AHRQ Annual Highlights, 2008 (continued)

Using Health Information Technology to Improve Patient Safety and Quality

AHRQ has worked for many years to harness the power of health information technology (Health IT) to improve the health of all Americans. By developing secure and private electronic health records and making health information available electronically when and where it is needed, Health IT can improve the quality of care, even as it makes health care more cost-effective. More than $210 million in grants and contracts fund over 100 projects to support and stimulate investment in Health IT. The goals of AHRQ's Health IT initiative are to:

• Improve the safety and quality of prescription drug management via the integration of utilization of medication management systems and technologies.
• Improve the delivery and utilization of evidence-based care in ambulatory settings.
• Improve the delivery of patient centered care in ambulatory care settings, including specific focus on transitions of care, personal health records, and improved patient-provider communication and decision-making.
• Foster the development, deployment, and reporting of measures of safety and quality in ambulatory care settings and across high risk transitions in care.

National Conference on Reducing Diagnostic Error in Medicine AHRQ and the American Medical Informatics Association co-sponsored the first national meeting dedicated to diagnostic errors in medicine May 31-June 1, 2008, in Phoenix, Arizona. The meeting's goals were to summarize the current state of the field and approaches to reducing diagnostic errors, examine the role of clinical decision-support systems in addressing diagnostic errors, identify and discuss ongoing research on diagnostic errors, stimulate creative thought directed at reducing harm from diagnostic errors, and establish a community of stakeholders interested in reducing diagnostic errors. In addition, experts explored both system-related contributions to errors and cognitive origins.

Clinical Decision Support Technologies Contracts

AHRQ awarded $5 million for two new health information technology contracts that will focus on the development, adoption, implementation, and evaluation of best practices using clinical decision support. Clinical decision support helps health professionals make informed patient care decisions. The Brigham and Women's Hospital in Boston and Yale University School of Medicine in New Haven, CT, were selected to incorporate clinical decision support into widely used Health IT products, demonstrate cross-platform utility, and establish lessons learned for clinical decision support implementation across the Health IT vendor community. The projects will focus on translation of clinical guidelines and outcomes related to preventive health care and treatment of patients with multiple chronic illnesses.

National Resource Center for Health Information Technology

The AHRQ National Resource Center for Health Information Technology (NRC) continued to be an important resource for the health care community in 2008. Much of the research and lessons learned from AHRQ's Health IT initiative is conducted and coordinated through the NRC. The NRC helps facilitate adoption of Health IT by disseminating the latest Health IT tools, best practices, and research results. In 2008, the NRC added tools to help health care organizations plan for, implement and evaluate Health IT.

Improving Pediatric Safety and Quality with Health Information Technology

Under the AHRQ-funded grant "Improving Pediatric Safety and Quality with Healthcare IT," the Partners Quality Improvement Group developed pediatric rules and reminders and created pediatric visit templates for the ambulatory environment. These pediatric reminders and templates are currently in use in the Partner's electronic health record, known as the Longitudinal Medical Record.

Health IT Survey Compendium

Surveys are useful tools for collecting both quantitative and qualitative data when evaluating Health IT projects. However, developing and validating surveys can be difficult, time-consuming, and costly. Individuals and organizations interested in evaluating Health IT applications can benefit from using surveys that have been developed and validated by others. The NRC has compiled a set of publicly available surveys to serve as a reference. The surveys have been categorized in four ways: survey type, technology, care setting, and respondent type.

Health IT Bibliography

The Health IT Bibliography is a collection of carefully selected, high quality resources for health care and information technology stakeholders searching for information on how Health IT can transform care delivery processes and improve quality, safety, and efficiency. A mixture of both peer-reviewed articles from professional journals and Web-based resources from highly respected health care and IT organizations are available. Summaries of each item are also provided. This resource is designed to be dynamic, growing with the Health IT community to include new knowledge, resources, and technologies.

Additional Tools and Resources

Other resources that continued to be supported in 2008 at AHRQ's NRC include:

• Health IT Evaluation Toolkit—provides guidance on how to evaluate Health IT. Example measures relevant to quality, safety, and efficiency are provided along with suggested data sources and the relative costs to collect the measures.
• Health IT Costs and Benefits Database Project—a searchable database that contains the results of a literature search on the relative costs and benefits of Health IT.
• The Health Information Privacy and Security Collaboration Toolkit provides guidance for conducting organization—level assessments of business practices, policies, and State laws that govern the privacy and security of health information exchange.
• HIE Evaluation Toolkit—provides guidance on how to evaluate health information exchange.
• Time and Motion Database—enables organizations to measure the impact of Health IT systems on clinical workflow through the collection of time-motion study data.
• Health IT Literacy Guide—the Accessible Health Information Technology (IT) for Populations with Limited Literacy: A Guide for Developers and Purchasers of Health IT provides Health IT developers with structure, strategies, and other resources for the development of Health IT technologies for populations with limited literacy.

Medication Management

In collaboration with the Centers for Medicare & Medicaid Services (CMS) Office for e-Health Standards and Services, AHRQ successfully delivered the evidence which led to adoption of three new standards for electronic prescribing, as required by the Medicare Modernization Act of 2003. The evidence was generated by AHRQ grantees using CMS funding, and their efforts were evaluated by AHRQ's National Resource Center for Health IT. The products of those projects formed the basis for the CMS Report to Congress which detailed the readiness of the adopted standards, as well as the status of several other standards which were tested but found to be unadoptable in their current state.

Health IT Implementation Stories

AHRQ-funded Health IT projects are helping to revolutionize everyday clinical practice. Following are the stories and lessons learned from some of these pioneering projects.

• Holomua Project to Improve Transitional Care in Hawaii—this project is developing a master visit registry (a form of health information exchange) to improve the coordination of care between hospitals and community health centers for Hawaii's vulnerable populations. Master Visit Registry (MVR) helps doctors locate a patient's history of visits, shows what type of care they received, who provided the care, which facility they visited, the type of visit, and diagnosis. The MVR allows facilities to share timely, accurate patient information, even if the patient isn't able to provide a medical history. In addition, the registry will help participating facilities develop policies and procedures that improve the coordination and continuity of health care as patients transfer between different locations. As of the summer of 2008, the system contained data on 450,000 patient visits from the previous year with roughly 220,000 patients.
• Electronic Vision Rehabilitation Record (EVRR®)—this project is helping to provide data describing quality or outcomes of treatment in rehabilitation care for the visually impaired. A unique computerized record system developed and implemented by New York-based Lighthouse International with funding from AHRQ—the Electronic Vision Rehabilitation Record (EVRR®)—is the first Web-enabled electronic record system that is focused on best practices of care for people who are visually impaired. Eventually, EVRR® will register patient data and track functional outcomes, allowing providers to demonstrate the impact of their services to funders and payers and advance the standard of care. Under the AHRQ grant, EVRR® is being implemented by Lighthouse in the New York City area; the Central Association for the Blind and Visually Handicapped in Utica, NY; and the Iris Network in Portland, ME. In addition, EVRR® is licensed by the Canadian National Institute for the Blind for use throughout Canada.
• The MidSouth eHealth Alliance (MSeHA)— MSeHA aims to improve patient care and reduce costs through eliminating duplicate or unneeded tests, reducing hospital stays, and decreasing emergency department utilization through health information exchange. The MSeHA currently exchanges data among 9 hospitals, 15 ambulatory clinics, and the University of Tennessee Medical Group in the region. Physicians in the emergency departments of these hospitals can view patient data through a secure, Web-based browser that provides a real-time data feed to the hospitals and clinics. To date, the exchange has generated more than 2.1 million patient records. Each day, the MSeHA handles about 33,000 patient records and 800,000 lab results. Project leaders are still busy figuring out how to measure the project's return on investment, but estimate that the data exchange is saving local emergency departments about $500,000 per year.
• Enhancing Quality Utilizing Information Technology in Patient Care (EQUIP)—the Alliance of Chicago Community Health Services is a unique partnership that is blazing a trail for EHR implementation among a group of safety net providers. The Alliance encompasses 29 sites in Chicago's Near North Side that provide care to about 100,000 people during 350,000 encounters a year. With funding from the Health Resources and Services Administration, AHRQ, and other sources, the Alliance has deployed a sophisticated, customized EHR system that provides evidence-based decision-making support to clinicians and aggregates population data for chronic disease management. To date, 10 sites representing 4 health centers are using the new system which can be accessed anywhere at anytime via the Internet. Improved workflow documentation is helping providers figure out how to do their jobs more efficiently. Trend data already indicate modest improvements in health status and adherence to practice guidelines since the conversion.
• Picture Archiving and Communications System (PACS)—a $1.4 million grant to Maine Medical Center from AHRQ has helped to expand the PACS network to other hospitals in the State. To date, the PACS has been extended to seven hospitals and numerous outpatient imaging centers, making it possible for these organizations to share images with radiologists and physicians at other locations, thereby helping to save time, money, and improve patient care. Using the system, medical staff can begin to diagnose patients without waiting for records to arrive or performing additional, unnecessary tests. Smaller hospitals that can't afford a full PACS system on their own or hire the support staff it takes to maintain such systems now have access to these images without having to maintain the system or pay for the associated on-going system support costs. In turn, patients get the benefits of having a team of radiologists at many hospitals review their records.

AHRQ 2008 Annual Conference Plenary and concurrent sessions on Health IT held at AHRQ's 2008 Annual Conference covered topics ranging from Health IT in the clinical setting used by providers to developing systems for Health IT in patients' homes. Findings from recent studies and how Health IT is being used to enhance performance, quality, and patient safety were presented. Topics included: Using Health IT to Enhance Inter-Provider Communication to Improve Care. Improving Quality of Care for Vulnerable Populations Through Health IT. e-Prescribing: Enabling Change and Measuring Impact. Clinical Decision Support Tools for Ambulatory Settings. Using Health IT to Improve Medication Management. Considerations in Design of Health IT for In-Home Use. Enabling Transitions in Care Through Health IT. Design of Patient-Centered Health IT. Enabling Chronic Disease Care Through Health IT. Improving Patient-Clinician Communication Through Consumer Health IT.

Recent Research Findings on Health IT

• Web-based electronic health records that allow patients to communicate with their providers about laboratory test results, medications, and care plans may help meet patients' needs. Providing patients with online medical record services that were integrated with clinical care was associated with Web site access, use, and patient satisfaction. Patients most used the site to review medical test results, medication refills, after-visit summaries, and patient-provider clinical messaging. Patients were satisfied or very satisfied with medication refills (96 percent), patient-provider messaging (93 percent), and medical test results (86 percent).
• Researchers used time-motion techniques to compare prescribing times at three ambulatory care sites that used paper-based prescribing, desktop, or laptop e-prescribing They concluded that use of desktop or laptop computers for e-prescribing for outpatients would not disrupt prescriber or staff workflow, when carefully implemented. Among 27 prescribers studied, the mean time spent to write an e-prescription was only 12 seconds longer than written prescriptions. Since the clinicians ordered an average of nine prescriptions during an observation period of 3.5 hours, this amounted to an additional 3 to 5 minutes of clinicians' time for e-prescribing over written prescribing. This small increment in time can be justified if e-prescribing improves the safety and quality of patient care.
• Less than one in five office-based medical practices have adopted electronic health records (EHRs). Of 847 practices that responded to a survey, only 18 percent were using EHRs. The adoption rate for EHRs was significantly lower for specialty-only practices (14 percent). The researchers found that 74 percent of the EHR practices used electronic visit notes, followed by online lab test results and medication lists (both 64 percent). The majority of practices without an EHR (52 percent) had no plans to implement one in the foreseeable future, with solo practices being the least likely to implement the technology (70 percent had no plans). Lack of adequate funding was cited as a barrier to implementation by 42 percent of the non- EHR practices.
• Researchers found that 57 percent of medication errors made in family physicians' offices could have been prevented by electronic medical records or computerized physician order entry. A study of adverse drug events reported by more than 440 family physicians and staff from 52 practices found that of 194 reported medication errors, 70 percent were prescribing errors, 10 percent were medication administration errors, 10 percent were documentation errors, and 3 percent were monitoring errors. Overall, 16 percent of the errors resulted in temporary harm. The two most commonly reported medication errors were related to medication dose and selection, followed by the actual prescription itself and communication issues. The most common reasons for these error types included incorrect dose, incorrect drug selection, patient contraindications to the prescribed drug, communications problems with the pharmacy, and insufficient information on the prescription.
• Large (more than 150 beds) and medium (26- 150 beds) hospitals tend to have more advanced Health IT capacity than small hospitals (25 or fewer beds), regardless of their affiliation with a health care system. In contrast, small hospitals owned by multihospital systems have more Health IT capacity than small independent hospitals. The mean EMR adoption stage was significantly different between small (0.85), medium (1.53), and large (1.79) hospitals. The level of EMR adoption did not differ among medium and large hospitals that belonged to a hospital system or were independent. However, small hospitals that were owned by a multihospital system had a significantly higher EMR adoption level than small independent hospitals (1.08 vs. 0.77). Given that most hospitals with 25 or fewer beds are located in rural areas, this study presents important findings for small rural hospitals.

More information on AHRQ's Health IT initiative, toolkits, and copies of reports can be found on the National Resource Center Web site.

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Eliminating Disparities in Health Care

AHRQ is leading Federal research efforts to develop knowledge and tools to help eliminate health care disparities in the United States. AHRQ supports and conducts research and evaluations of health care with emphasis on disparities related to race, ethnicity, socioeconomic status, and geographic variation. The Agency focuses on priority populations including minorities, women, children, the elderly, low-income individuals, and people with special health care needs such as people with disabilities or those who need chronic or end-of-life care.

National Healthcare Quality and Disparities Reports

Released in early 2008, significant findings from the National Healthcare Quality Report (NHQR) and its companion report, the National Healthcare Disparities Report (NHDR), were reported in AHRQ's Annual Highlights for 2007. Overall, findings from the reports indicate that while the quality of health care is continuing to improve, the rate of improvement appears to be slowing. These reports are mandated by Congress and are read widely by policymakers, health care analysts, public health advocates, health insurers, journalists, and consumers. Data from the reports are also available on the AHRQ Web site through NHQRnet (http://nhqrnet.ahrq.gov) and NHDRnet (http://nhdrnet.ahrq.gov).

Some significant findings from the reports show that:

• About one-fourth of Americans aged 65 and older with disabilities reported using at least one prescription drug deemed inappropriate for persons his or her age. Only about half as many (13 percent) elderly people without disabilities used inappropriate drugs. Older people with disabilities who never finished or stopped at high school were more likely to use potentially inappropriate drugs than those who went on to college.
• Only about 1 in 10 adult Americans have all the skills needed to manage their health care proficiently. These skills, known collectively as health literacy, include weighing the risks and benefits of different treatments, knowing how to calculate health insurance costs, and being able to fill out complex medical forms.
• The hospitalization rate for diabetes-related amputations among Hispanics increased from 63 admissions per 100,000 people in 2001 to nearly 80 admissions per 100,000 people in 2004. During the same period, the rate for whites remained steady at roughly 28 to 31 admissions per 100,000 people.
• In 2004, only 38 percent of adult Hispanics age 40 and over with diabetes received three recommended annual screenings—foot exams, eye exams and blood sugar level checks (hemoglobin A1c test). The percentage was 47 for whites and 47 for blacks.

State Snapshots

AHRQ's State Snapshots Web tool was launched in 2005, and has been updated annually. Based on data drawn from various sources that have State level data available, including government surveys, health care facilities and health care organizations, the State Snapshots is an application that helps State health leaders, researchers, consumers, and others more easily access information about the status of health care quality in individual States, including each State's strengths and weaknesses. The data the State Snapshots are drawn from the 2007 National Healthcare Quality Report and provide State rankings for 15 "selected measures." These rankings show that no State does well or poorly in all areas:

• Texas ranked 4th best at minimizing nursing home patients' pressure sores but 41st on vaccinating older people against pneumonia.
• Ohio ranked 7th for its high percentage of pregnant women who received prenatal care but 46th for its high rate of breast cancer deaths.
• New Mexico ranked 4th best on improving the mobility of nursing home residents but 50th for its low number of heart attack patients who received the right medications at hospital discharge.

Improving Hispanic Elders Health: Community Partnerships for Evidence-Based Solutions (Hispanic Elders Learning Network)

The Hispanic Elders Learning Network supports the development of local, evidence-based intervention plans for reducing health disparities and improving the delivery of health care and related aging and social services for Hispanic elders. The project was inspired by growing health disparities between Hispanics and non- Hispanic whites reported in the AHRQ 2006 National Healthcare Disparities Report. The project highlights eight communities with the largest Hispanic populations: Chicago, Houston, Los Angeles, Lower Rio Grande Valley (Texas), Miami, New York, San Antonio, and San Diego. Each location has formed an interdisciplinary coalition of clinical and community representatives to customize plans to target their services in ways that would contribute to improving the health status of the elderly. Federal partners in this effort are AHRQ, AoA, CDC, CMS, and HRSA, linked with a team of national experts including the National Council on Aging and the George Washington University Department of Community Health and Prevention.

Recent Research Findings on Disparities and Minority Health

• Blacks and Hispanics who go to hospital emergency departments in pain are significantly less likely than whites to get pain-relieving opioid drugs. Researchers analyzed treatments for more than 150,000 pain-related visits to U.S. hospitals between 1993 and 2005. They found 23 percent of blacks and 24 percent of Hispanics received opioids compared with 31 percent of whites. While the use of opioids increased overall, the differences in use between racial and ethnic groups did not diminish. In 2005, the last year of the survey, 40 percent of whites in pain received opioids; 32 percent of all others received the drugs. Among patients in severe pain, opioids were prescribed to 52 percent of whites, 42 percent of Hispanics and 39 percent of blacks.
• Researchers analyzed the pregnancy outcomes of 10,755 Medicaid-insured women, who gave birth at the Duke University Medical Center between 1994 and 2004. Black women, who were younger, were more likely to have another medical condition while pregnant, to remain in the hospital for more than 4 days, and to have hospital charges over $7,500. Compared with white women, Hispanic women were 34 percent less likely to have preterm births, and black women had 30 percent higher odds of preeclampsia and 74 percent higher odds of small for gestational age infants. Since all the women were poor, Medicaid-insured patients, poverty, and insurance status did not explain these differences.
• The Native Telehealth Outreach and Technical Assistance Program equipped and trained nine health advocates from a variety of backgrounds, including an HIV counselor, a registered nurse, and an elementary school teacher. The participants learned about available health resources and had access to a state-of-the-art multimedia facility to develop their educational projects. Eighteen months after initial training, eight of the nine participants had developed projects, including an educational video on hepatitis C, an interactive CD-ROM for elementary school students on the effects of alcohol and other drugs on the body, an interactive CD-ROM sharing Native American insights and information on diabetes, and a Web site and brochure campaign on the diverse birth control methods available to the tribal community. These products were disseminated throughout the rural communities.

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Getting Value for Money Spent on Health Care

According to data from the Medical Expenditure Panel Survey (MEPS), Americans spent $1.02 trillion in health care expenses for hospital inpatient and outpatient care, emergency room services, office-based health care providers, dental services, home health care, prescription medicines, and other medical services in 2005. Nearly 85 percent of the U.S. population had some medical expense with an average annual expense per person of approximately $4,000. The average expense for a person age 65 and over was more than $9,000, three times the average for a person under age 65 ($3,200). Despite this level of health care spending, health care quality in this Nation still needs improvement.

Value-Driven Health Care Initiative

AHRQ is working closely with HHS to fulfill the goals of HHS Secretary Mike Leavitt's Value- Driven Health Care Initiative. The goal of the Initiative is to create a health care system where patients can get better information about the quality and cost of their care that includes competition to provide them with the best value.

Chartered Value Exchanges

In February 2008, working with AHRQ, HHS designated 13 community collaboratives as Chartered Value Exchanges. The Chartered Value Exchanges are local collaborations of health care providers, employers, insurers, and consumers working jointly to improve care and make quality and price information widely available. The first 13 Chartered Value Exchanges are:

• Wisconsin Healthcare Value Exchange, Madison, Wisconsin.
• Healthy Memphis Common Table, Germantown, Tennessee.
• Greater Detroit Area Health Council, Detroit, Michigan.
• Oregon Health Care Quality Corporation, Portland, Oregon.
• Pittsburgh Regional Health Initiative, Pittsburgh, Pennsylvania.
• Puget Sound Health Alliance, Seattle, Washington.
• Utah Partnership for Value-driven Health Care, Salt Lake City, Utah.
• Louisiana Health Care Quality Forum, Baton Rouge, Louisiana.
• Maine Chartered Value Exchange Alliance, Scarborough, Maine.
• Minnesota Healthcare Value Exchange, St. Paul, Minnesota.
• Massachusetts Chartered Value Exchange, Watertown, Massachusetts.
• Alliance for Health, Grand Rapids, Michigan.
• New York Quality Alliance, Albany, New York.

In September 2008, HHS designated 11 community collaborations as Chartered Value Exchanges:

• Aligning Forces for Quality, York, Pennsylvania.
• California Chartered Value Exchange, San Francisco, California.
• The Colorado Chartered Value Exchange, Denver, Colorado.
• eHealth Connecticut, Inc., Middletown, Connecticut.
• Greater Louisville Value Exchange Partnership, Louisville, Kentucky.
• Health Improvement Collaborative of Greater Cincinnati and HealthBridge, Cincinnati, Ohio.
• Kansas City Quality Improvement Consortium, Kansas City, Missouri.
• Michigan Health Information Alliance, Mt. Pleasant, Michigan.
• Nevada Partnership for Value-driven Health Care, Las Vegas, Nevada.
• Quality Health First Program, Managed by the Indiana Health Information Exchange, Indianapolis, Indiana.
• Virginia Health Care Alliance, Glen Allen, Virginia.

As Chartered Value Exchanges, these communities will have access to information from Medicare that gauges the quality of care that physicians provide to patients. These performance measurement results may be combined with similar private-sector data to produce a more comprehensive guide to the quality of care in these communities. In addition, they will join a nationwide Learning Network sponsored by AHRQ. This network will provide peer-to-peer learning experiences through facilitated meetings, both face-to-face and on the Web and access to HHS experts and new tools, including an ongoing private Web-based knowledge management system.

Consumer Financial Incentives Guide for Employers and Other Health Care Purchasers

Consumer financial incentives are either a reward offered to influence patients to behave in a particular way, or, less often, a penalty for failing to do so. By using financial incentives, health care purchasers hope to encourage patients to take actions that either may improve the results of their treatment—such as selecting a high-quality physician, reducing or eliminating high-risk behaviors and using preventive services—or may reduce costs by eliminating unnecessary emergency room visits and decreasing preventable hospitalizations.

In 2008, AHRQ released a new guide that can help employers, private health plans, the Federal government, and State Medicaid agencies as they consider consumer financial incentives as part of an overarching strategy to improve the quality of health care and get better value for what they spend on services. Consumer Financial Incentives: A Decision Guide for Purchasers consists of an evidence summary organized around a series of 21 questions that purchasers need to consider when implementing consumer financial incentives. The guide reviews the application of incentives to five types of consumer decisions, including selecting a high-value provider, selecting a high-value health plan, deciding among treatment options, reducing health risks by seeking preventive care, and reducing health risks by decreasing or eliminating high-risk behavior.

More information on Value-Driven Health Care is available at http://www.hhs.gov/valuedriven.

Care Management of Patients with Complex Health Care Needs

Americans are growing older today in a way unlike any preceding generation. However, one result is an unprecedented number of older Americans with chronic illnesses. In 2000, 60 million Americans had multiple chronic conditions, and it is projected that this will rise to over 81 million by 2020 (Partnership for Solutions, 2002). The primary care system in this country is unprepared for the challenges posed by a growing population of patients with complex combinations of chronic diseases. The complicated medical regimens, interactions of different diseases, and cumulative effect of different conditions on morbidity, mortality, and quality of life make it difficult to identify optimal approaches for such patients. Care for these patients is often fragmented across multiple settings and providers, with limited, or no communication or coordination and no sense of overarching responsibility. Currently, the management of the patient with complex healthcare needs is often a web of many-to-many relationships with information moving haphazardly among different providers, settings, and the patient. To help meet the needs of both patient and providers and improve the safety and quality of care to patients with complex health care needs, in FY2008, AHRQ funded 30 research projects in care management and Health IT (Go to Appendix Tables 1 and 2).

Recent Research Findings on Value, Health Care Costs, and Improving Performance

• Obesity surgeries for patients between the ages of 55 and 64 in the United States soared from 772 procedures in 1998 to 15,086 surgeries in 2004—a nearly 2,000 percent increase. In addition, there was a 726 percent increase in surgeries among patients age 18 to 54. Among the reasons for the dramatic increases is that the mortality outcomes from obesity surgery have improved greatly. The national death rate for patients hospitalized for bariatric surgery declined 78 percent, from 0.9 percent in 1998 to 0.2 percent in 2004. The average hospital cost for a bariatric surgery patient stay, excluding physician fees, was $10,395 in 2004 as compared with $10,970 in 1998, adjusted for inflation. The overall hospital costs for bariatric surgery patients increased more than eight-fold—from $147 million in 1998 to $1.3 billion in 2004.
• Researchers conducted telephone interviews in 2005 and 2006 with 609 employers in 41 U.S. markets, representing about 78 percent of the U.S. metropolitan population. Of the executives surveyed, 65 percent said they look at health plan quality data when choosing a plan for their employees. However, just 17 percent use that data to negotiate bonuses or penalties in plan contracts. Instead, geographic coverage and premium rates drove their decisionmaking 85 percent of the time. One explanation for not using the data is employers do not see the business case of how value-based purchasing may affect productivity or workforce recruitment and retention. Employers do appear to be embracing health promotion in the workplace. Nearly half of all businesses surveyed provide screening, treatment, or disease management on site, and 70 percent provide clinical help lines.
• People who buy their own health insurance saw their average annual premiums rise 18 percent between 2002 and 2005, a modest increase compared with the 34 percent jump in average premiums for people insured through their employers, according to data taken from the MEPS. The annual cost of these nonemployer policies was paid entirely out of pocket. The average annual premium for a one-person policy was $2,835 in 2005, up from $2,531 in 2002. Annual premiums for family policies were $5,568 in 2005, up from $4,442 in 2002. For people with company-sponsored insurance, average annual premiums paid out-of-pocket rose from $1,231 to $1,655 between 2002 and 2005.
• With soaring health care costs, private insurance may no longer provide sufficient financial protection. MEPS data from 2001 to 2004 indicates that the rise in out-of-pocket health care expenses, along with stagnant incomes, led one in five privately insured people in middle-income families to face a high financial burden by 2004. After accounting for inflation, total spending for premiums and services rose $553 to $3,211, a 21 percent increase over the period, while family incomes were largely unchanged. The increase in families' financial burdens was driven entirely by people with private (employer-sponsored) insurance. Recent projections estimate that both overall private health insurance costs and out-of-pocket spending will continue to rise by about 6 to 7 percent annually through 2016.

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