John Hsu

Harvard Medical School, Boston, Massachusetts, United States

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Publications (76)352.94 Total impact

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    ABSTRACT: IMPORTANCE The Patient Protection and Affordable Care Act (ACA) includes subsidies that reduce patient cost sharing for low-income families. Limited information on the effects of cost sharing among children is available to guide these efforts. OBJECTIVE To examine the associations between cost sharing, income, and care seeking and financial stress among children with asthma. DESIGN, SETTING, AND PARTICIPANTS A telephone survey in 2012 about experiences during the prior year within an integrated health care delivery system. Respondents included 769 parents of children aged 4 to 11 years with asthma. Of these, 25.9% of children received public subsidies; 21.7% were commercially insured with household incomes at or below 250% of the federal poverty level (FPL) and 18.2% had higher cost-sharing levels for all services (eg, ≥$75 for emergency department visits). We classified children with asthma based on (1) current receipt of a subsidy (ie, Medicaid or Children's Health Insurance Program) or potential eligibility for ACA low-income cost sharing or premium subsidies in 2014 (ie, income ≤250%, 251%-400%, or >400% of the FPL) and (2) cost-sharing levels for prescription drugs, office visits, and emergency department visits. We examined the frequency of changes in care seeking and financial stress due to asthma care costs across these groups using logistic regression, adjusted for patient/family characteristics. MAIN OUTCOMES AND MEASURES Switching to cheaper asthma drugs, using less medication than prescribed, delaying/avoiding any office or emergency department visits, and financial stress (eg, cutting back on necessities) because of the costs of asthma care. RESULTS After adjustment, parents at or below 250% of the FPL with lower vs higher cost-sharing levels were less likely to delay or avoid taking their children to a physician's office visit (3.8% vs 31.6%; odds ratio, 0.07 [95% CI, 0.01-0.39]) and the emergency department (1.2% vs 19.4%; 0.05 [0.01-0.25]) because of cost; higher-income parents and those whose children were receiving public subsidies (eg, Medicaid) were also less likely to forego their children's care than parents at or below 250% of the FPL with higher cost-sharing levels. Overall, 15.6% of parents borrowed money or cut back on necessities to pay for their children's asthma care. CONCLUSIONS AND RELEVANCE Cost-related barriers to care among children with asthma were concentrated among low-income families with higher cost-sharing levels. The ACA's low-income subsidies could reduce these barriers for many families, but millions of dependents for whom employer-sponsored family coverage is unaffordable could remain at risk for cost-related problems because of ACA subsidy eligibility rules.
    JAMA pediatrics. 05/2014;
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    Journal of Health Economics. 01/2014;
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    ABSTRACT: To examine whether primary care team cohesion changes the association between using an integrated outpatient-inpatient electronic health record (EHR) and clinician-rated care coordination across delivery sites. Self-administered surveys of primary care clinicians in a large integrated delivery system, collected in 2005 (N = 565), 2006 (N = 678), and 2008 (N = 626) during the staggered implementation of an integrated EHR (2005-2010), including validated questions on team cohesion. Using multivariable regression, we examined the combined effect of EHR use and team cohesion on three dimensions of care coordination across delivery sites: access to timely and complete information, treatment agreement, and responsibility agreement. Among clinicians working in teams with higher cohesion, EHR use was associated with significant improvements in reported access to timely and complete information (53.5 percent with EHR vs. 37.6 percent without integrated-EHR), agreement on treatment goals (64.3 percent vs. 50.6 percent), and agreement on responsibilities (63.9 percent vs. 55.2 percent, all p < .05). We found no statistically significant association between use of the integrated-EHR and reported care coordination in less cohesive teams. The association between EHR use and reported care coordination varied by level of team cohesion. EHRs may not improve care coordination in less cohesive teams.
    Health Services Research 12/2013; · 2.29 Impact Factor
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    ABSTRACT: The CMS-HCC risk adjustment system for Medicare Advantage (MA) plans calculates weights, which are effectively relative prices, for beneficiaries with different observable characteristics. To do so it uses the relative amounts spent per beneficiary with those characteristics in Traditional Medicare (TM). For multiple reasons one might expect relative amounts in MA to differ from TM, thereby making some beneficiaries more profitable to treat than others. Much of the difference comes from differences in how TM and MA treat different diseases or diagnoses. Using data on actual medical spending from two MA-HMO plans, we show that the weights calculated from MA costs do indeed differ from those calculated using TM spending. One of the two plans (Plan 1) is more typical of MA-HMO plans in that it contracts with independent community providers, while the other (Plan 2) is vertically integrated with care delivery. We calculate margins, or average revenue/average cost, for Medicare beneficiaries in the two plans who have one of 48 different combinations of medical conditions. The two plans' margins for these 48 conditions are correlated (r=0.39, p<0.01). Both plans have margins that are more positive for persons with conditions that are managed by primary care physicians and where medical management can be effective. Conversely they have lower margins for persons with conditions that tend to be treated by specialists with greater market power than primary care physicians and for acute conditions where little medical management is possible. The two plan's margins among beneficiaries with different observable characteristics vary over a range of 160 and 98 percentage points, respectively, and thus would appear to offer substantial incentive for selection by HCC. Nonetheless, we find no evidence of overrepresentation of beneficiaries in high margin HCC's in either plan. Nor, using the margins from Plan 1, the more typical plan, do we find evidence of overrepresentation of high margin HCC's in Medicare more generally. These results do not permit a conclusion on overall social efficiency, but we note that selection according to margin could be socially efficient. In addition, our findings suggest there are omitted interaction terms in the risk adjustment model that Medicare currently uses.
    Journal of Health Economics 12/2013; 32(6):1278-88. · 1.60 Impact Factor
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    ABSTRACT: The US federal government is spending billions of dollars in physician incentives to encourage the meaningful use of electronic health records (EHRs). Although the use of EHRs has potential to improve patient health outcomes, the existing evidence has been limited and inconsistent. To examine the association between implementing a commercially available outpatient EHR and emergency department (ED) visits, hospitalizations, and office visits for patients with diabetes mellitus. Staggered EHR implementation across outpatient clinics in an integrated delivery system (Kaiser Permanente Northern California) between 2005 and 2008 created an opportunity for studying changes associated with EHR use. Among a population-based sample of 169,711 patients with diabetes between 2004 and 2009, we analyzed 4,997,585 person-months before EHR implementation and 4,648,572 person-months after an EHR was being used by patients' physicians. We examined the association between EHR use and unfavorable clinical events (ED visits and hospitalizations) and office visit use among patients with diabetes, using multivariable regression with patient-level fixed-effect analyses and adjustment for trends over time. In multivariable analyses, use of the EHR was associated with a statistically significantly decreased number of ED visits, 28.80 fewer visits per 1000 patients annually (95% CI, 20.28 to 37.32), from a mean of 519.12 visits per 1000 patients annually without using the EHR to 490.32 per 1000 patients when using the EHR. The EHR was also associated with 13.10 fewer hospitalizations per 1000 patients annually (95% CI, 7.37 to 18.82), from a mean of 251.60 hospitalizations per 1000 patients annually with no EHR to 238.50 per 1000 patients annually when using the EHR. There were similar statistically significant reductions in nonelective hospitalizations (10.92 fewer per 1000 patients annually) and hospitalizations for ambulatory care-sensitive conditions (7.08 fewer per 1000 patients annually). There was no statistically significant association between EHR use and office visit rates. Among patients with diabetes, use of an outpatient EHR in an integrated delivery system was associated with modest reductions in ED visits and hospitalizations but not office visit rates. Further studies are needed to quantify the association of EHR use with changes in costs.
    JAMA The Journal of the American Medical Association 09/2013; 310(10):1060-5. · 29.98 Impact Factor
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    ABSTRACT: Background/Aims Many Medicare beneficiaries have conditions or disabilities that affect their functional status and self-care capabilities. There is limited information on the potential associations between functional limitations, home support, and self-care activities such as managing and taking medications. Methods We conducted telephone interviews in a stratified random sample of community-dwelling Medicare Advantage beneficiaries in an integrated delivery system, age 65+ years (N = 1,201; response rate = 70.0%). Participants reported their functional status as measured by activities of daily living (ADLs; e.g., bathing) and instrumental activities of daily living (IADLs; e.g., preparing meals), and whether they received any support from family members or caretakers in obtaining, paying for, or taking medications. We also examined drug cost-related changes in medication use: cost-reducing behaviors (e.g., switching to generics), cost-related non-adherence (e.g., not refilling), and financial stress (e.g., cutting back on necessities). We used multivariate logistic regression to assess associations between functional status, support with medications, and drug cost responses, adjusting for patient characteristics. Results Nearly half of respondents (42%) reported having a functional limitation: 26.7% reported 1-2; and 15.6% reported 3+. Among beneficiaries with functional limitations, 15.8% received help with their medications versus 4.8% among those without limitations (P <0.001). Overall, 17% reported a cost-reducing behavior, 3% non-adherence, and 8% financial stress due to drug costs; these behaviors were more common among beneficiaries with functional limitations. In multivariate analyses, beneficiaries with 3+ functional limitations who did not receive help with their medications had higher rates of cost-related non-adherence (OR = 6.06, 95% CI: 1.71-21.51) and financial stress (OR = 4.06, 95% CI: 1.73-9.51) than those without limitations and without help with their medications. Beneficiaries with 3+ functional limitations who received help with their medications were also more likely to experience financial stress (OR = 2.81, 95% CI: 1.13-6.98). However, there were no significant differences in the odds of general non-adherence compared with beneficiaries who did not receive help. Conclusions Beneficiaries with functional limitations frequently report receiving informal support with their medication regimens and cost-related drug use behavior changes. Among beneficiaries with multiple limitations, those receiving assistance were less likely to reduce adherence. Support with self-care activities for beneficiaries with limited functional status could improve adherence and outcomes.
    Clinical Medicine &amp Research 09/2013; 11(3):159-160.
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    ABSTRACT: Background/Aims Patient use of web portals to interact with their healthcare delivery system and healthcare providers could improve the quality and safety of care. Among patients with diabetes in a large integrated delivery system (IDS), we examined the association between patient use of the web portals and cholesterol test results. Methods The health system implemented a web-based tool for all patients who registered to use the website in November 2005, allowing members to securely access a personal health record, as well as e-mail their physicians, and view their lab results. In this study, we defined patients as web-portal users when patients emailed their physicians or viewed lab results at the first time. We examined the association of patient web-portal use and low-density lipoprotein cholesterol (LDL) level using linear regression with fixed effect at patient level, adjusting for medical center electronic health record (EHR) implementation, quarter for seasonality, and year for temporal trend. Results The 169,711 patients in the IDS diabetes registry at the start of 2004 were followed through 2009. The number of patients who had used patient web-portal increased dramatically from 16% in 2006 to 35% in 2009. During 2004-2009, a total number of 1,070,856 LDL tests were performed among the study subjects and 18% of the tests were done after patients used the web-portal. Overall patient web-portal use was associated with reduction of LDL value by 0.81 mg/dL (95% CI: 0.64-0.97). Further examination among patients stratified by their baseline LDL (last value in 2003) showed that the largest reduction in LDL was found among those with worst control: on average, LDL level dropped by 0.36 mg/dL (95% CI: 0.14-0.57) among those with baseline LDL <100 mg/dL, 0.90mg/dL (95% CI: 0.63-1.18) among those with baseline LDL 100- <130mg/dL, and 2.04 mg/dL (95% CI: 1.59-2.50) among those with baseline LDL >130 mg/dL. Conclusions Patient use of a web-based portal to review laboratory results or email their clinicians increased substantially between 2006 and 2009. Patient use of web portals was associated with improvement of LDL level, with greater improvement among patients in worse control.
    Clinical Medicine &amp Research 09/2013; 11(3):150-151.
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    ABSTRACT: Medicare Part D provides formulary protections for antipsychotics but does not exempt these drugs from cost-sharing. We investigated the impact of Part D coverage on antipsychotic drug spending, adherence, and clinical outcomes among beneficiaries with varying indications for use. METHODS:: We conducted a historical cohort study of Medicare Advantage beneficiaries who received antipsychotic drugs, with diagnoses of schizophrenia or bipolar disorder or with no mental health diagnoses (N=10,190). Half had a coverage gap; half had no gap because of low-income subsidies. Using fixed effects regression models, we examined changes in spending and adherence as beneficiaries experienced cost-sharing increases after reaching the gap. We examined changes in hospitalizations and emergency department visits using proportional hazard models. RESULTS:: Across all diagnostic groups, total monthly expenditure on antipsychotic drugs decreased with cost-sharing increases in the gap compared with those with no gap (eg, schizophrenia: -$123 95% confidence interval [-$138, -$108]), and out-of-pocket spending increased (eg, schizophrenia: $104 [$98, $110]). Adherence similarly decreased, with the largest declines among those with schizophrenia (-20.6 percentage points [-22.3, -18.9] in proportion of days covered). Among beneficiaries with schizophrenia and bipolar disorder, hospitalizations and emergency department visit rates increased with cost-sharing increases (eg, schizophrenia: hazard ratio=1.32 [1.06, 1.65] for all hospitalizations), but did not among subjects without mental health diagnoses. Clinical event rates did not change among beneficiaries with low-income subsidies without gaps. CONCLUSIONS:: There is evidence of interruptions in antipsychotic use attributable to Part D cost-sharing. Adverse events increased among beneficiaries with approved indications for use, but not among beneficiaries without such indications.
    Medical care 07/2013; 51(7):614-621. · 3.24 Impact Factor
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    ABSTRACT: OBJECTIVE: There is limited information on the protective value of Medicare Part D low-income subsidies (LIS). We compared responses to drug costs for LIS recipients with near-poor (≤200 percent of the Federal Poverty Level) and higher income beneficiaries without the LIS. DATA SOURCES/STUDY SETTING: Medicare Advantage beneficiaries in 2008. STUDY DESIGN: We examined three drug cost responses using multivariate logistic regression: cost-reducing behaviors (e.g., switching to generics), nonadherence (e.g., not refilling prescriptions), and financial stress (e.g., going without necessities). DATA COLLECTION: Telephone interviews in a stratified random sample (N = 1,201, 70 percent response rate). PRINCIPAL FINDINGS: After adjustment, a comparable percentage of unsubsidized near-poor (26 percent) and higher income beneficiaries reported cost-reducing behaviors (23 percent, p = .63); fewer LIS beneficiaries reported cost-reducing behaviors (15 percent, p = .019 vs near-poor). Unsubsidized near-poor beneficiaries were more likely to reduce adherence (8.2 percent) than higher income (3.5 percent, p = .049) and LIS beneficiaries (3.1 percent, p = .027). Near-poor beneficiaries also more frequently experienced financial stress due to drug costs (20 percent) than higher income beneficiaries (11 percent, p = .050) and LIS beneficiaries (11 percent, p = .015). CONCLUSIONS: Low-income subsidies provide protection from drug cost-related nonadherence and financial stress. Beneficiaries just above the LIS income threshold are most at risk for these potentially adverse behaviors.
    Health Services Research 05/2013; · 2.29 Impact Factor
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    ABSTRACT: Health plans participating in the Medicare managed care program, called Medicare Advantage since 2003, have historically attracted healthier enrollees than has the traditional fee-for-service program. Medicare Advantage plans have gained financially from this favorable risk selection since their payments have traditionally been adjusted only minimally for clinical characteristics of enrollees, causing overpayment for healthier enrollees and underpayment for sicker ones. As a result, a new risk-adjustment system was phased in from 2004 to 2007, and a lock-in provision instituted to limit midyear disenrollment by enrollees experiencing health declines whose exodus could benefit plans financially. To determine whether these reforms were associated with intended reductions in risk selection, we compared differences in self-reported health care use and health between Medicare Advantage and traditional Medicare beneficiaries before versus after these reforms were implemented. We similarly compared differences between those who switched into or out of Medicare Advantage and nonswitchers. Most differences in 2001-03 were substantially narrowed by 2006-07, suggesting reduced selection. Similar risk-adjustment methods may help reduce incentives for plans competing in health insurance exchanges and accountable care organizations to select patients with favorable clinical risks.
    Health Affairs 12/2012; 31(12):2630-40. · 4.64 Impact Factor
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    ABSTRACT: Within Medicare, the Medicare Advantage program has historically attracted better risks-healthier, lower-cost patients-than has traditional Medicare. The disproportionate enrollment of lower-cost patients and avoidance of higher-cost ones during the 1990s-known as favorable selection-resulted in Medicare's spending more per beneficiary who enrolled in Medicare Advantage than if the enrollee had remained in traditional Medicare. We looked at two measures that can indicate whether favorable selection is taking place-predicted spending on beneficiaries and mortality-and studied whether policies that Medicare implemented in the past decade succeeded in reducing favorable selection in Medicare Advantage. We found that these policies-an improved risk adjustment formula and a prohibition on monthly disenrollment by beneficiaries-largely succeeded. Differences in predicted spending between those switching from traditional Medicare to Medicare Advantage relative to those who remained in traditional Medicare markedly narrowed, as did adjusted mortality rates. Because insurance exchanges set up under the Affordable Care Act will employ similar policies to combat risk selection, our results give reason for optimism about managing competition among health plans.
    Health Affairs 12/2012; 31(12):2618-28. · 4.64 Impact Factor
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    ABSTRACT: Consumer-directed health plans are plans with high deductibles that typically require patients to bear no out-of-pocket costs for preventive care, such as annual physicals or screening tests, in order to ease financial barriers and encourage patients to seek such care. We surveyed people in California who had a consumer-directed health plan and found that fewer than one in five understood that their plan exempted preventive office visits, medical tests, and screenings from their deductible, meaning that this care was free or had a modest copayment. Roughly one in five said that they had delayed or avoided a preventive office visit, test, or screening because of cost. Those who were confused about the exemption were significantly more likely to report avoiding preventive visits because of cost concerns. Special efforts to educate consumers about preventive care cost-sharing exemptions may be necessary as more health plans, including Medicare, adopt this model.
    Health Affairs 12/2012; 31(12):2641-8. · 4.64 Impact Factor
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    ABSTRACT: Physicians can receive federal payments for meaningful use of complete certified electronic health records (EHRs). Evidence is limited on how EHR use affects clinical care and outcomes. To examine the association between use of a commercially available certified EHR and clinical care processes and disease control in patients with diabetes. Quasi-experimental design with outpatient EHR implementation sequentially across 17 medical centers. Multivariate analyses adjusted for patient characteristics, medical center, time trends, and facility-level clustering. Kaiser Permanente Northern California, an integrated delivery system. 169 711 patients with diabetes mellitus. Use of a commercially available certified EHR. Drug treatment intensification and hemoglobin A1c (HbA1c) and low-density lipoprotein cholesterol (LDL-C) testing and values. Use of an EHR was associated with statistically significant improvements in treatment intensification after HbA1c values of 9% or greater (odds ratio, 1.10 [95% CI, 1.05 to 1.15]) or LDL-C values of 2.6 to 3.3 mmol/L (100 to 129 mg/dL) (odds ratio, 1.06 [CI, 1.00 to 1.12]); increases in 1-year retesting for HbA1c and LDL-C levels among all patients, with the most dramatic change among patients with the worst disease control (HbA1c levels ≥9% or LDL-C levels ≥3.4 mmol/L [≥130 mg/dL]); and decreased 90-day retesting among patients with HbA1c levels less than 7% or LDL-C levels less than 2.6 mmol/L (<100 mg/dL). The EHR was also associated with statistically significant reductions in HbA1c and LDL-C levels, with the largest reductions among patients with the worst control (0.06-mmol/L [2.19-mg/dL] reduction among patients with baseline LDL-C levels ≥3.4 mmol/L [≥130 mg/dL]; P < 0.001). The EHR was implemented in a setting with strong baseline performance on cardiovascular care quality measures. Use of a commercially available certified EHR was associated with improved drug treatment intensification, monitoring, and physiologic control among patients with diabetes, with greater improvements among patients with worse control and less testing in patients already meeting guideline-recommended glycemic and lipid targets. National Institute of Diabetes and Digestive and Kidney Diseases.
    Annals of internal medicine 10/2012; 157(7):482-9. · 13.98 Impact Factor
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    ABSTRACT: Background/Aims The Affordable Care Act phases out the Medicare Part D coverage gap over the next decade; however, beneficiaries will continue to face substantial cost-sharing even after 2020. Higher cost-sharing has been associated with reductions in necessary drug use. Non-adherence to antipsychotics, a mainstay of schizophrenia treatment, is associated with worse clinical outcomes. We investigated the impact of Part D cost-sharing on antipsychotic spending and adherence for beneficiaries with schizophrenia, focusing on within-person cost-sharing increases associated with the gap. Methods We included Medicare Advantage (MA) beneficiaries enrolled in plans linked with an integrated delivery system (IDS, N=999) and non-integrated systems (non-IDS, N=3,878) who received 1+ inpatient or 2+ outpatient schizophrenia diagnoses during 2006-2007 and antipsychotics in 2006. We examined total and out-of-pocket antipsychotic spending and adherence based on the proportion of days covered (PDC) using Part D drug event data. We examined changes in monthly costs and adherence before and after beneficiaries reached the gap using within-person fixed effects models to account for unmeasured, time-stable confounders across comparison groups. Results Overall, 34% of subjects faced a gap in 2007; most remaining beneficiaries received low- income subsidies (LIS) that covered the gap. Among gap subjects, 45% (IDS) and 55% (non-IDS) reached the gap threshold of $2,400 in total drug spending. Monthly out-of-pocket spending increased substantially in both systems during vs. before the gap (IDS: $139 [$118 to $159]; non-IDS: $84 [$79 to $91]). Total monthly antipsychotic costs and adherence decreased after reaching the gap among non-IDS beneficiaries (costs: -$163 [-$179 to -$146]; adherence: -14.7 percentage points [-16.2 to -13.1]). Among IDS beneficiaries, changes in total costs and adherence pre- vs. post-gap were not significant (costs: -$82 [-$179 to $15]; adherence: 3.1 pp [-0.6 to 6.8]). For LIS beneficiaries with no gap, adherence did not decrease after reaching the gap spending threshold. Discussion Antipsychotic adherence decreased during the gap among non-IDS MA beneficiaries, but did not among IDS beneficiaries or among LIS recipients without a gap. Cost-related non- adherence to antipsychotics among beneficiaries with schizophrenia could result in adverse clinical outcomes. Work is needed to explore potential system-level characteristics that influence patients' responses to cost-sharing.
    Clinical Medicine &amp Research 08/2012; 10(3):182.
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    ABSTRACT: Identify important organizational elements for providing self-management support (SMS). Semi-structured qualitative interviews conducted in two healthcare systems. Kaiser Permanente Northern California and the Danish Health Care System. 36 managers and healthcare professionals in the two healthcare systems. Elements important to providing self-management support to persons with diabetes. Healthcare professionals' provision of SMS was influenced by healthcare system organization and their perceptions of SMS, the capability and responsibility of healthcare systems, and their roles in the healthcare organization. Enabling factors for providing SMS included: strong leadership; aligned incentives; use of an integrated health information technology (HIT) system; multidisciplinary healthcare provider teams; ongoing training for healthcare professionals; outreach; and quality goals. Barriers to providing SMS included lack of collaboration between providers and skeptical attitudes towards prevention and outreach. Implementation of SMS can be improved by an understanding of the elements that enhance its provision: (1) initiatives seeking to improve collaboration and integration between providers; (2) implementation of an integrated HIT system; and (3) ongoing training of healthcare professionals.
    Scandinavian journal of primary health care 07/2012; 30(3):189-94. · 2.21 Impact Factor
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    ABSTRACT: Blood pressure, lipid, and glycemic control are essential for reducing cardiovascular disease (CVD) risk. Many health care systems have successfully shifted aspects of chronic disease management, including population-based outreach programs designed to address CVD risk factor control, to non-physicians. The purpose of this study is to evaluate provision of new information to non-physician outreach teams on need for treatment intensification in patients with increased CVD risk. Cluster randomized trial (July 1-December 31, 2008) in Kaiser Permanente Northern California registry of members with diabetes mellitus, prior CVD diagnoses and/or chronic kidney disease who were high-priority for treatment intensification: blood pressure ≥ 140 mmHg systolic, LDL-cholesterol ≥ 130 mg/dl, or hemoglobin A1c ≥ 9%; adherent to current medications; no recent treatment intensification). Randomization units were medical center-based outreach teams (4 intervention; 4 control). For intervention teams, priority flags for intensification were added monthly to the registry database with recommended next pharmacotherapeutic steps for each eligible patient. Control teams used the same database without this information. Outcomes included 3-month rates of treatment intensification and risk factor levels during follow-up. Baseline risk factor control rates were high (82-90%). In eligible patients, the intervention was associated with significantly greater 3-month intensification rates for blood pressure (34.1 vs. 30.6%) and LDL-cholesterol (28.0 vs 22.7%), but not A1c. No effects on risk factors were observed at 3 months or 12 months follow-up. Intervention teams initiated outreach for only 45-47% of high-priority patients, but also for 27-30% of lower-priority patients. Teams reported difficulties adapting prior outreach strategies to incorporate the new information. Information enhancement did not improve risk factor control compared to existing outreach strategies at control centers. Familiarity with prior, relatively successful strategies likely reduced uptake of the innovation and its potential for success at intervention centers. Identifier NCT00517686.
    BMC Health Services Research 07/2012; 12:183. · 1.77 Impact Factor
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    ABSTRACT: Self-management support is considered to be an essential part of diabetes care. However, the implementation of self-management support within healthcare settings has appeared to be challenging and there is increased interest in "real world" best practice examples to guide policy efforts. In order to explore how different approaches to diabetes care and differences in management structure influence the provision of SMS we selected two healthcare systems that have shown to be comparable in terms of budget, benefits and entitlements. We compared the extent of SMS provided and the self-management behaviors of people living with diabetes in Kaiser Permanente (KP) and the Danish Healthcare System (DHS). Self-administered questionnaires were used to collect data from a random sample of 2,536 individuals with DM from KP and the DHS in 2006-2007 to compare the level of SMS provided in the two systems and identify disparities associated with educational attainment. The response rates were 75 % in the DHS and 56 % in KP. After adjusting for gender, age, educational level, and HbA1c level, multiple linear regression analyses determined the level of SMS provided and identified disparities associated with educational attainment. Receipt of SMS varied substantially between the two systems. More people with diabetes in KP reported receiving all types of SMS and use of SMS tools compared to the DHS (p < .0001). Less than half of all respondents reported taking diabetes medication as prescribed and following national guidelines for exercise. Despite better SMS support in KP compared to the DHS, self-management remains an under-supported area of care for people receiving care for diabetes in the two health systems. Our study thereby suggests opportunity for improvements especially within the Danish healthcare system and systems adopting similar SMS support strategies.
    BMC Health Services Research 06/2012; 12:160. · 1.77 Impact Factor
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    ABSTRACT: To help preserve continuity of health insurance coverage during the recent recession, the American Recovery and Reinvestment Act provided a 65 percent Consolidated Omnibus Budget Reconciliation Act (COBRA) premium subsidy for workers laid off in 2008-2010. We examined COBRA enrollment levels with the subsidy and the health, access, and financial consequences of enrollment decisions. Telephone interviews linked with health system databases for 561 respondents who were laid off in 2009 and eligible for the COBRA subsidy (80 percent response rate). Overall, 38 percent reported enrolling in COBRA and 54 percent reported having some gaps in insurance coverage since being laid off. After adjustments, we found that those who had higher cost-sharing, who had higher incomes, were older, or were sicker were more likely to enroll in COBRA. COBRA enrollees less frequently reported access problems or that their health suffered because of poor access, but they reported greater financial stress due to health care spending. Despite the substantial subsidy, a majority of eligible individuals did not enroll in COBRA, and many reported insurance coverage gaps. Nonenrollees reported more access problems and that their health worsened. Without a mandate, subsidies may need to be widely publicized and larger to encourage health insurance enrollment among individuals who suffer a negative income shock.
    Health Services Research 04/2012; 47(5):1980-98. · 2.29 Impact Factor
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    ABSTRACT: Employers are increasingly offering high-deductible health insurance plans with associated health savings accounts (HSAs), but there is limited information on account contributions or effects on patient care seeking. We examined HSA contributions and their source, patient-reported effects of costs on care seeking, and reports of financial burden. We conducted telephone interviews with 488 adult members of small group of employer-sponsored HSA-eligible plans within an integrated delivery system. HSA contribution sources and amounts varied with 32% receiving an employer contribution and also making their own employee contribution, 35% only receiving an employer contribution (no employee contribution), 19% only making their own contribution (no employer contribution), and 14% with no HSA contribution from either source. After adjustment for respondent characteristics, those who made their own HSA contributions in addition to their employer's contribution were significantly more likely to report that costs affected their care-seeking behavior, compared with those with only employer contributions (39% vs. 31% for emergency department and 60% vs. 49% for office visits, all P<0.05). Respondents who contributed to their HSA or who paid out-of-pocket for care were significantly more likely to report financial burdens than those with only employer contributions (P<0.05). The majority of consumers receive employer contributions to their HSA, but few have fully funded accounts. Those with only an employer contribution reported fewer changes in their care-seeking behavior and were less likely to report experiencing financial burdens.
    Medical care 02/2012; 50(7):585-90. · 3.24 Impact Factor
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    ABSTRACT: As many other European healthcare systems the Danish healthcare system (DHS) has targeted chronic condition care in its reform efforts. Benchmarking is a valuable tool to identify areas for improvement. Prior work indicates that chronic care coordination is poor in the DHS, especially in comparison with care in Kaiser Permanente (KP), an integrated delivery system based in the United States. We investigated population rates of hospitalisation and readmission rates for ambulatory care sensitive, chronic medical conditions in the two systems. Using a historical cohort study design, age and gender adjusted population rates of hospitalisations for angina, heart failure, chronic obstructive pulmonary disease, and hypertension, plus rates of 30-day readmission and mortality were investigated for all individuals aged 65+ in the DHS and KP. DHS had substantially higher rates of hospitalisations, readmissions, and mean lengths of stay per hospitalisation, than KP had. For example, the adjusted angina hospitalisation rates in 2007 for the DHS and KP respectively were 1.01/100 persons (95%CI: 0.98-1.03) vs. 0.11/100 persons (95%CI: 0.10-0.13/100 persons); 21.6% vs. 9.9% readmission within 30 days (OR = 2.53; 95% CI: 1.84-3.47); and mean length of stay was 2.52 vs. 1.80 hospital days. Mortality up through 30 days post-discharge was not consistently different in the two systems. There are substantial differences between the DHS and KP in the rates of preventable hospitalisations and subsequent readmissions associated with chronic conditions, which suggest much opportunity for improvement within the Danish healthcare system. Reductions in hospitalisations also could improve patient welfare and free considerable resources for use towards preventing disease exacerbations. These conclusions may also apply for similar public systems such as the US Medicare system, the NHS and other systems striving to improve the integration of care for persons with chronic conditions.
    BMC Health Services Research 12/2011; 11:347. · 1.77 Impact Factor

Publication Stats

999 Citations
352.94 Total Impact Points


  • 2004–2014
    • Harvard Medical School
      • • Department of Health Care Policy
      • • Department of Population Medicine
      Boston, Massachusetts, United States
  • 2010–2013
    • Massachusetts General Hospital
      • Mongan Institute for Health Policy
      Boston, MA, United States
  • 2002–2013
    • Kaiser Permanente
      Oakland, California, United States
  • 2012
    • Permanente Medical Group
      Pasadena, California, United States
  • 2011–2012
    • Steno Diabetes Center
      Gjentofte, Capital Region, Denmark
    • Harvard Pilgrim Health Care
      Quincy, Massachusetts, United States
  • 2010–2012
    • CSU Mentor
      Long Beach, California, United States
    • University of Copenhagen
      • Department of Public Health
      Copenhagen, Capital Region, Denmark
  • 2009
    • University of California, San Francisco
      San Francisco, California, United States
  • 2003–2007
    • University of California, Berkeley
      • School of Public Health
      Berkeley, CA, United States
  • 2006
    • University of St Andrews
      • School of Management
      Saint Andrews, SCT, United Kingdom
  • 2005
    • Indiana University-Purdue University Indianapolis
      Indianapolis, Indiana, United States