Redefining the role of research in an
evolving health care market
The U.S. health care system is currently undergoing two major
transformations. First, public programs in health and social
services are being reorganized, downsized, and privatized. These
changes are reshaping and redefining the responsibility for
social welfare programs that have provided health and income
support for poor, elderly, and disabled persons for decades.
Second, even more dramatic changes are taking place in the
private health care market. These include the shift to managed
care, increasing vertical and horizontal integration, and the
forging of new relationships among insurers, providers, and
purchasers in an increasingly competitive market.
These major transformations in health care financing and delivery
may call for a shift in the way we think about Government- and
foundation-supported research, note Clifton R. Gaus, Sc.D.,
Administrator of the Agency for Health Care Policy and Research,
and Irene Fraser, Ph.D., Director of AHCPR's Center for
Organization and Delivery Studies. In today's changing health
care arena, Government agencies and private-sector organizations
will face new challenges to provide the data, tools, and analysis
necessary to help the health care marketplace work more
efficiently and effectively.
These agencies and organizations also will be expected to support
and conduct research and evaluations to assess how well the
market is meeting critical health care objectives and then
disseminate the findings of their research. In particular, it
will be important to have objective, scientific answers to
questions in these eight areas:
- Effects of changes on the capacity of public programs and
the private health care market.
- Extent to which managed care entities achieve integration of
services.
- Impact on quality of care for the average consumer and for
vulnerable subsets of the population.
- Effects of changes in the marketplace on access to care.
- Impact of market changes on the equity or distribution of
costs and benefits across socioeconomic lines.
- Changes in health status.
- Extent to which these social experiments result in the
anticipated individual behavior (e.g., will Medicaid
beneficiaries decrease use of emergency services?).
- Effects of these changes on costs for all payers (i.e.,
direct public program expenses, plan payments, out-of-pocket
payments, uncompensated care, and costs incurred by other State
and local programs).
Our ability to answer these questions at the national level will
be enhanced as a result of the new integrated survey design
developed by the U.S. Department of Health and Human Services,
which will encompass most of the department's health data
collections. Efficiency and analytic power will be increased by
linking these surveys, which cover all aspects of health care
status, use, costs, and financing by type of service, source of
care, and type of payment.
Beginning this year, AHCPR's Medical Expenditure Panel Survey
(MEPS) will be fielded. MEPS is a longitudinal survey with a
national sample of 10,000 households. Data will be collected from
families on costs, coverage, benefits, health status, income, and
access to care. As part of MEPS, an employer survey will collect
information about health insurance levels, premiums, payout
ratios, and so forth, for the families in the household component
and for a State-by-State sample of employers. [Editor's note: See
the July-August 1996 issue of Research Activities for
a more
complete description of MEPS.]
In meeting the new challenges that lie ahead, it will be
important for agencies and organizations to apply the best
science available to the question of what does and does not work
clinically, through outcomes research, effectiveness research,
and technology assessment. A recent analysis of AHCPR's outcomes
research and clinical practice guidelines, for example,
identified many clear ways in which plans and providers could
improve quality and reduce costs. Even assuming a conservative guideline
adoption rate of 1 to 20 percent, annual projected cost savings
approached $175 million per condition for practice guidelines
that were adopted, note Dr. Gaus and Dr. Fraser.
Finally, the authors points out that in light of the budget
constraints now facing Government and foundations, the new
research paradigm will call for increased collaboration and new
partnerships among researchers from all sectors. For example,
through public-private partnerships, many States and communities
are designing and implementing systems to assess community needs
and track the ability of the market to meet those needs.
For more information, see "Shifting paradigms and the role of
research," by Clifton R. Gaus, Sc.D., and Irene Fraser, Ph.D., in
the Summer 1996 issue of Health Affairs 15(2), pp. 235-242.
Reprints (AHCPR Publication No. 96-R107) are available from the
AHCPR Publications Clearinghouse.
AHCPR releases guideline on early Alzheimer's
disease and
begins new focus on gathering science-based evidence
Significant mental impairment is not a part of normal aging and
should be a signal for action on the part of clinicians,
patients, and family members, according to a new clinical
practice guideline released in September by the Agency for Health
Care Policy and Research. In approximately 20 percent of cases,
signs of decline are not due to Alzheimer's disease or related
dementias but result from other conditions that are treatable.
The guideline is an evidence-based resource to help distinguish
between normal age-associated changes in cognitive ability and
the early symptoms of Alzheimer's disease, according to Paul T.
Costa, Jr., of the National Institute on Aging, and co-chair of
the panel of public- and private-sector experts responsible for
the guideline. The guideline provides the tools clinicians need
to conduct an initial assessment when symptoms suggest possible
dementia. Early recognition of Alzheimer's disease and related
dementias can prevent costly and inappropriate treatment and give
patients and family members time to address the complex
financial, legal, and medical issues these conditions present.
According to the guideline, increased difficulty with activities
such as learning and retaining new information, handling complex
tasks, reasoning, and spatial ability and orientation might be
symptomatic of Alzheimer's disease. Symptoms like these should
trigger a clinical assessment. A family history of dementia
and/or Down syndrome are risk factors that also merit special
attention.
An initial clinical assessment should combine information on the
symptoms' onset, progression, and duration; results of a physical
examination; an evaluation of mental and functional status; and
reports from family members and/or friends. Clinicians also
should assess and consider other factors, such as physical
disability, and they should rule out delirium and depression.
Patients who are depressed, taking multiple medications, or
abusing alcohol often are misdiagnosed or not treated because
their symptoms are confused with Alzheimer's disease or other
dementias, according to T. Franklin Williams, M.D., F.A.C.P.,
Professor of Medicine Emeritus, University of Rochester Medical
Center, and guideline panel co-chair. Depression is the most
common psychiatric illness in older persons, and can be difficult
to distinguish from dementia.
When findings of an initial evaluation point to Alzheimer's
disease, the AHCPR-sponsored guideline recommends further
clinical evaluation and stresses the importance of followup and
continuity of care. Only when the initial assessment is complete
is it appropriate to conduct laboratory tests, and then only when
the clinician has determined that the patient's ability to
function is declining, delirium and depression have been
excluded, and other factors and medical conditions have been
ruled out.
Followup and continuity of care, which facilitate the patient's
and family's ability to make informed decisions, are crucial to
accurate assessment and the patient's well-being. Followup, with
assessment of declining mental function, may be the most useful
diagnostic procedure for differentiating Alzheimer's disease from
normal aging.
AHCPR's clinical practice guideline on Alzheimer's disease is the
Agency's final guideline and marks a transition in the guideline
program. AHCPR's guideline program has been restructured in
response to requests from public- and private-sector guideline
users seeking the scientific foundation to develop their own
high-quality, evidence-based guidelines. This new focus will
allow the Agency to use its resources to develop a broader base
of scientific information that will enable more guidelines to be
developed. In the future, AHCPR will serve as a "science partner"
with other organizations by providing evidence reports that will
include literature reviews, evidence tables, decision analyses,
meta-analyses, and other products.
An Overview for clinicians and
consumers (AHCPR Publication No.
96-R123) of the Alzheimer's clinical practice guideline, and the
Consumer Version, Early
Alzheimer's Disease: A Guide for
Patients and Families (AHCPR Publication No. 96-0704), are
available online.
The documents, Recognition and Initial Assessment of
Alzheimer's
Disease and Related Dementias, Clinical Practice Guideline No.
19, and Early Identification of Alzheimer's Disease and Related
Dementias: Quick Reference for Clinicians, are in production
and
will be available later this year. Watch for an announcement of
their availability in an upcoming issue of Research
Activities.
Consumers and health care professionals view
quality of
care differently
Consumers and health professionals think differently about what
constitutes quality of care, according to a report issued by the
Oregon Consumer Scorecard Project (OCS Project). The OCS Project,
4funded by the Agency for Health Care Policy and Research,
examined other scorecard efforts nationwide and developed and
focus-group tested a number of different formats and presentation
methods in reaching their conclusions.
In addition to helping Oregon achieve its public health policy
goals, the OCS Project provides a model for other States to
follow in their efforts to develop scorecards. According to
Clifton R. Gaus, Sc.D., AHCPR's Administrator, the OCS Project
represents a significant step forward in designing tools
consumers can use to make more informed choices about their
health care needs, especially consumers in rural areas and
persons with significant chronic health conditions and/or
disabilities.
The OCS Project, directed by Pamela Hanes, Ph.D., of the Oregon
Health Policy Institute, revealed that consumers judge health
plans, and health professionals and facilities, on the basis of
very personal measures, such as how they gain access to specialty
care for acute and/or chronic conditions. Health professionals,
on the other hand, use population-based performance measures in
judging quality of care, such as outcomes of cancer treatment
over time and growth and development indicators for children.
These kinds of measures currently have little meaning for most
consumers, yet their potential to shape quality of care and hold
health plans accountable is great.
Among the Project's other major findings are that:
- Consumers prefer having a variety of formats for reviewing
information about health care plans and providers, but
printed scorecards should always be available because of
their lower cost and ease of distribution.
- Regardless of the scorecard format, consumers need access
to
a "personal guide," a trained, knowledgeable individual who
can assist consumers with scorecard information.
- Consumers expressed a strong desire for information that
describes health plans in their own geographic areas, as
opposed to information that evaluates plans throughout the
State.
- Consumers are savvy about marketing techniques; what they
want is information on the real differences between health
plans.
- Health plans face a "data burden" that is costly and could
be relieved by establishing uniform standards for all health
plans and purchasers. These standards would need to be
independently audited to assure compliance with data
specifications.
The OCS Project was carried out through AHCPR's regional Rural
Center at the University of Washington and the Oregon Health
Sciences University, Portland. The Project was conducted on
behalf of the Oregon Consumer Scorecard Consortium, a
public-private partnership created to develop a reliable source
of health plan information for consumers. The final report (AHCPR
Publication No. 96-N027) is in press and will be available from
AHCPR in February 1997 from the AHCPR
Publications Clearinghouse.
New consumer guide talks about safe,
effective use of
prescription medicines
A new booklet released recently by the Agency for Health Care
Policy and Research gives consumers the information they need to
talk with their doctors, pharmacists, and other health care
professionals about using prescription medicines safely and
effectively. Prescription Medicines and You: A Consumer
Guide was
developed through a partnership between AHCPR and the National
Council on Patient Information and Education (NCPIE).
Over two-thirds of physician visits end with a prescription being
written. Yet, for some illnesses, up to half of all patients do
not take their prescription medicines correctly, often because of
a lack of information, according to NCPIE Chairman Paul G.
Rogers, J.D. For this reason, it is very important for patients
and health care professionals to work together. For this
partnership to be successful, patients need to know which
questions to ask and what they should tell their doctor,
pharmacist, or nurse to help them get the most from their
medicine.
The booklet urges consumers to get involved in their prescription
medicine use by taking part in decisions about their treatment,
following their treatment plan, and watching for problems and
getting help in solving them.
NCPIE, formed in 1982, is a nonprofit coalition focused on
improving communication between health care professionals and
patients about prescription medicines. This is accomplished
through a variety of educational resources; consumer, patient,
and health professional awareness campaigns; and conferences.
NCPIE's membership includes nearly 300 organizations representing
health professionals, consumers, pharmaceutical companies,
voluntary health agencies, managed care organizations, and the
Food and Drug Administration.
NCPIE sponsors the annual "Talk About Prescriptions" Month each
October. This year's theme is "Team Up and Talk About
Prescriptions."
New audiotape presents information for
consumers who have vision problems
The Agency for Health Care Policy and Research has produced a new
audiotape to help consumers make informed decisions about surgery
and pain control after surgery. The audiotape is a narration of
two AHCPR booklets, Be Informed: Questions To Ask Your Doctor
Before You Have Surgery (Side A) and Pain Control After
Surgery—A Patient's Guide (Side B). Side A provides 12
questions for
patients to ask their primary care doctor and surgeon before
having surgery—and tells why each question is important.
Side B
explains treatment options and provides other information to help
patients suffering from postsurgical pain.
Free single copies of the audiotape (AHCPR 96-DP02) are available
from the AHCPR Publications
Clearinghouse. Supplies are limited. Copies are also
available from
the Library of Congress' Regional and Subregional Libraries for
the Blind and Physically Handicapped. Contact your local
librarian for more information. Both brochures also are available
online. Select Be Informed:
Questions To Ask Your Doctor Before You Have Surgery or Pain Control
After Surgery.
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