• Reading list

    The Economics of Child Well-Being, by Gabriella Conti and James J. Heckman (The National Bureau of Economic Research)

    This paper presents an integrated economic approach that organizes and interprets the evidence on child development. It also discusses the indicators of child well-being that are used in international comparisons. Recent evidence on child development is summarized, and policies to promote child well-being are discussed. The paper concludes with some open questions and suggestions for future research.

    Design and Use of Performance Measures to Decrease Low-Value Services and Achieve Cost-Conscious Care, by David W. Baker, Amir Qaseem, P. Preston Reynolds, Lea Anne Gardner, Eric C. Schneider and on behalf of the American College of Physicians Performance Measurement Committee (Annals of Internal Medicine)

    Improving quality of care while decreasing the cost of health care is a national priority. The American College of Physicians recently launched its High-Value Care Initiative to help physicians and patients understand the benefits, harms, and costs of interventions and determine whether services provide good value. Public and private payers continue to measure underuse of high-value services (for example, preventive services, medications for chronic disease), but they are now widely using performance measures to assess use of low-value interventions (such as imaging for patients with uncomplicated low back pain) and using the results for public reporting and pay-for-performance. This paper gives an overview of performance measures that target low-value services in order to help physicians understand the strengths and limitations of these measures, provides specific examples of measures that assess use of low-value services, and discusses how these measures can be used in clinical practice and policy.

    Improving quality of care while controlling the cost of health care is a national priority. Several organizations that have traditionally focused on increasing use of beneficial services have intensified their efforts to decrease the use of low-value health care services. In 2006, the National Committee on Quality Assurance proposed a quality performance criterion for overuse of spine imaging. In 2008, the National Priorities Partnership identified “overuse” as 1 of 6 national health care priorities. More recently, the American College of Physicians launched its High-Value Care initiative, which seeks to help physicians and patients understand the benefits, harms, and costs of interventions and whether services provide good value. For example, the American College of Physicians’ paper on high-value care for low back pain advocates using diagnostic imaging only when patients have progressive neurologic deficits or signs or symptoms suggestive of a serious or specific underlying condition; routine imaging is otherwise considered to be low-value.

    Just as we need performance measures to assess underuse of high-value services, we need valid, evidence-based measures of overuse. For example, at the same time that we should be measuring the proportion of patients aged 50 to 75 years who have been screened for colorectal cancer, we should be assessing the proportion of patients older than age 75 years who had colorectal cancer screening that was not indicated. Performance measures for low-value services have the potential to be an important lever for changing clinician behavior through feedback, public reporting, clinical decision support, and financial incentives. This paper gives an overview of performance measures for low-value services, provides specific examples of possible measures to assess use of low-value services, and discusses how these measures can be used in clinical practice and policy.

    The Insurance Value of Medicare, by Katherine Baicker and Helen Levy (The New England Journal of Medicine)

    Medicare’s Enduring Struggle to Define “Reasonable and Necessary” Care, by Peter J. Neumann and James D. Chambers (The New England Journal of Medicine)

    Comparing Local and Regional Variation in Health Care Spending, by Yuting Zhang, Seo Hyon Baik, A. Mark Fendrick and Katherine Baicker (The New England Journal of Medicine)

    Background. Wide geographic variation in health care spending has generated both concern about inefficiency and policy debate about geographic-based payment reform. Evidence regarding variation has focused on hospital referral regions (HRRs), which incorporate numerous local hospital service areas (HSAs). If there is substantial variation across local areas within HRRs, then policies focusing on HRRs may be poorly targeted.

    Methods. Using prescription drug and medical claims data from a 5% random sample of Medicare beneficiaries from 2006 through 2009, we compared variation in health care spending and utilization among 306 HRRs and 3436 HSAs. We adjusted for beneficiary-level demographic characteristics, insurance status, and clinical characteristics.

    Results. There was substantial local variation in health care (drug and nondrug) utilization and spending. Furthermore, many of the low-spending HSAs were located in high-spending HRRs, and many of the high-spending HSAs were in low-spending HRRs. For drug spending, only 50.7% of the HSAs located within the borders of the highest-spending quintile of HRRs were in the highest-spending quintile of HSAs; conversely, only 51.5% of the highest-spending HSAs were located within the borders of the highest-spending HRRs. Similar patterns were observed for nondrug spending.

    Conclusions. The effectiveness of payment reforms in reducing overutilization while maintaining access to high-quality care depends on the effectiveness of targeting. Our analysis suggests that HRR-based policies may be too crudely targeted to promote the best use of health care resources.

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