Title: Extent and Impact of the Use of Observations Stays in the Medicare Program
Grantee Institution: Social and Scientific Systems, Inc.
Principal Investigator: Janet Sutton, Ph.D.
Grant Period: July 01, 2008 - December 31, 2009
Email: jsutton@s-3.com
Awarded: $221,791.00

The researchers will examine the extent of Medicare observation visits, as well as their implications. Observation visits, as distinct from inpatient visits, are covered under Medicare Part B, rather than Medicare Part A. This has implications for hospital payments, beneficiary copayments, and beneficiary eligibility for SNF coverage. The researchers will examine how observation stays are used in the Medicare program, as well as how they affect beneficiary out-of-pocket liability and hospital payments. The objective of this project is to better understand the extent to which observation visits, rather than inpatient visits, are used, as well as the implications for hospitals and beneficiaries.

Title: Resource Use and Efficiency in Episodes of Care
Grantee Institution: Palo Alto Medical Foundation Research Institute
Principal Investigator: Hal S. Luft, Ph.D.
Grant Period: July 01, 2008 - September 30, 2009
Email: lufth@pamfri.org
Awarded: $320,018.00

The researchers seek to examine some of the underlying assumptions of episode-based payments, which are hypothesized to encourage more clinically and economically efficient practices by primary care physicians (PCPs). Specifically, they will assess whether episode-based measures of resource use at the individual PCP level, rather than the physician group or medical staff level, are statistically reliable and appropriate. Using data from the Palo Alto Medical Foundation (PAMF), a large multispecialty physician group that uses electronic medical records (EMRs), the researchers will examine whether some PCPs have practice patterns significantly more (or less) expensive than the average at either the episode level or with groups of acute or chronic episodes. If there is variation in PCP practice patterns, the researchers will explore the role of components, such as PCP office visits, referrals, imaging, lab tests, and drugs, in these differences. They will also study clinicians’ explanations for differences in practice patterns, such as unmeasured severity, location, or other factors. They will compare PAMF-based patterns of care with overall patterns at an episode level (but not physician level) from a large national data set. The objective of the study is to determine whether consistent styles of practice across PCPs within a large medical group can be detected, which would help inform policymakers about whether physician-oriented incentives are worth pursuing.

Title: Comparing the Cost Effectiveness of Chronic Care between Medicare Advantage and FFS Medicare Beneficiaries
Grantee Institution: University of Minnesota
Principal Investigator: David J. Knutson, M.S.
Grant Period: July 01, 2008 - December 31, 2010
Email: Knutson@umn.edu
Awarded: $399,978.00

Researchers at the University of Minnesota will compare the technical efficiency of care—a measure that links resource inputs with quality outcomes—for chronically ill Medicare Advantage (MA) and fee-for-service (FFS) beneficiaries. MA health plans are viewed by some as providing an opportunity to improve care for beneficiaries with chronic illnesses. Because MA plans do not submit encounter data to CMS, however, it has not been possible to directly address whether MA plans are more efficient than traditional Medicare FFS plans in caring for these beneficiaries. In particular, the researchers will: 1) validate that the new HEDIS Relative Resource Use (RRU) measures can be applied to FFS; and 2) compare RRUs in FFS and MA plans within geographic areas. The objective of the project is to provide policymakers with more information about the factors that contribute to efficiency and to identify the relative strengths of MA and FFS for chronically ill beneficiaries.

Title: Getting Tools Used: Lessons Learned from Successful Decision Support Tools Unrelated to Health Care
Grantee Institution: Center for the Advancement of Health
Principal Investigator: Jessie C. Gruman, Ph.D.
Grant Period: July 01, 2008 - June 30, 2009
Email: jgruman@cfah.org
Awarded: $125,979.00

The researchers will develop case studies of four successful decision-support tools from the transportation, education, electronic, and nutrition industries in order to promote greater public demand and use of decision tools for health care. The case studies will focus on the development, marketing and dissemination of the representative tools and consider questions such as: 1) Who initiated development of the tool and why? 2) Who was the audience? 3) How was the benefit of the tool framed? 4) How did this tool become a household name? 5) What were the dissemination strategies? 6) How was it marketed? 7) How were the tool and the dissemination strategies modified over time? 8) What were the barriers to the tool’s acceptance? 9) What was the timeline leading to acceptance? 10) How has the tool influenced consumer choice over time? and 11) Why did similar attempts not succeed? The objective of this project, awarded under a special topic solicitation on consumer activation, is to help health care decision tool developers refine their approaches to development, dissemination, and promotion and to increase public use of these tools to make informed choices about health and health care.

Title: Promoting Readiness and Interest in Self Management
Grantee Institution: Visiting Nurse Service of New York
Principal Investigator: Penny H. Feldman, Ph.D.
Grant Period: July 01, 2008 - September 30, 2009
Email: pfeldman@vnsny.org
Awarded: $136,180.00

The researchers will investigate how patient activation occurs and under what circumstances in a historically under-represented population – Black/African Americans – who suffer disproportionately high rates of chronic illness. Patient activation, or engaging patients in their care, can improve the quality of care and health outcomes of those living with chronic conditions. Specifically, the researchers will: 1) evaluate psycho-social and clinical/functional determinants that influence a change in patients’ activation levels over time; 2) examine patients’ perspectives on their involvement in their care; 3) investigate factors that may help or hinder home care nurses’ promotion of self management and patient engagement; and 4) provide recommendations to improve clinician education and patient interventions. The objective of the proposed project, funded under a special topic solicitation on consumer activation, is to promote patient-centered care by identifying and providing recommendations to overcome patient-related barriers to self-management and to cultivate facilitators of clinician involvement in promoting patient self care.

Title: Measuring the Costs of Defensive Medicine in the United States: Phase II
Grantee Institution: University of Southern Maine
Principal Investigator: J. William Thomas, Ph.D.
Grant Period: June 01, 2008 - July 31, 2009
Email: jwthomas@usm.maine.edu
Awarded: $288,724.00

In this study, the researchers will conduct the second phase of a two-part project which examines the costs of defensive medicine. In the first phase of the project (Grant #58347), the researchers constructed a database of tort signals and health claims data from CIGNA HealthCare. The tort signals – medical malpractice premiums and the number of malpractice suits filed in a physician’s geographic area – are factors which may be viewed by physicians as indicators of litigation risk. In phase two of the study, the researchers will conduct analyses of the tort signals and claims data in order to: 1) quantify costs associated with positive defensive medicine in the United States for the complete spectrum of medical care; 2) identify specific clinical conditions for which positive defensive medicine exists, and quantify defensive medicine costs for each of these conditions; and 3) identify the specific types of services and resources (e.g. medications) associated with defensive medicine in each identified condition. The objective of the project is to measure the degree to which fears of medical malpractice litigation motivates physicians to practice positive defensive medicine, which includes ordering tests, procedures, and/or medications that offer little or no clinical benefit to patients.

Title: The Impacts of Undocumented Immigrants on the U.S. Health Care System
Grantee Institution: The Urban Institute
Principal Investigator: Stephen Zuckerman, Ph.D.
Grant Period: June 01, 2008 - December 31, 2009
Email: szuckerm@urban.org
Awarded: $287,995.00

The researchers will examine the impact of undocumented immigration on the U.S. health care system. They will also explore how efforts to secure citizenship for undocumented immigrants could increase access to public and private insurance for this population. The researchers will focus on three research questions: 1) How much have undocumented immigrants contributed to the rate of uninsurance and to growth in the numbers of non-elderly uninsured in recent years? 2) How much uncompensated care do U.S. providers deliver to undocumented immigrants who lack health insurance coverage? and 3) To what extent would undocumented children and adults qualify for Medicaid or SCHIP coverage should they become legal residents? The objective of the project is to provide current estimates of the actual burden of undocumented immigrants on the health care system to help inform public discussion on policy options.

Title: Impact of State Medicaid Policy Changes on Nursing Home Hospitalization
Grantee Institution: Brown University
Principal Investigator: Vincent Mor, Ph.D.
Grant Period: June 01, 2008 - May 31, 2010
Email: vincent_mor@brown.edu
Awarded: $307,261.00

The researchers will examine the effect of changes in state nursing home bed hold payment policies. Bed hold policies are designed to prevent facilities from discharging low paying (i.e., Medicaid), costly, or complicated patients and to encourage continuity of residence by continuing to reimburse nursing homes if a resident is transferred to a hospital. The researchers will study the impact of these policies on the rate of hospitalization of nursing home residents, as well as on whether residents return to their originating nursing home following hospital discharge. In particular, they will: 1) describe variation in the rates of hospitalization between 1999 and 2005; 2) describe changes in the pattern of post-hospitalization discharge locations; 3) test the effect of changes in state Medicaid bed-hold payment policies between 1999 and 2005 on the rate of all hospitalizations of long stay nursing home residents; 4) test whether state bed-hold policies differentially affect the occurrence of “potentially avoidable” and “terminal” hospitalizations among nursing home residents; 5) test the effect of changes in state Medicaid bed-hold payment policies between 1999 and 2005 on the discharge location; 6) quantify the financial implications of changes in state bed hold policies; and 7) examine changes in residents’ functional status associated with hospitalization in the periods before and after changes in bed-hold policies. The objective of this study is to inform the debate about how best to address increasing hospitalizations of nursing home residents.

Title: Is Small-Area Variation in Healthcare Utilization Explained by Physician Financial Self-Interest?
Grantee Institution: American College of Radiology
Principal Investigator: Mythreyi Bhargavan, Ph.D.
Grant Period: May 01, 2008 - October 31, 2009
Email: mbhargavan@acr.org
Awarded: $254,109.00

The researchers will explore the extent to which small-area variation (SAV) in health care utilization and expenditure is accounted for by physicians with a financial self-interest (FSI), particularly as it relates to imaging procedures. They will investigate the variation/financial self-interest relationship: 1) for imaging modalities, including CT, MRI, interventional radiology, ultrasound, nuclear medicine, and radiography; 2) by examining total health costs; 3) by exploring the relation of FSI in coronary revascularization to the volume of cardiac-related procedures; and 4) by determining whether having FSI in both imaging and revascularization has a greater effect than each alone. The objective of the study is to determine whether FSI is one of the causes of utilization variation and whether FSI might be addressed to reduce health care costs without sacrificing quality or access.

Title: Local Public Health Capacities to Address the Needs of Culturally and Linguistically Diverse Populations
Grantee Institution: Social and Scientific Systems, Inc.
Principal Investigator: Claudia Schur, Ph.D.
Grant Period: May 01, 2008 - December 31, 2009
Email: cschur@s-3.com
Awarded: $199,824.00

The researchers will examine the public health needs of culturally and linguistically diverse populations. Specifically, they will develop detailed community multicultural profiles describing the cultural and linguistic diversity of populations served by local health departments (LHDs). They will then use these profiles to analyze the relationships between population characteristics and existing public health capacity and to identify and survey select communities for more in-depth information about serving these populations. They will seek answers to the following research questions: 1) How do jurisdictions with LHDs compare in terms of the composition of the population served? To what extent do communities include substantial numbers of racial/ethnic minorities, immigrants, and/or persons who speak a language other than English? 2) Does the structure and capacities of LHDs vary with respect to the multicultural profile of the populations they serve? How do LHD resources and activities correspond to local community characteristics? 3) What are the specific strategies that LHDs engage in to meet the needs of diverse populations? What types of strategies appear to be most successful? Are community partnerships used either for training purposes or for the delivery of culturally appropriate services? 4) What obstacles appear to be most difficult to overcome in serving different types of population subgroups? Which types of services are most difficult to deliver? What characteristics or combinations of characteristics of communities and LHDs create the most substantial obstacles? The objective of this project is to develop policy recommendations for implementation of promising strategies to better serve diverse populations.

Title: Effect of Decreased Emergency Department Access on Patient Outcomes
Grantee Institution: Naval Postgraduate School Graduate School of Business and Public Policy
Principal Investigator: Yu-Chu Shen, Ph.D.
Grant Period: April 01, 2008 - March 31, 2010
Email: yshen@nps.edu
Awarded: $229,918.00

The researchers will examine whether decreased emergency department (ED) access results in adverse patient outcomes or changes in other health indicators. There is a great deal of literature documenting decreased access to EDs. However, there is little empirical evidence linking access to EDs and health outcomes. The researchers will use acute myocardial infarction (AMI) patients to examine health outcomes, since AMI patients are relatively homogeneous and the time sensitivity of treatment should be reflected in differences in outcomes. They will examine two types of ED access between 1995 and 2005: permanent ED closure and temporary ED closure as measured by ambulance diversion time. Specifically, the researchers will focus on how changes in distance to the closed ED affect health outcomes of two types of AMI patients: (1) those who survived the ambulance ride and have an outpatient claim from the ED; and 2) those who survived the ED admission to have an inpatient claim. The objective of this project is to provide improved understanding of the impact of ambulance diversion in the health care system.

Title: Small Area Variation in Medicaid Utilization and Expenditures: Implications for Cost Containment and Quality of Care
Grantee Institution: University of California, San Diego
Principal Investigator: Richard G. Kronick, Ph.D.
Grant Period: March 01, 2008 - August 31, 2009
Email: rkronick@ucsd.edu
Awarded: $336,513.00

The researchers will investigate the variation in Medicaid services and payments and explore the implications of these variations for cost containment options. They will compare the services received and cost of care for Medicaid beneficiaries across state Medicaid programs and across hospital referral regions (HRRs) within states. Specifically, the researchers will determine: (1) how much variation there is across states, across HRRs within states, and in Medicaid expenditures per beneficiary; (2) the extent to which variation in expenditures per beneficiary is due to variation in the rate of use of services, and the extent to which it is a result of variation in the rate of payment per unit of service; and (3) whether variation in the use of services and in expenditures per beneficiary is related to variations in the quality of care or the outcomes of care for Medicaid beneficiaries. The objective of this study is to provide policymakers with an understanding of the impact of policy choices regarding benefit limits and payment rates on costs and utilization, and their implication for quality of care.

Title: Can Disease Management Control Costs?
Grantee Institution: Mathematica Policy Research, Inc.
Principal Investigator: Deborah N. Peikes, Ph.D.
Grant Period: March 01, 2008 - August 31, 2009
Email: dpeikes@mathematica-mpr.com
Awarded: $346,228.00

The researchers will test the ability of disease management (DM) and care coordination (CC) programs to control health care costs, examine which features make certain programs effective, for which target populations, and how they can be replicated. They will build on prior work for CMS' Medicare Coordinated Care Demonstration that estimated program impacts over the first four years of program operations, described the basic features of the 15 programs’ interventions, and linked program features to overall program effectiveness. Five interrelated studies would determine: 1) the effects of DM/CC on costs over a longer follow-up period and the types of beneficiaries for whom DM/CC is most effective; 2) the operational features of DM/CC programs that were able to reduce costs and how they can be replicated; 3) what features of the DM/CC programs did not work and why; 4) whether intensifying contacts at the time of hospital discharge contributes to reducing costs; and 5) whether DM/CC interventions are more effective at reducing costs if the doctor has a greater number of patients receiving the intervention. The objective of this study is to help decision makers determine whether to offer disease management and care coordination to Medicare beneficiaries, as well as chronically ill patients with commercial insurance and Medicaid, and will provide information about how best to implement this intervention.

Title: How Does Fragmentation of Care Contribute to the Costs of Care?
Grantee Institution: Harvard University School of Public Health
Principal Investigator: Eric C. Schneider, M.D.
Grant Period: March 01, 2008 - August 31, 2009
Email: eschneid@hsph.harvard.edu
Awarded: $297,461.00

The researchers will develop new measures of care fragmentation that can be used to assess fragmentation within episodes of care and evaluate the relationship between care fragmentation and the costs of care for Medicare beneficiaries. They hypothesize that a higher degree of fragmentation of care will be associated with higher episode-specific costs of care after controlling for type of clinical episode, severity of clinical episode, clinical comorbidities, and the sociodemographic characteristics of patients. To test this hypothesis, the researchers will modify existing measures of fragmentation and develop new measures based on their relevance for episodes of care, select an approach to measuring costs, and select the clinical episodes for which they will test for the association between fragmentation and costs. The objective of this study is to improve quality and reduce the growth of health care costs in the U.S. by assisting the Medicare program and other insurers to measure and monitor fragmentation and target improvements to episodes with higher fragmentation.

Title: Sources of Health Care Cost Growth
Grantee Institution: Stanford University
Principal Investigator: M. Kate Bundorf, Ph.D./Anne B. Royalty, Ph.D.
Grant Period: March 01, 2008 - August 31, 2009
Email: bundorf@stanford.edu
Awarded: $275,519.00

The researchers will study the sources of cost growth among the privately insured by analyzing the contributions to higher spending of changes in prices and changes in the number and types of services performed. They will also examine how changes in prices and changes in the number and types of services have differentially affected different categories of spending and different demographic groups. These findings for the privately insured will also be compared to trends in cost growth in public programs. The researchers will explore which policies or benefit designs will be more effective in reducing spending, as well as whether costs are driven more by increased utilization of certain types of services or by increases in the prices of particular services. In addition, the researchers suggest that the findings will be useful in developing policies to expand coverage by identifying the sources of cost increases that may affect coverage rates. The objective of this study is to provide information for policymakers to design interventions to reduce health spending in ways that benefit consumers.

Title: Defining Affordability for the Uninsured and People with Chronic Conditions
Grantee Institution: The Urban Institute
Principal Investigator: Lisa H. Clemans-Cope, Ph.D./Cynthia D. Perry, Ph.D.
Grant Period: March 01, 2008 - February 28, 2009
Email: lclemans@ui.urban.org
Awarded: $199,918.00

The researchers will examine affordability of health insurance. In particular, they will study how different measures of affordability affect access to health insurance for: 1) those that are currently uninsured; and 2) those that have chronic health conditions requiring persistently high health care expenditures. The researchers will use alternative measures of affordability (health care spending falling below a given standard of spending as a percent of family income) to: 1) describe the availability of affordable health insurance among the currently insured and uninsured populations; and 2) explain why take-up of health insurance varies, given affordability. The objective of this project is to provide empirical evidence of various measures of affordability to inform policy choices for increasing coverage and ensuring equitable financial burdens for those who acquire coverage.

Title: Medicare Spending, Disparities, and Returns to Healthy Behaviors
Grantee Institution: University of Maryland, Baltimore
Principal Investigator: Bruce C. Stuart, Ph.D.
Grant Period: March 01, 2008 - August 31, 2009
Email: bstuart@rx.umaryland.edu
Awarded: $264,047.00

The researchers will examine persistently low cost Medicare beneficiaries and determine the extent to which health behavior, preventive services, race and socioeconomic status (SES) appear to be related to low spending. Specifically, the researchers will (1) estimate cost savings in traditional Medicare spending associated with persistently good health behavior and preventive measures; (2) identify population characteristics that can be used to optimally target preventive interventions; and (3) develop simulation models to show how selectively reducing beneficiary cost sharing for primary and secondary preventive measures can achieve significant costs offsets in reduced spending on traditional Medicare services – this mechanism is referred to as “value-based insurance design.” The objective of the proposed project is to identify which disease states and beneficiary segments show the greatest promise for improved compliance and persistency in use of preventive therapies.

Title: Cost and Efficiency in Treating High-Cost Medicare Beneficiaries: The Role of Physician Practice and Health System Factors
Grantee Institution: Center for Studying Health System Change
Principal Investigator: James D. Reschovsky, Ph.D.
Grant Period: March 01, 2008 - August 31, 2009
Email: jreschovsky@hschange.org
Awarded: $338,826.00

The researchers will examine key physician practice and market characteristics that may contribute to high costs and inefficient care in the Medicare program. The study is composed of three phases. In phase one, they will analyze the treatment of high-cost Medicare beneficiaries in order to identify key physician, practice, and market characteristics associated with differences between actual and predicted Medicare payments and medical care use. In phase two, they will examine whether the factors associated with greater than predicted resource use affect high-cost beneficiaries’ health outcomes. Finally, the researchers will examine possible sources of geographic cost variations for high-cost beneficiaries and the extent to which these variations reflect differences in patient characteristics or supply-related factors and practice patterns of providers in a particular region. The objective of this project is to identify potential policy levers that can influence cost effectiveness in the delivery of medical care to high-cost Medicare patients.

Title: Variation in Health Care Cost Growth
Grantee Institution: Harvard Medical School
Principal Investigator: Michael Chernew, Ph.D.
Grant Period: March 01, 2008 - February 28, 2009
Email: chernew@hcp.med.harvard.edu
Awarded: $298,040.00

The researchers will investigate the factors related to variation in cost growth in the Medicare and commercial sectors. Specifically, the researchers will determine: (1) whether the factors related to the rate of growth in the Medicare program are the same factors that are related to level of cost; (2) whether the factors associated with cost growth in commercial markets are the same as those related to Medicare cost growth; and (3) the extent to which cost growth varies between employers and health plans and what factors are related to that variation in cost growth. While most research and policy initiatives are aimed at managing the level of costs as opposed to cost growth, the researchers suggest that additional attention must be devoted to understanding and developing initiatives relating to the trajectory of cost growth, since the factors related to high levels of costs may not be the same as factors related to cost growth. The objective of this study is to provide knowledge that will support development of cost containment approaches that address cost growth.

Title: The Impact of Pay for Performance on Hospitals that Care for Minorities and the Poor
Grantee Institution: Harvard University School of Public Health
Principal Investigator: Ashish Jha, M.D., M.P.H.
Grant Period: February 01, 2008 - July 31, 2008
Email: ajha@hsph.harvard.edu
Awarded: $101,656.00

The researchers will examine the impact of financial incentives to improve quality on hospitals that care for minority or other underserved populations. The Centers for Medicare and Medicaid Services have implemented pay for performance (P4P) demonstrations, and are considering implementing P4P nationally. However, the impact of P4P has not been widely evaluated. Hospitals that care for underserved populations may have greater potential for quality improvement; conversely these facilities lack the tools and resources to improve quality and compete for the additional resources. The researchers will examine changes in quality for hospitals in the Medicare Premier P4P Demonstration that serve disadvantaged populations (minority and poor); these changes will be compared with changes in hospitals in the demonstration that do not serve disadvantaged populations and with hospitals not in the demonstration (and not subject to P4P) that serve disadvantaged populations. The objective of the project is to provide more information about the impact of P4P on hospitals that serve disadvantaged populations, and help policymakers to design incentive systems that encourage higher quality care without disproportionately harming hospitals that care for these populations.

Title: Measuring the Costs and Benefits of Medicare Private Fee-for-Service
Grantee Institution: Boston VA Research Institute Inc.
Principal Investigator: Steven D. Pizer, Ph.D.
Grant Period: February 01, 2008 - January 31, 2010
Email: steven.pizer@med.va.gov
Awarded: $299,549.00

The researchers will explore how private fee-for-service (PFFS) plans and beneficiary choices are affected by Medicare payment policy. PFFS plans cover services from any Medicare-qualified provider and pay physicians by fee-for-service. The researchers will measure the effects of payment changes on PFFS plan decisions regarding market entry, benefit design, and premiums and then analyze the effects of changes in benefits and premiums on enrollment. They will address the following research questions: (1) how would plan availability be affected if payment rates were reduced; (2) how would premiums and benefits be affected by changes in payment rates; and (3) how does the value to beneficiaries of the PFFS option compare to its cost to the taxpayers? The objective of the proposed project is to inform policymakers about the costs and benefits of paying private Medicare health insurance plans.

Title: Medicaid Long-Term Care Programs: Simulating Rate Setting and Cross-Payer Effects
Grantee Institution: State of Maryland Department of Health and Mental Hygiene
Principal Investigator: Tricia Roddy, M.H.S.A.
Grant Period: February 01, 2008 - January 31, 2010
Email: roddyt@dhmh.state.md.us
Awarded: $160,086.00

The financing of long-term care has become increasingly more complex as both Medicare and Medicaid seek to serve the dual eligible population. While states are examining ways to support integrated programs of care for duals through capitated payments for Medicaid-covered costs, important questions remain about how Medicare and Medicaid services and costs are related. Using data for 2006 and 2007, researchers from the State of Maryland Department of Health and Mental Hygiene will establish a framework within which to examine the implications of cross-program effects in long-term care including an array of potential factors that would affect the calculation of capitation payment rates. The researchers will accomplish this by: (1) developing a simulation using estimated and actual expenditures to model the full spectrum of public program expenditures for duals; (2) examining how and to what extent providing Medicaid community supports, in particular, may affect the use of Medicare acute care and Medicaid institutional resource use; and (3) exploring how those effects might be applied in setting Medicaid payment rates. The objective of this study is to provide state and federal administrators and policymakers a better understanding of the interactive effects of public programs as efforts in coordinated care evolve.

Title: Characteristics and Determinants of Intragovernmental Activity Within State Public Health Systems
Grantee Institution: University of Massachusetts at Amherst (School of Public Health)
Principal Investigator: William Bartosch, Ph.D.
Grant Period: January 01, 2008 - August 31, 2009
Email: bartosch@schoolph.umass.edu
Awarded: $199,014.00

The researchers will examine intragovernmental activities within four northeastern states to determine their impact on fragmentation in the public health system. They will study the interactions of state administrative agencies in addressing two public health challenges— substance abuse and HIV/AIDS — to better understand how they facilitate or impede efficient and effective implementation of core public health functions. In particular, they will: 1) identify the types of intragovernmental activities within state public health systems that are required by law or regulation; 2) describe the types of intragovernmental activities that occur in states that are intended to address core public health functions; 3) identify factors influencing the type of engagement and barriers to such activity; and 4) identify models of successful intergovernmental collaboration. The objective of this project is to generate lessons for states about how they can more efficiently and effectively identify and respond to public health problems with scarce resources.

Title: Understanding the Resource Allocation Decisions of Public Health Officials in the U.S.
Grantee Institution: The Regents of the University of Michigan (University of Michigan Health System)
Principal Investigator: Susan Dorr Goold, M.D., M.S.H.A., M.A.
Grant Period: January 01, 2008 - December 31, 2009
Email: sgoold@umich.edu
Awarded: $208,902.00

The researchers will examine the nature and scope of resource allocation decisions made by public health officials. They will: 1) describe the nature and scope of resource allocation decisions officials confront; 2) identify the processes officials use when they make allocation decisions; 3) assess the degree of discretion officials report in allocating resources and the factors that influence that discretion; and 4) explore whether discretion affects officials’ abilities to assure that their communities’ most important public health needs are met. The objective of this project is to better inform discussions of public health system function by shedding light on how resource allocation decisions are made and the extent to which variation exists in those processes as a result of varying levels of discretion among public health officials.

Title: Developing and Applying a Descriptive Framework for Analyzing Food Safety Resources
Grantee Institution: The George Washington University School of Public Health and Health Services
Principal Investigator: Michael Taylor, J.D.
Grant Period: January 01, 2008 - June 30, 2009
Email: mike.taylor@gwumc.edu
Awarded: $199,770.00

The researchers will develop a descriptive framework for public health-oriented analysis of food safety resources. The researchers will use the framework to describe and analyze federal food safety expenditures comprehensively and will apply it on a pilot basis to selected states and localities. Development of the framework will necessitate addressing the following research questions: 1) How should government food safety expenditures be organized into functional categories that enable the evaluation of resource allocation from a public health perspective? 2) Can actual food safety expenditure data be translated into these public health-oriented categories in a way that is feasible and useful for policymakers? 3) How are federal food safety resources allocated across these public health-oriented categories? 4) What are the recent trends in federal food safety expenditures across the system and across these public health-oriented categories, including federal allocations to state and local agencies? 5) How does the current federal resource allocation compare with what data and expert judgment suggest about opportunities to reduce risk across the system? 6) Can the framework be feasibly and usefully applied to state and local expenditures, taking into account budget data availability and the large number of individual agencies? 7) For a pilot set of states and localities, how are current food safety resources allocated across public health-oriented categories? and 8) What budgetary practices of government agencies foster or impede understanding and analysis of food safety expenditures from a public health perspective? The objective of this project is to provide policymakers with a tool for describing and analyzing government food safety expenditures on a system-wide basis and in ways that are relevant to reducing food borne illness.

Title: A Systematic Study of Nebraska’s Regional Public Health Agency Model
Grantee Institution: Board of Regents of the University of Nebraska (University of Nebraska Medical Center)
Principal Investigator: Li-Wu Chen, Ph.D.
Grant Period: January 01, 2008 - December 31, 2009
Email: liwuchen@unmc.edu
Awarded: $199,713.00

The researchers will evaluate Nebraska’s change from single-county health departments to multi-county or regional public health systems. The researchers posit that a regional approach could have advantages for states like Nebraska due to the state’s relatively small population base and large geographic area. They will examine the regional public health agency model based on variation and/or effectiveness of the following factors: 1) macro context, i.e., political, social, and economic environment; 2) structural capacity, i.e., human, organizational, fiscal, and informational resources); 3) processes, i.e., community partnerships, resource allocation; and 4) outcomes, i.e., practice and performance of public health services. The objective of this project is to inform federal and state policymakers about the lessons learned through Nebraska’s experience with a regional public health agency model, so that performance of public health practice can be improved.

Title: Informing the Design of Funding Allocation Formulas in Public Health
Grantee Institution: Emory University, Rollins School of Public Health
Principal Investigator: James Buehler, M.D.
Grant Period: January 01, 2008 - December 31, 2009
Email: jbuehle@sph.emory.edu
Awarded: $225,749.00

The researchers will examine formula-based allocation strategies in public health practice. In particular, they will assess the impact on funding allocations of various formula design options, including the use of different indicators of target population need, the cost of providing services, state or local resource availability, and various approaches to combining indicators in formula calculations. The will also study the policy implications associated with using different indicators or strategies, including measures of population health disparities and approaches to assuring equity versus equivalency in funding allocations. The objective of this project is to generate practical guidance for public health program managers seeking to make informed choices when developing allocation formulas to best serve program goals.

Title: Waiting for Outpatient Care and Choice in Financing
Grantee Institution: Boston VA Research Institute Inc.
Principal Investigator: Julia Prentice, Ph.D.
Grant Period: December 01, 2007 - November 30, 2009
Email: julia.prentice@va.gov
Awarded: $99,986.00

The researchers will examine how increasingly long wait times for medical appointments have resulted in individuals exiting healthcare systems with lengthy waits and paying more to access alternative systems with shorter waits. They are exploring whether these time/cost tradeoffs affect how individuals choose among healthcare financing options. Specifically, the researchers will focus on veterans who receive care through the Department of Veterans Affairs (VA) or pay more out-of-pocket to access the Medicare program. The researchers hypothesize that: (1) long waits in local VA facilities will reduce the probability that individuals will use VA healthcare and (2) individuals with greater resources, as compared to individuals with fewer resources, will be more likely to choose more expensive Medicare plans rather than wait for care in the VA. The objective of the study is to inform policymakers, who make decisions on reimbursement rates, how time/cost tradeoffs affect patients’ health care financing choices.

Title: Impact of Profitability on Hospital Responses to Financial Stress
Grantee Institution: University of Pennsylvania School of Medicine
Principal Investigator: Kevin Volpp, M.D., Ph.D.
Grant Period: December 01, 2007 - November 30, 2009
Email: volpp70@mail.med.upenn.edu
Awarded: $455,218.00

The researchers will examine the impact of financial pressure on hospitals on the quality of care provided. They will test whether hospitals' responses to a change in the level of reimbursement is likely to vary by DRG-specific incentives, using the Medicare BBA as an example. They would: 1) calculate the generosity of Medicare payment by diagnoses and service lines for 1995, 2000, and 2005; 2) compare the quality of care received by patients hospitalized with conditions from more vs. less profitable service lines in 1995, 2000, and 2006; 3) test the effects of changes in reimbursement on mortality for more vs. less generously reimbursed diagnoses and service lines; and 4) test the effects of changes in reimbursement on Patient Safety Indicators (PSIs) for more vs. less generously reimbursed diagnoses and service lines. The researchers note that existing studies on the effects of financial stress on hospitals have examined acute myocardial infarctions, one profitable condition that may provide a misleading sense of the overall impacts on quality and cost/quality tradeoffs. The objective of this study is to provide policymakers with better ability to measure profitability and quality for hospital service lines (e.g., neurosurgery, cardiology, etc.), the level at which many important decisions about resource allocation are made.

Title: The Provision and Reporting of Community Benefits by Hospitals: Lessons from Maryland
Grantee Institution: Urban Institute
Principal Investigator: Bradford Gray, Ph.D.
Grant Period: November 01, 2007 - October 31, 2008
Email: bgray@ui.urban.org
Awarded: $184,057.00

The researchers will examine factors at the hospital and community level that underlie variations in the amount of hospitals’ charity care and other community benefit activities. Through a series of interviews and quantitative analysis the researchers will provide a critical account of the practical realities, advantages, and disadvantages of Maryland’s experience providing and reporting on not-for-profit hospitals’ charitable activities. The Maryland approach is a working public model of the acclaimed Catholic Heath Association’s (CHA) guidelines that measure and document the charity care it provides to communities. The researchers will develop benchmarks for the amount and variation of charity care and other community benefit activities. The objective of the study is to provide policymakers evidence-based information as they make decisions about requirements for hospitals’ provision of charity care, as well as the accountability of nonprofit hospitals.

Title: Economic Impact of Adverse Health Events on the Uninsured Near Elderly
Grantee Institution: Northwestern University, Kellogg School of Management
Principal Investigator: David Dranove, Ph.D.
Grant Period: November 01, 2007 - October 31, 2008
Email: d-dranove@northwestern.edu
Awarded: $98,210.00

The researchers will assess how insurance status affects personal wealth and earnings in the population nearing age 65 that have a heightened probability of adverse health but have not yet qualified for Medicare. Specifically, they will analyze: 1) the extent to which measurable dimensions of household wealth (e.g., total net worth, home equity, funds in retirement plans) fall after an adverse health event; 2) the extent to which individuals in the U.S. who lack health insurance suffer disproportionate losses in household wealth; 3) whether the probability of sentinel financial events, including loss of home and loss of estate, increases after an adverse health event; and 4) the extent to which the probability of a sentinel financial event is higher for individuals who lack health insurance. The objective of this study is to better understand the indirect effects of lack of insurance on individuals’ overall financial well-being.

Title: How Do Rising Healthcare Costs Affect Worker Compensation?
Grantee Institution: Johns Hopkins University (Bloomberg School of Public Health)
Principal Investigator: Bradley Herring, Ph.D.
Grant Period: November 01, 2007 - October 31, 2008
Email: bherring@jhsph.org
Awarded: $54,750.00

The researchers will measure the extent to which increases in health insurance premiums are borne by workers in the form of lower wages relative to the extent to which they are borne by employers in the form of lower profits. They will also examine whether there are significant differences in this relationship between small and large firms and between low and high income workers. Finally, they will examine the extent to which any wage offsets vary by the expected health care costs across groups of workers with different characteristics, such as age, gender, health status, and family size. The objective of the study is to better understand where the burden of rising health care costs falls, so as to develop appropriate policy incentives.

Title: Health Savings Accounts, High Deductible Policies, and the Uninsured: Simulating the Effects of HSA Tax Policy
Grantee Institution: Brigham Young University
Principal Investigator: James Cardon, Ph.D.
Grant Period: November 01, 2007 - December 31, 2008
Email: cardon@byu.edu
Awarded: $116,606.00

The researchers will explore how Health Savings Accounts (HSA) and various tax-based health insurance proposals impact the uninsured population. They also will simulate how tax deduction and credit policies for non-group insurance affect the employment-based group market. Through an innovative approach, the model will consider employer choice and individual preferences in the face of the risk of uncertain medical expenditures. The behavior of three important consumer groups will be examined: (1) the currently uninsured who do not have access to group coverage; (2) the currently uninsured who have access to group coverage but choose to be uninsured; and (3) the currently insured group in group coverage. The researchers will model a variety of policy changes and assess the value to each consumer group and the likelihood of changing from the status quo. The objective of this project is to inform policymakers about the impact of HSAs and various tax-based health insurance proposals on the uninsured and group market.

Title: Identifying Best Practices in the Coordination of Care
Grantee Institution: Center for Studying Health System Change
Principal Investigator: Ann S. O'Malley, M.D., M.P.H.
Grant Period: October 01, 2007 - September 30, 2008
Email: aomalley@hschange.org
Awarded: $99,445.00

The researchers will examine how care is coordinated in ambulatory care settings. Specifically, they will identify and document “best practices” in physician offices that have developed care coordination processes and determine the financial implications of increased coordination. For example, the researchers will assess whether a periodic care coordination fee or itemized billing for coordination activities is more efficient. They will also examine a group of “average practices” to assess how they set priorities for coordination activities and what barriers they encounter. The objective of the proposed project is to better inform the replication of organized care coordination processes in medical practices.

Title: Effects of Prior Authorization of New Medications among Medicaid Beneficiaries with Bipolar Disorder
Grantee Institution: Harvard Pilgrim Health Care Inc.
Principal Investigator: Stephen B. Soumerai, Sc.D.
Grant Period: October 01, 2007 - March 31, 2009
Email: ssoumerai@hms.harvard.edu
Awarded: $231,641.00

The researchers will evaluate the effects of prior authorization of new medications among Medicaid beneficiaries with bipolar disorder in the state of Maine. As part of their study, they will: (1) describe baseline demographic and clinical characteristic and patterns of treatment; (2) examine the impact of prior authorization on utilization and expenditures of preferred versus non-preferred atypical antipsychotic (AA) agents and anticonvulsant (AC) agents among patients continuously enrolled for the entire study period in Maine and New Hampshire (comparison state); and (3) examine the impact of prior authorization on rates of hospital admission and rates of cessation of all medical treatment, two potential adverse outcomes. The objective of the project is to examine the effect of prior authorization, an increasingly popular drug utilization management policy for patients with chronic mental illness, on medication use and associated outcomes.

Title: Paying Physician Group Practices for Quality: A Regional Natural Experiment
Grantee Institution: University of Washington School of Public Health and Community Medicine
Principal Investigator: Douglas A. Conrad, Ph.D.
Grant Period: October 01, 2007 - March 31, 2009
Email: dconrad@u.washington.edu
Awarded: $328,829.00

The researchers will evaluate the impact of a quality-based scorecard and financial incentives developed by Premera Blue Cross in Washington State. They will compare clinics exposed to two waves of a progressive “paying for quality” intervention with a control group of clinics not subject to the intervention. Specifically, the researchers will assess the joint effects of quality-based financial incentives and the quality scorecard on physicians’ clinical quality, patient satisfaction, and efficiency in caring for patients. They will distinguish the effects on quality, patient satisfaction, and efficiency of providing information to medical groups relative to their performance on an array of clinical quality measures from the incremental effect on quality and efficiency of clinical quality-based financial incentives. The objective of the project is to assist organizational leaders and public policymakers to craft more cost-effective quality incentives.

Title: Medical Spending and Health of the Elderly
Grantee Institution: George Mason University
Principal Investigator: Jack Hadley, Ph.D.
Grant Period: October 01, 2007 - June 30, 2009
Email: jhadley1@gmu.edu
Awarded: $416,888.00

The researchers will assess the marginal contribution of increased medical spending on health status. Specifically, they will explore whether: (1) Elderly people who spend more on medical care have better health outcomes than people who spend less; (2) The marginal effect of medical care spending on health varies across subpopulations of the elderly, stratified by demographic characteristics; and (3) whether Medical spending has an effect on health at the margin. The project will build upon prior research, which examined whether Medicare beneficiaries who live in geographic areas with higher average spending have better health outcomes, but did not address the impact on individuals. The objective of this project is to help guide policymakers’ decisions about policy options to reduce health care spending.

Title: Financing American Indian Health Care: Impacts and Options for Improving Access and Quality of Care
Grantee Institution: Sanford Research/University of South Dakota
Principal Investigator: Kathryn Langwell
Grant Period: September 01, 2007 - August 31, 2008
Email: kathrynlangwell@bhsu.edu
Awarded: $138,427.00

The researchers will examine health care access and quality of care for American Indians who receive care through the Indian Health Service (IHS). In particular, they will: 1) determine the resources (national and regional per capita spending) available for health care for this population from 2000 to 2005; 2) assess service priorities and the mechanisms for explicit and implicit rationing of care; 3) analyze the impact of priorities and rationing mechanisms on access to care, availability of services, quality, and outcomes; and 4) develop options for improving access and quality for American Indian heath care and analyze the feasibility and costs of these options. The objective of the project is to contribute to the understanding of the impact of current financing and organization of the Indian Health Service on access and quality and the contribution of these factors to the health disparities experienced by this population.

Title: Reimbursement Policy and Cancer Chemotherapy Treatment and Outcomes
Grantee Institution: Harvard Medical School
Principal Investigator: Joseph P. Newhouse, Ph.D.
Grant Period: August 01, 2007 - July 31, 2009
Email: newhouse@hcp.med.harvard.edu
Awarded: $398,283.00

The researchers will examine the impact of MMA-mandated changes in Medicare payment rates for chemotherapy drugs. Specifically, they will estimate the effect of the significant payment reduction on incentives to prescribe chemotherapy, the probability of using chemotherapy, and the choice of chemotherapy agents administered to newly diagnosed cancer patients. Some hypothesize that the reduction in payment rates will cause physicians to be reluctant to accept Medicare patients, while others argue that since Medicare is such an important source of physician income, the rate reduction could lead to physician-induced demand. If the researchers find an effect of MMA on either utilization or drug choice, they will conduct a follow-up study of the impact of the MMA on patient health outcomes. The objective of the study is to assess whether the MMA, by altering financial incentives, affects chemotherapy utilization and/or the choice of drugs used.

Title: Examining the Impact of Informational Messages on Seniors' Choice of Medicare Drug Plans
Grantee Institution: Princeton University
Principal Investigator: Eldar Shafir, Ph.D.
Grant Period: August 01, 2007 - July 31, 2008
Email: shafir@princeton.edu
Awarded: $99,961.00

The applicants will examine how well people choose from among the large set of alternatives in the Part D plan and evaluate whether psychologically attuned interventions can help improve those choices. Specifically, they will evaluate people’s actual choice of plan in light of the medications they use and then experimentally increase the availability of or access to cost information. They will encourage clients to explicitly consider their personal preferences (such as their attitude toward the use of generic medications or mail order prescription drug services) to see how the availability of such considerations might influence chosen plan quality and beneficiary satisfaction with the chosen plan. The objective of this study is to inform policies surrounding Part D and other policies relying on consumer choice in complicated environments.

Title: The Impact of Assisted Living Growth on the Market for Nursing Home Care
Grantee Institution: Harvard Medical School
Principal Investigator: David Grabowski, Ph.D.
Grant Period: June 01, 2007 - May 31, 2009
Email: grabowski@med.harvard.edu
Awarded: $281,784.00

How is the growth in assisted living linked with decreased occupancy rates, increased resident acuity, and increased resident reliance on Medicaid in nursing homes? In particular, they will: 1) document the growth of the assisted living sector over time; 2) isolate the effect of assisted living growth on nursing home utilization; 3) examine the relationship between assisted living growth and nursing home payer mix; 4) estimate the effect of assisted living growth on nursing home resident acuity; and 5) assess whether the growth in assisted living has implications for nursing home quality. They will also establish a national assisted living database to facilitate empirical work to isolate the effect of assisted living growth on the nursing home market. The objective of the project is to better inform policymakers as they address the best incentives for meeting the nation’s growing long term care needs, at reasonable cost, in a dynamic market.

Title: Evaluating Cost Efficiency of Specialist Physicians
Grantee Institution: University of Southern Maine
Principal Investigator: J. William Thomas, Ph.D.
Grant Period: April 01, 2007 - March 31, 2009
Email: jwthomas@usm.maine.edu
Awarded: $376,366.00

The researchers will analyze alternative strategies for measuring specialist physician cost efficiency. Accurate measures of physician cost efficiency allow consumers to make more informed decisions, while helping health plans make better choices about which physicians to include in their networks. Specifically, the researchers will explore the: (1) feasibility of using multi-plan claims databases for cost efficiency measurement; (2) need for risk adjusting episode expected costs to account for patients' comorbidities; (3) methodology for dealing with cost outlier episodes; (4) methodology for attributing responsibility for individual episodes to individual physicians; (5) minimum episode sample sizes required for cost efficiency measurement; (6) methodology for case-mix standardization; (7) influence and availability of pharmaceutical claims on cost efficiency measurement; and (8) suitability of ratio of observed to expected cost as a cost efficiency metric. The objective of the study is to develop standard methods for measuring the cost efficiency of specialist physicians, providing a broad range of stakeholders with reliable means for developing physician networks, assigning tiers, and implementing better public reporting.

Title: Physicians' Responses to Variations in Medicare Fees for Specific Services
Grantee Institution: Center for Studying Health System Change
Principal Investigator: James D. Reschovsky, Ph.D.
Grant Period: March 01, 2007 - June 30, 2008
Email: jreschovsky@hschange.org
Awarded: $246,076.00

The researchers will examine how physicians’ provision of specific medical services to Medicare FFS beneficiaries responds to variations in Medicare physician fees for those services, physicians’ characteristics, and to local market factors. The study will test whether the quantities of specific services physicians provide to their Medicare fee-for-services patients are:1) positively related to the Medicare fee for each service; 2) inversely related to the fees paid by private insurance and to the level of demand from non-Medicare patients; and 3)positively related to indicators of physicians’ incentives to “induce demand.” Potential outcomes include: 1) indicating the percentage change in service volume for a particular fee change; 2) estimating how service volumes vary with local market conditions; 3) characterizing physician opportunities and underlying incentives to induce demand; and 4) identifying services for which service-specific fee adjustments might be an effective tool to constrain unnecessary use. This project expands upon a previous study by the applicants that investigated overall provision of total Medicare services by physicians. The objective of the project is to fill a gap in past and current physician payment research by assessing if changing relative prices of specific services will contribute to meeting the broad policy goals of discouraging the provision of services that unnecessarily add to cost growth without improving quality or outcomes.

Title: Examining the Quality of Hospital Care and Simulating the Impact of Several Pay-for-Performance Scoring Methods on Hospital Rankings
Grantee Institution: Massachusetts General Hospital Institute for Health Policy
Principal Investigator: Joel S. Weissman, Ph.D./Lisa I. Iezzoni, M.D.
Grant Period: March 01, 2007 - August 31, 2008
Email: liezzoni@partners.org
Awarded: $175,981.00

The researchers will examine the quality of hospital care. Using patient-level data from a large sample of hospitals collected by the Hospital Quality Alliance (HQA), they will estimate the proportion of patients receiving recommended care, create new measures of patient care quality, and simulate the impact of several pay-for-performance (P4P) scoring methods on hospital rankings. They will also examine the extent to which care varies by race, ethnicity, or insurance status within and across hospitals. The objective of the study is to assist CMS, other public and private payers, and accrediting organizations in developing strategies to improve hospital performance measurement and payment methods, and, ultimately, the quality of patient care.

Title: Study of the Effects of High-Deductible Health Plans on Families with Chronic Conditions
Grantee Institution: Harvard Pilgrim Health Care, Inc.
Principal Investigator: Alison Galbraith, M.D.
Grant Period: February 01, 2007 - July 31, 2009
Email: alison_galbraith@harvardpilgrim.org
Awarded: $403,958.00

This project will analyze the impact of high-deductible health plans on families who do not have a choice in health plans. The researchers will examine the effect of high deductibles on family health care decision making strategies, unmet health care needs, and the financial burden for families relative to that of traditional plans. They will also explore whether one family member’s health or resource use influences that of other family members, particularly when one member has a chronic condition. The objective of the project is to inform policymakers about the potential advantages and disadvantages of high-deductible plans for families dealing with chronic conditions, especially when they have no choice in health plans.

Title: Impact of MMA Part D on Medicare Residents in Nursing Homes
Grantee Institution: University of Massachusetts Medical School
Principal Investigator: Becky Briesacher, Ph.D.
Grant Period: January 01, 2007 - June 30, 2008
Email: becky.briesacher@umassmed.edu
Awarded: $221,483.00

The applicants will evaluate the impact of the transfer of prescription drug coverage for dual-eligibles (Medicare and Medicaid) living in nursing homes from Medicaid to Medicare Part D, as required by the MMA. In particular, they will: 1) measure the rates of enrollment into Medicare Part D for nursing home residents from 2005 to 2007; 2) assess the impact of Medicare Part D on overall prescription drug utilization patterns; 3) identify the major drug classes most affected by the program, including an examination of benzodiazepines and their exclusion from Part D coverage; and 4) determine the impact of Medicare Part D on overall rates of hospitalizations and falls, as indicators of quality care. The objective of the project is to better inform state and federal policymakers about the impact of Medicare Part D on drug utilization, as well as quality (measured by hospitalizations and falls).

Title: Examining Effective Strategies that Local Communities Have Used to Meet Expanded Public Health Workforce Needs
Grantee Institution: Center for Studying Health System Change
Principal Investigator: Robert Hurley, Ph.D.
Grant Period: January 01, 2007 - June 30, 2008
Email: rhurley@hschange.org
Awarded: $56,652.00

The researchers will examine local communities’ effective strategies for meeting expanding public health workforce needs. They plan to study six of the twelve Community Tracking Study (CTS) communities that have faced particularly unique and/or challenging situations. They will also conduct interviews with key public health stakeholders, covering topics such as key local factors that have an impact on the public health workforce, current public health workforce needs and areas of severe shortages, current recruitment and retention challenges and strategies to overcome them, and resource and other needs that might facilitate recruitment and retention. The objective of this project is to better understand how local agencies are dealing with the public health workforce shortages identified in the 2005 CTS site visits.

Title: Incorporating Disparities into State Strategies to Monitor and Improve Health Status
Grantee Institution: Mathematica Policy Research Inc.
Principal Investigator: Marsha Gold, Sc.D.
Grant Period: January 01, 2007 - March 31, 2008
Email: mgold@mathematica-mpr.com
Awarded: $199,135.00

The researchers will examine state capacity to develop the 10 leading indicators defined in Healthy People 2010 overall and by geographic group. In particular, they will study: 1) the strengths and weaknesses of data available within states to adequately assess the health of a population that includes diverse groups; and 2) the organizational, political, and other forces that promote or impede use of such data to intervene in ways that improve the health of the state’s population. The three part study includes: 1) an inventory of state practices with respect to available data on leading indicators; 2) case studies of four states to learn about how the indicators and disparities in the indicators across subgroups are viewed in developing initiatives to improve public health; and 3) a dissemination plan for translating information in ways that would be useful to diverse audiences. The objective of this project is to further the vision articulated in HealthyPeople 2010, setting health goals that explicitly link overall improvements in public health to reduced disparities in health status across diverse subgroups of the population.

Title: Local Community Strategies to Develop their Public Health Surge Capacity to Handle Emergencies Affecting Many People
Grantee Institution: Center for Studying Health System Change
Principal Investigator: Laurie Felland
Grant Period: January 01, 2007 - June 30, 2008
Email: lfelland@hschange.org
Awarded: $67,173.00

The researchers will examine local community strategies to develop their public health surge capacity. They note that following Hurricane Katrina, public health agencies recognize and urgent need to ensure that they can meet increased demand in times of high need. The researchers plan to build on the Community Tracking Study site visits, conducting more focused, in-depth case studies on the surge capacity in six selected communities. The objective of the study is to identify key strategies that selected communities have used to develop surge capacity, pinpointing lessons that can be drawn from each community’s experience.

Title: Comparison of Public Health Organizational Structures Using Dynamic Network Analysis
Grantee Institution: Columbia University
Principal Investigator: Jacqueline Merrill, D.N.Sc.
Grant Period: January 01, 2007 - December 31, 2008
Email: jacqueline.merrill@dbmi.columbia.edu
Awarded: $209,952.00

The researchers will examine how intra-organizational public health networks are linked to process and outcomes. Using dynamic organizational analysis, they would study several agency networks. They will determine baselines for public health organizational networks, identify common elements, and relate common elements identified to performance. The researchers will also compare the public health networks to similar networks in the private sector, allowing their findings to be interpreted in that context and theory. The objective of this project is to provide public health managers with better understanding of the dynamics and impact of intra-organization networks, so that they can better plan for and justify allocating limited resources.

Title: Assessment of Training Needs for Public Health Financial Managers
Grantee Institution: University of Kentucky
Principal Investigator: Julia Costich, Ph.D., J.D.
Grant Period: January 01, 2007 - June 30, 2008
Email: jfcost0@uky.edu
Awarded: $124,970.00

The researchers will examine competencies of financial managers in state and local public health departments. A national sample of public health finance officers, and the senior public health officials to whom they report, will be surveyed. The survey will gather information on their self-assessment of current knowledge and performance in relation to public health finance competencies, as well as their preference for educational formats. Using newly issued competencies in public health financial management as benchmarks, the researchers would identify areas of need, mechanisms for delivering training, and potential funding sources. The objective of this project is to identify professional development needs for financial officers in state and local public health agencies.

Title: Understanding and Assessing Partnership Connections in Public Health Departments
Grantee Institution: RAND Corporation
Principal Investigator: Danielle Vogenbeck, Ph.D.
Grant Period: January 01, 2007 - June 30, 2008
Email: vogen@rand.org
Awarded: $195,991.00

The researchers will examine partnerships, designed to leverage limited resources and fulfill common missions, among state and local public health agencies and other organizations, agencies, and groups. In particular, they intend to: 1) define what good connectivity means in a public health partnership; 2) quantify good connectivity as percentile score measured against a standard; and 3) develop a tool to measure connectivity and document the analytic process through which the tool produces a connectivity score. The objective of this project is to develop a tool to allow public health partners to measure their multi-agency collaborations in order to strengthen them.

Title: Public Health Funding and Population Health
Grantee Institution: University of Washington
Principal Investigator: David E. Grembowski, Ph.D.
Grant Period: January 01, 2007 - June 30, 2008
Email: grem@u.washington.edu
Awarded: $161,789.00

The researchers will examine the relationship between local health department expenditures and county-level disparities in mortality and infant mortality rates for Black and White racial/ethnic groups. They will also estimate whether changes in expenditures are associated with changes in those rates over time. The objective of this project is to inform the debate about the level of resources that should be allocated to public health systems rather than to medical care or other determinants of population health.

Title: Public Health System Organization and Performance in Rural Communities
Grantee Institution: University of Minnesota
Principal Investigator: Douglas R. Wholey, Ph.D.
Grant Period: January 01, 2007 - June 30, 2008
Email: whole001@umn.edu
Awarded: $199,070.00

The researchers will examine public health system organization and public health performance in eight rural communities through a comparative case study. Their focus is particularly on rural communities, since the scarcity of resources there increases the importance of integrating public and private resources optimally. In particular, they will: 1) describe the organization of key essential services networks within each rural community; 2) describe the structures and processes that integrate activities across the essential services networks; and 3) compare public health system performance. The objective of this project is to illuminate the relationship between local public health systems and public health outcomes.

Title: An Academic Health Center and Public Health Practice Collaboration: Disseminating Continuous Quality Improvement Capability to Local and State Public Health Agencies
Grantee Institution: University of Minnesota
Principal Investigator: William J. Riley, Ph.D.
Grant Period: January 01, 2007 - December 31, 2008
Email: riley001@umn.edu
Awarded: $200,002.00

The researchers will develop a pilot program to expand the use of continuous quality improvement (CQI) principles to public health agencies, with a focus on reducing health disparities. They intend to implement CQI through collaboration among the School of Public Health at the University of Minnesota and local and state public health agencies. They will create a coordinated academic curriculum in CQI, preparing personnel to lead CQI efforts, and they would implement CQI capabilities into eight separate public health agency projects. The objective of this project is to demonstrate that CQI can be used in public health organizations to improve performance of core processes.

Title: Changes in Drug Utilization for Seniors without Prior Prescription Drug Insurance
Grantee Institution: Brigham & Women's Hospital, Inc.
Principal Investigator: Sebastian Schneeweiss, M.D., Sc.D.
Grant Period: November 01, 2006 - October 31, 2007
Email: schneeweiss@post.harvard.edu
Awarded: $100,000.00

As of June 2006, 22.5 million seniors had enrolled in a Medicare Part D prescription drug plan (citation omitted). While surveys of Medicare Part D enrollees have been conducted, no study to date has evaluated the effects of enrollment in Medicare Part D on actual drug use and out-of-pocket spending by subjects who were previously without drug insurance (citation omitted). This study sought to assess the effect of Medicare Part D on the utilization of selected essential drugs among seniors previously lacking drug benefits using data from three large pharmacy chains. The researchers’ analysis of this large-scale natural experiment showed that the implementation of the Medicare Part D benefit was associated with a substantial reduction in out-of-pocket spending for prescription drugs, and a meaningful increase in use of selected essential medications, including statins, clopidogrel, and warfarin, in patients who opted to enroll in Medicare Part D plan in 2006. Relative to the projected 2005 trends, warfarin, clopidogrel, and statin use in 2006, measured in daily doses dispensed, increased by 5 percent, 18 percent, and 28 percent. Proton-pump inhibitors (PPIs), a medication class that is frequently overused, experienced the steepest increase in use (58 percent) with the introduction on Medicare Part D which could potentially reflect patients switching from over-the-counter PPIs to prescription PPIs (citation omitted). There was a rapid uptake of newly marketed generic medications by the Part D plans such as generic statins and clopidogrel. The benefit was not evenly distributed throughout the year. Among the 11 percent of patients who reached the coverage gap, utilization of clopidogrel, warfarin, and statins decreased at roughly 5 percentage points per month relative to the baseline trend. Consequently, overall utilization of statins and clopidogrel, drugs with proven effectiveness in reducing severe morbidity, declined to a volume almost as low as without Part D coverage. In conclusion, the first year of Medicare Part D was a mixed blessing for elderly patients without prior drug benefits. To the credit of the benefit, patients who enrolled were more likely to use essential medications, including clopidogrel, statins, and warfarin that are likely to result in better health outcomes. However, a sizable proportion of sicker patients reached the coverage gap in the first year and experienced a sharp drop in the use of the same drugs, which may result in worse health outcomes. Additionally, while the data suggest that private drug plans stimulate greater generic drug use, there is also evidence that coverage within these plans may not adequately distinguish between under-used essential medications and over-used medications. If the goal of the Part D benefit is to provide access to highly effective prescription drugs to seniors most efficiently, efforts to close the coverage gap, coupled with formulary designs that better differentiate between the value and effectiveness of covered medications, may assist in optimizing coverage and the health of our seniors.

Title: Defensive Medicine as a Response to Medical Malpractice Liability in the United States
Grantee Institution: University of Southern Maine
Principal Investigator: J. William Thomas, Ph.D.
Grant Period: September 01, 2006 - February 29, 2008
Email: jwthomas@usm.main.edu
Awarded: $247,111.00

What is the extent and costs of defensive medicine across the entire spectrum of medical care provided in the United States. In this first phase of the project, they will build databases supporting analysis of defensive medicine costs. In anticipated follow-on analyses, the researchers will use medical and pharmaceutical claims data from CIGNA Healthcare to identify those clinical conditions in which defensive medicine exists, estimate the frequency and costs of defensive medicine in those conditions, and identify the sources of defensive medicine (e.g., type of tests, procedures, and medications) in those conditions. The researchers will also analyze the relationship between the cost of episodes of care and “tort signals,” which include medical malpractice insurance premiums and frequency of malpractice claims. The objective of the study is to develop a data set permitting more accurate estimation of defensive medicine costs.