Consistent insurance coverage is important for children and youth with special healthcare needs to thrive. Further, lack of access to informational resources minimizes families' knowledge of available public programs.

SUMMARY

Children and youth with special healthcare needs constitute a vulnerable population in need of comprehensive and accessible care. Provision of care via a medical home can be efficient and effective in this population of children and their families. Due to the relatively high cost of providing fragmented care to these children and youth, advances in coordinating access to services will have a cost-effective outcome.

More physicians are not the answer

The Association of American Medical Colleges has called for an increase of 30% in matriculation in United States medical schools to treat the growing number of elderly patients with chronic illnesses. However, increasing the physician supply is unlikely to address the underlying problem, that being the growth of chronic disease, which necessitates a shift in orientation from treatment to management and prevention. This shift will in turn require a change in the makeup of health care providers. Instead of more physicians, more nonphysician professionals must be trained so as to aggressively coordinate comprehensive chronic disease care. A disease management model led by physicians, but including advanced practice nurses and other professionals, offers the opportunity to enhance efficiency, improve quality, reduce hospitalization, and meet evidence-based mandates. Such a workforce transition can become the inaugural step in converting the entire health care system from treatment based to prevention and management based. In conclusion, the position of the Association of American Medical Colleges should be a platform for discussion.

[External and internal financing in health care]

The objective of this contribution is to characterize the functional and institutional features of the German health-care system. This takes place after a short introduction and examination of the ongoing debate on health care in Germany. External funding describes the form of revenue generation. Regarding external funding of the German health care system, one of the favored alternatives in the current debate is the possibility of introducing per capita payments. After a short introduction to the capitation option, focus is on the so-called health fund that is currently debated on and being made ready for implementation in Germany, actually a mixed system of capitation and contributions based on income. On the other hand, internal funding is the method of how different health-care services are purchased or reimbursed. This becomes a rather hot topic in light of new trends for integrated and networked care to patients and different types of budgeting. Another dominating question in the German health-care system is the liberalization of the contractual law, with its "joint and uniform" regulations that have to be loosened for competition gains. After a discussion of the consequences of diagnosis-related groups (DRGs) in Germany, the article is concluded by a note on the political rationality of the current health-care reform for increased competition within the Statutory Health Insurance and its players as exemplified by the health fund. To sum up, it has to be said that the complexity and specific features of how the German system is financed seem to require ongoing reform considerations even after realization of the currently debated health-care reform law which, unfortunately, is dominated by political rationalities rather than objective thoughts.