The Synthesis project. Research synthesis report最新文献

As a result of the Patient Protection and Affordable Care Act, more than 30 million people are expected to be newly insured, many of whom will be seeking a source for primary care. At the same time, media reports and some studies are proclaiming a current or imminent shortage of primary care providers. This Synthesis examines the evidence on the primary care workforce including: the supply and distribution of the workforce; the historical and projected demand on the primary care workforce; the effects of payment policies and scope of practice laws on the workforce; and how the primary care workforce is evolving.

Although the malpractice crisis--the inability of health care providers to obtain affordable liability insurance--has abated in many states, medical liability costs and pressures remain a concern. In addition, the perceived threat of litigation spurs "defensive medicine"--the practice of ordering services primarily to reduce the physician's liability exposure rather than because they are medically necessary. There is wide consensus that liability pressure undermines efforts to curb overuse of health services, although there is disagreement about the magnitude of its effect. This Update reviews the evidence on the effects of medical malpractice reforms published since the Medical Malpractice: Impact of the Crisis and Effects of State Tort Reforms synthesis was released in 2006. Key findings include: Except for caps on noneconomic damages, there is little evidence that other traditional tort reforms affect medical liability costs or defensive medicine. Average awards are reduced by 20 percent to 30 percent, and premiums in states with caps on noneconomic damages rise 6 percent to 13 percent more slowly than premiums in states without caps. There is evidence that tort reforms-particularly caps on noneconomic damages-reduce health spending, but the size of the reduction is subject to debate. Because of the lack of success of many traditional tort reforms, a number of innovated tort reforms are receiving increased attention. Although they show promise in theory, they have not been widely evaluated so the evidence of their effectiveness is weak.

As health reform drives the largest expansion of health insurance since Medicare and policy-makers grapple with how to slow the increase in health care spending, cost-sharing--the division of health care costs between patients and insurers--is considered an important tool. This synthesis reviews the evidence on cost-sharing. Key findings include: Research consistently shows demand for health care is price sensitive, but it is unlikely cost-sharing will significantly slow the growth of health care spending. Almost 50 percent of costs are associated with the 5 percent of the population facing serious medical conditions. Studies show these patients rely on their doctors to guide treatment decisions. Increased cost-sharing may shift the financial burden from insurers and public payers to patients. Patients are not able to discern between appropriate and inappropriate care in response to increased cost-sharing. For the average person, increased cost-sharing may not adversely affect their health, but for vulnerable populations, increased cost-sharing is associated with adverse health outcomes. Low-income populations are disproportionately affected by increased cost-sharing. People in poor health respond differently to cost-sharing changes than healthy people. Finally, cost-sharing is not well-targeted on low-value services making it difficult for patients to make appropriate decisions.

Patients with complex health care needs account for a high percentage of annual medical expenditures. Care management is a set of activities intended to improve patient care and reduce the need for medical services by helping patients and caregivers more effectively manage health conditions. This synthesis reviews the evidence on care management and its ability to improve patient care and reduce costs. Key findings include: care management can improve quality of care, although it takes time; studies that followed patients longer were more likely to reveal improvements. Care management's impact on cost reduction is less consistent. Programs that support patient transitions from hospital-to-home were the most successful because they reduced hospital readmissions. Care management within primary care settings may also generate savings. Elements of effective programs include: good identification of patients who could benefit from care management; specially-trained RN/care managers with low patient loads, working with physicians and a multidisciplinary team; and in-person patient contact. Finally, the current fee-for-service systems present barriers to widespread use of care management.

It is well established that preventive care reduces the prevalence of disease and helps people live longer, healthier lives. Analysis of the cost-effectiveness of preventive care can guide policy-makers to allocate scarce resources. This synthesis reviews the evidence on the cost-effectiveness of clinical preventive care. Key findings include: although many preventive services are a good value (defined as costing less than $50,000 to $100,000 per Quality Adjusted Life Year), only a few, such as childhood immunizations and counseling adults on the use of low-dose aspirin are widely regarded as cost-saving. Costs to reduce risk factors, screening costs, and the cost of treatment when disease is found can offset any savings from preventive care. Prevention can reduce the incidence of disease, but savings may be partially offset by health care costs associated with increased longevity. Whether these additional competing risk costs outweigh the savings from avoiding the targeted disease depends on how healthy people are during the added life years. Given that so few preventive services save money and that these services are already in wide use, it is unlikely that prevention can reduce health care spending. The authors question whether the emphasis on savings is appropriate and suggest it is better to focus on high value preventive care, taking into account increased longevity and quality of life.

Tax subsides for employer-sponsored health insurance are the largest subsidy for private health insurance and support key mechanisms of the U.S. insurance system, but they overwhelmingly benefit high-wage employees. When employers purchase or provide insurance for their employees, their contributions to the premium are excluded from income and payroll taxes. This tax exclusion provided more than $100 billion in income and payroll tax subsidies in 2002. High-income workers benefit more from these subsidies than those with lower incomes because of their higher marginal tax rate. Applying the tax exclusion in their respective tax brackets means high-income families (those earning more than $200,000) receive a subsidy worth one-third of the premium, while the lowest income families receive a subsidy worth just 10 percent. Despite these issues, ESI is a successful mechanism in many ways, covering a significant majority of Americans and providing a good pooling mechanism.

Americans rely on emergency departments (EDs) to play a critical role in the health care safety net. But while the number of ED visits climbed significantly, the number of EDs dropped from 5,000 to 4,000 from 1991 to 2006. This synthesis examines the evidence on who uses EDs, the causes and consequences of overcrowding, and the cost of providing care in the ED. Key findings include: privately insured patients account for the largest and fastest growing segment of ED users. Low income and poor health are strong predictors on ED use. After adjusting for health status and other demographic and market factors, the uninsured use the ED at the same rate as the privately insured, while patients with Medicaid/SCHIP or Medicare had much higher utilization rates. The use of EDs for non-urgent, preventable conditions is growing due to limited access to primary care providers, although the identification of these conditions is imprecise. Patient boarding, or the inability to move patients from the ED to the appropriate inpatient unit, and a shortage of on-call specialists are major causes of ED overcrowding. The true cost of providing care in the ED is complex and not well understood. Finally, expansion of health insurance coverage is likely to increase rather than decrease stress on overcrowded EDs because the insured represent the fastest growing subpopulation of ED users.

The U.S. is spending a growing share of the GDP on health care, outpacing other industrialized countries. This synthesis examines why costs are higher in the U.S. and what is driving their growth. Key findings include: health care inefficiency, medical technology and health status (particularly obesity) are the primary drivers of rising U.S. health care costs. Health payer systems that reward inefficiencies and preempt competition have impeded productivity gains in the health care sector. The best evidence indicates medical technology accounts for one-half to two-thirds of spending growth. While medical malpractice insurance and defensive medicine contribute to health costs, they are not large enough factors to significantly contribute to a rise in spending. Research is consistent that demographics will not be a significant factor in driving spending despite the aging baby boomers.

Physician self-referral ranges from suggesting a follow-up appointment, to sending a patient to a facility in which the doctor has an ownership interest or financial relationship. Physician referral to facilities in which the physicians have an ownership interest is becoming increasingly common and not always medically appropriate. This Synthesis reviews the evidence on physician self-referral arrangements, their effect on costs and utilization, and their effect on general hospitals. Key findings include: the rise in self-referral is sparked by financial, regulatory and clinical incentives, including patient convenience and doctors trying to preserve their income in the changing health care landscape. Strong evidence suggests self-referral leads to increased usage of health care services; but there is insufficient evidence to determine whether this increased usage reflects doctors meeting an unmet need or ordering clinically inappropriate care. The more significant a physician's financial interest in a facility, the more likely the doctor is to refer patients there. Arrangements through which doctors receive fees for patient referrals to third-party centers, such as "pay-per-click," time-share, and leasing arrangements, do not seem to offer benefits beyond increasing physician income. So far, the profit margins of general hospitals have not been harmed by the rise in doctor-owned facilities.