Grantee Publication

Public acceptance of a role for policy in reducing the use of low value care in the United States is tenuous but increasing with growing awareness of the burden that health care spending places on federal and state budgets and with patients’ increasing exposure to health care costs. In recent years, the American Board of Internal Medicine Foundation’s Choosing Wisely program, the U.S. Preventive Services Task Force, and the National Quality Forum have advanced the dialogue about low-value care by identifying services that deserve that label.

In February 2013, the American College of Rheumatology identified measuring bone density more often than once every 2 years as low-value care. This position was published as part of the American Board of Internal Medicine Foundation’s “Choosing Wisely” campaign. Drawing on HCFO-funded work, this article measured the prevalence and described the geographic variation of short-interval (repeated in under 2 years) dual-energy X-ray absorptiometry tests (DXAs) among Medicare beneficiaries and estimated the cost of this testing and its responsiveness to payment change.

In 2011, the American Board of Internal Medicine Foundation created the Choosing Wisely initiative, which encourages physicians to be responsible stewards of finite healthcare resources. Drawing on HCFO-funded work, this article estimates the proportion of low-risk Medicare beneficiaries receiving non-invasive cardiac screening tests without a clear, pertinent symptomatic indication, as well as the regional variation in and spending associated with these tests.

Drawing on HCFO-funded work, this article evaluates the impact of hospital value-based purchasing (HVBP) on clinical quality and patient experiences during its initial implementation period (July 2011-March 2012).  The researchers use hospital-level clinical quality and patient experience data from Hospital Compare to conduct their analysis. Acute care hospitals were exposed to HVBP by mandate while critical access hospitals and hospitals located in Maryland were not exposed.

The Medicare program has implemented pay-for-performance (P4P), or Value-Based Purchasing, for inpatient care and for Medicare Advantage plans, and plans to implement a program for physicians in 2015. Drawing on HCFO- and other funded work, this article reviews evidence on the effectiveness of P4P and identifies design criteria deemed to be best practice in P4P. The researchers then assess the extent to which Medicare's existing and planned Value-Based Purchasing programs align with these best practices.

Even as the number of children with health insurance has increased, coverage transitions—movement into and out of coverage and between public and private insurance— have become more common. Drawing on HCFO-funded work, this article examines whether insurance instability has implications for access to primary care. Because unobserved factors related to parental behavior and child health may affect both the stability of coverage and utilization, the researchers estimate the relationship between insurance and the probability that a child has at least one physician visit per year.

The Accountable Care Organization (ACO) concept proposed by the Affordable Care Act legislation is based on models developed by Integrated Delivery Systems (IDS). It is widely believed that these organizations reduce costs and improve quality of care through better integration and coordination of services. This article attempts to shed light on this issue by analyzing the costs and quality of care provided by 52 medical group practices in a large upper Midwest community.

In a tiered network, health insurers sort providers into tiers based on cost and quality performance, and patients have a financial incentive (they pay lower cost-sharing) to see a provider in a higher performing tier. Cost-efficiency is typically gauged using episode-level costs and utilization, while quality is judged through claims-based process measures, external certification, and, in some cases, use of health information technology.

Historically, low Medicaid reimbursement rates have limited the willingness of health care providers to accept Medicaid patients, leading to access problems in many communities. This problem has been especially acute in the case of dental care. We combine data from several sources to examine the effect of payment rates on access to dental care among children on Medicaid and on dentists’ participation in the program.

Although health care is one of the largest industries in the United States, 73% of US residents who are ill have difficulty obtaining nonemergency care on nights, weekends, and holidays. Commercial e-visit websites—companies without bricks-and-mortar clinics that use the Internet to connect patients to clinicians whom they never meet in person—may address the need for accessible, convenient care. This Viewpoint explores some of the potential benefits associated with e-visits, including flexible hours, a decrease in emergency room visits, and increased availability of doctors.