President's Essay
danger signs ahead...
he trajectory of change for the health care system foretells
danger signs ahead. It is a course that may lead to poorer outcomes for consumers,
with prospects of higher costs, more barriers to care and missed opportunities
to improve quality. Six years ago, many leaders were enthusiastic about integrated
delivery systems that promised substantial cost savings and a more seamless experience
for patients whose care would be coordinated and managed according to the most
effective medical practices. Now, a powerful backlash against managed care-some
of it well founded-has led to consumer desire for broad provider choice. This,
in turn, is leading to a dismantling of many of the structures that were the source
of optimism.
The key that has reverberated throughout the health system is the retreat of managed
care over the last several years. For reasons that include lack of plan choice
on the part of consumers, physician unhappiness with loss of autonomy and low
fees, clumsy execution on the part of health plans and media attention to these
problems, a virulent backlash has developed against managed care:
- Fearful that their medical care will be compromised, consumers see broad choices among physicians and hospitals as their key protection.
- Employers that pressed employees to enroll in managed care plans have responded to the backlash by demanding that health plans make key changes.
- Plans have responded by including wider provider networks, products that offer direct access to specialists and benefits for out-of-network use, external appeals processes and fewer authorization requirements.
- Governments have directed similar changes through policies that regulate health maintenance organizations (HMOs).
- Higher Costs in 2001
- More Cost Sharing
- New Barriers to Access
- Increase in the Uninsured
- Concerns About Quality of Care
- No Vision Ahead
- References
Higher Costs in 2001
fter remaining under 4 percent from 1995 through 1998, health
insurance premium increases exceeded 8 percent in 2000 and are expected to be
higher in 2001.1 A major determinant of health care
cost trends over the last decade has been the interplay between health costs and
the economy’s performance. Employers started their push to move employees into
managed care plans when health benefit costs were rising rapidly and loomed large
compared with profits. A key sweetener for employees was the fact that the typical
managed care benefit structure offered broader benefits (e.g., preventive services)
and required much less cost sharing than traditional coverage. Indeed, out-of-pocket
spending on medical services for those with insurance declined during the 1990s.2
Of particular note, pharmaceuticals became more affordable to consumers because
of lower cost sharing; in 1999, drugs accounted for 44 percent of the increase
in costs underlying private insurance.3
This was a double-edged sword for consumers. Along with less financial responsibility
for health care came more management of care. But when consumers encountered barriers
to care, or heard through friends or the media about restrictions faced by others,
they complained to their employers and lawmakers. With health care premium trends
decreasing, profits increasing and labor markets unusually tight, employers responded
to these complaints. They offered less restrictive plans with wide networks, direct
access to specialists and fewer restrictions. Many of these changes are leading
to higher costs now.
Another factor driving costs higher is increased provider leverage. More choice
has substantially weakened health plan bargaining power with providers. Hospitals
and some specialty physicians have received substantial rate increases from plans
as a result of consumer and employer demands that plans offer a broad choice of
providers. Indeed, showdowns between health plans and hospitals over contract
terms have occurred in many communities, often with substantial media attention.4
Employer pressure on health plans to minimize instability of provider networks
has further weakened plans’ bargaining position and has led to higher rates.
|
Stuart Altman
Brandeis University |
“Managed care has been defanged, and the leverage providers
have gained will not be easily reversed. This should send a chill down
the backs of employers, public purchasers and consumers because we can
expect our premiums to surge.”
|
More Cost Sharing
he retreat from managed care is likely to lead to much more
extensive cost-sharing responsibilities for consumers. With premiums rising, corporate
profits down and labor markets loosening, employers are beginning to consider
options to keep their benefit outlays from growing rapidly. The backlash against
managed care suggests that patients will have to pay more at the point of service.
A harbinger is the recent action by the California Public Employees’ Retirement
System (CalPERS) to increase cost sharing in its HMO plans as a way to pare down
a negotiated 13 percent premium increase to 6 percent.
Greater cost sharing is likely to take place for two reasons.
- First, with the shift to looser restrictions in managed care moving ahead at full steam, it is unlikely that employers will take a 180-degree turn back to tight restrictions.
- Second, with many restrictions dismantled, the typical managed care benefit structure is increasingly seen as providing inadequate financial incentives to control costs.
|
Karen Ignagni
American Association of Health Plans |
“Policy makers should know that we can’t have it both
ways: we can’t by law or regulation take away basic tools of managed care
or encumber plans, employers and doctors with more liability, and then
still expect the system to deliver on its promise.”
|
New Barriers to Access
isruptions to the health system caused by the retreat from
managed care are also posing barriers to access to care. For the first time in
decades, hospital capacity problems have emerged in a number of communities. Most
visible are problems in emergency departments, where ambulance diversions are
occurring with increasing frequency, resulting in patients being rerouted to other
hospitals and delays in care.5 Some of the reasons
for crowding include regulations limiting managed care restrictions on emergency
room use, stepped-up enforcement of the Emergency Medical Treatment and Labor
Act and acute shortages of nurses and other skilled personnel.
Overall hospital capacity has played a role as well. From 1994 to 1999, the number
of emergency departments declined by 8 percent. Patients who need intensive care
when beds are not available often must remain in the emergency department to get
the care they need. Over the same period, inpatient beds declined by 15 percent,
as intense pressure to cut costs coming from both low payment rates in managed
care contracts and reductions in the growth of Medicare payment rates under the
1997 Balanced Budget Act led to closure of capacity deemed not essential. With
hospitals vigorously adding facilities to provide the most prestigious and profitable
services, investing in emergency facilities, which tend to lose money, may be
losing out in the competition for scarce capital resources.
A different type of barrier to access seen over the past two years is network
instability. In many communities, important providers have declined to renew contracts
with health plans, largely because of disagreements over payment rates. For example,
in Orange County, Calif., St. Joseph Health System terminated the largest of its
managed care contracts, with PacifiCare, affecting 100,000 consumers.
Such terminations can be highly disruptive to consumers, who often face a choice
of changing providers—perhaps during a course of treatment—or paying substantially
more out of pocket.6, 7 Closures
of physician organizations, such as medical groups owned by failed physician practice
management companies, also contribute to network instability.
|
James Bentley
American Hospital Association |
“Many hospitals are experiencing emergency room capacity
problems and staff shortages and expect things to get worse before they
get better. Looser managed care has resulted in patient logjams, and with
premiums rising hospitals are likely to treat growing numbers of uninsured
who have no place else to go.”
|
Increase in the Uninsured
s we enter a period in which the economy may not be as robust
and insurance premiums are increasing more rapidly again—in part due to the retreat
from managed care—the proportion of people who are uninsured is likely to increase.
The literature suggests a substantial sensitivity of health insurance coverage
to premiums.8
Federal policy might offset this trend somewhat. Over the past year, diverse interest
groups have reached out to each other to work on legislation to reduce the number
of uninsured.9 Many envision a compromise consisting
of expansions of public programs providing coverage for the poor and tax credits
for individuals with somewhat higher incomes to purchase private insurance. Initially,
enactment of proposed federal legislation to expand public programs and offer
tax credits to purchase coverage would outweigh the erosion of coverage from higher
premiums. However, it is clear that rising health care costs will outstrip the
gains over time, making the goal of universal coverage more difficult to reach.
Another dynamic affecting insurance coverage is state and local policy for the
low-income uninsured. In recent site visits to 12 nationally representative communities,
HSC noticed increased support at the state and local level for funding safety
net providers, such as public hospitals and community health centers. A number
of states, for example, have devoted large portions of tobacco settlement money
to the safety net.
Although some analysts have raised the conceptual choice between policies promoting
expansion of coverage and those providing more services for the uninsured, HSC
has found that communities pursuing efforts in this area are doing more on both
counts. President Bush has put forward initiatives related to both care and coverage.
Discussions may lead to a consensus that some low-income individuals can best
be assisted by enabling them to obtain health insurance coverage while others
cannot be brought into the health insurance system and are best supported through
funding safety net providers.
|
John Rother
AARP |
“Shifting costs onto consumers—directly or through artfully
constructed defined-contribution schemes—is not the solution to rising
premiums. The end result may be higher barriers to needed services and,
ultimately, fewer working Americans with health insurance.”
|
Concerns About Quality of Care
ntegrated delivery had offered the hope of accountability
for the quality of care provided to an enrolled population. The movement away
from integrated delivery systems and capitated payment of provider organizations—aspects
of the retreat from managed care—is removing a potential platform for providers
to improve quality. Integrated delivery systems were seen as improving quality
through the use of evidence-based medicine applied to the needs of a defined population.
Although longstanding integrated delivery systems, such as Kaiser Permanente,
are pursuing this vision vigorously, the expectation of creating many more such
systems has diminished. Some of this occurred because of the difficulty of getting
large organizations with different cultures to work together effectively, but
the retreat from managed care may have been a more significant blow.
The desire for broad provider choice has meant that the archetypical integrated
delivery insurance product— an HMO with the provider network comprising a single
hospital system and physicians associated with it—is not an attractive one. HMOs
today tend to offer enrollees access to most hospital systems in the area. Furthermore,
in many communities, interest in HMO products has declined.
In addition, global capitation— hospitals and physicians together assuming all
financial risk for health services— has not developed as expected. Both providers
and health plans have pulled away from this arrangement over the past two years.
In many cases, this retrenchment has been the result of unfavorable experience—providers
losing money or plans having to support providers in financial difficulty. But
the lack of growth in the market share of HMO products is an important factor
as well. Preferred provider organizations (PPOs) do not lend themselves to capitated
payment, and providers report important difficulties in accepting risk in point-of-service
(POS) products.
The absence of capitated payment undermines the business case for providers to
engage in quality improvement activities. For example, when hospitals are paid
on a per diem basis, programs to reduce length of stay detract from the bottom
line. When disease management programs have significant educational components
or require investment in information systems by physician practices paid under
fee-for-service arrangements, the practices receive lower payment for physician
services but are not paid for the services that are a substitute for seeing the
doctor. The potential exists for disease management and other such programs to
fall out of favor, leaving patients facing fractured, uncoordinated and, potentially,
poor-quality care. According to the recent Institute of Medicine report, Crossing
the Quality Chasm,10 the lack of functioning
systems and related incentives is at the heart of quality problems plaguing health
care in this country.
|
Janet Corrigan
Institute of Medicine |
“Quality of care is a concern across all sectors, in large
part because there is no system but rather an aggregation of many parts
with little coordination among them. It is unclear what kinds of organizations
will integrate care in the future, but they should include science-based
practice, well-designed care processes and programs to improve population
health.”
|
No Vision Ahead
any people perceive the retreat from managed care to be a
positive development and welcome less interference with delivery of care. But
the retreat has set in motion a number of negative trends for consumers.
- Cost trends will be higher and consumers will face more cost sharing.
- New barriers to access are appearing, such as capacity shortages in emergency departments and disruptions in physician-patient relationships because of network instability.
- Higher costs will lead to more people going without coverage, although public policy to expand coverage may postpone this development.
- The integrated deliver platform to improve quality has been stymied by consumer demands for broad provider choice.
References
| 1. | Gabel, Jon R., “Job-Based Health Insurance in 2000: Premiums Rose Sharply While Coverage Grows,” Health Affairs, Vol. 19, No. 5 (September/October 2000). |
| 2. | Gabel, Jon R., Paul B. Ginsburg, Jeremy Pickreign and James D. Reschovsky, “Trends in Out-of-Pocket Spending by Insured American Workers, 1990-1997,” Health Affairs, Vol. 20, No. 2 (March/April 2001). |
| 3. | Hogan, Christopher, Paul B. Ginsburg and Jon R. Gabel, “Tracking Health Care Costs: Inflation Returns,” Health Affairs, Vol. 19, No. 6 (November/December 2000). |
| 4. | Strunk, Bradley C., Kelly J. Devers and Robert E. Hurley, Health Plan-Provider Showdowns on the Rise, Issue Brief No. 40, Center for Studying Health System Change, Washington, DC (June 2001). |
| 5. | Brewster, Linda R., Liza S. Rudell and Cara S. Lesser, Emergency Room Diversions: A Symptom of Hospitals Under Stress, Issue Brief No. 38, Center for Studying Health System Change, Washington, DC (May 2001). |
| 6. | Strunk et al., op. cit. |
| 7. | Short, Ashley C., Glen P. Mays and Timothy K. Lake, Provider Network Instability: Implications for Choice, Costs and Continuity of Care, Issue Brief No. 39, Center for Studying Health System Change, Washington, DC (June 2001). |
| 8. | Kronick, Richard, and Todd Gilmer, “Explaining the Decline in Health Insurance Coverage, 1979-1995,” Health Affairs, Vol. 18, No. 2 (March/April 1999). |
| 9. | Kahn, III, Charles N., and Ronald Pollack, “Building a Consensus for Expanding Health Coverage,” Health Affairs, Vol. 20, No. 1 (January/February 2001). |
| 10. | Institute of Medicine, Crossing the Quality Chasm, Washington, DC: National Academy Press (2001). |
HSC's New Direction | Mission and Vision
...new direction
hen The Robert Wood Johnson Foundation (RWJF) and Mathematica,
Inc., formed HSC in 1995, many policy and industry leaders shared a common vision
of the road ahead for health care. They saw a reliance on managed care, integrated
delivery systems and private markets as the way to contain costs and enhance quality,
although many worried about how the uninsured would fare as this experiment unfolded.
For the past six years, HSC has tracked changes in the health care system and
assessed the implications for both insured and uninsured people through site visits
and surveys, informing policy makers about how health care continues to evolve
and, in some cases, unravel. Through interviews with consumers, physicians and
leaders on the front lines of health care delivery and financing, HSC researchers
have worked to decipher the twists and turns of the health system to determine
the bottom line for patients.
RWJF was visionary in establishing an authoritative information source about the
market forces and regulatory changes transforming the nation’s health care system.
At the time, much existing information was anecdotal, dated or focused on cutting-edge
communities. Little was known about how changes in health system organization
at the market level, as well as local and national policy initiatives, affected
coverage, access to care for the uninsured, quality and costs. Policy makers often
lacked credible information, often needing to rely on research produced by special
interests or think tanks with strong ideological points of view.
- In its six years, HSC has:
- The Community Tracking Study (CTS)
- HSC Mission
- HSC Vision
- Key Policy Area 1 - Private Insurance Coverage
- Key Policy Area 2 - Access to Care for the Uninsured
- Key Policy Area 3 - Managed Care and Markets
- Making HSC's Data More Accessible
- Strategically Managing Research and Dissemination for Maximum Policy Impact
In its six years, HSC has:
- Designed, launched and refined a major data collection effort focused on private-market dynamics. Currently in its third round, the Community Tracking Study includes multiple, national surveys and visits to local communities. This combination of surveys and site visits provides HSC with a real-world focus and the ability to examine the interplay among health care sectors and between the private market and public policy at the community and national levels.
- Established a policy research program noted for its objectivity
and focused on providing information for policy makers concerned about growing
numbers of uninsured, rising costs, access to care under managed care and
other pressing policy issues.
- Developed a visible public affairs effort, including numerous publications, regular conferences, extensive contact with news media and ongoing interaction with the health policy community.
Through the strategic-planning process, HSC honed its mission, crafted a vision statement to chart the organization’s course and developed goals and objectives to enhance the policy impact of HSC’s research.
The Community Tracking Study (CTS)
...national in scope, focused at the local level
ational in scope but focused on communities where care is
organized and delivered, the CTS consists of national surveys every other year
of households and physicians and visits to 12 communities. A third survey of employers
was conducted in 1997.
The telephone surveys are concentrated in 60 communities and have a panel of respondents
carried over from previous rounds for tracking purposes. The third round of site
visits was completed in March 2001, and the third round of the surveys also will
be completed in 2001.
- Household Survey. Sixty-thousand individuals in 33,000 families participate in the Household Survey, which assesses whether consumer access to the health care system is improving or declining over time. Particular areas of inquiry include access, satisfaction, use of services and insurance coverage. Information about health status and sociodemographic characteristics is also collected. An Insurance Followback Survey of the plans that household respondents are enrolled in is conducted to enhance reliability. Mathematica Policy Research, Inc., (MPR) conducts the Household and Followback Surveys for HSC.
- Physician Survey. Twelve thousand practicing physicians across the country provide perspective on how health care delivery is changing. Physicians answer questions about compensation, whether they are able to provide needed services for patients and the effect various care management strategies have on their practices. Gallup conducts the Physician Survey for HSC.
- Employer Survey. Twenty-two thousand public and private employers were interviewed to understand how they are shaping the health system. These employers, which span size and industry sector, are asked questions about the choice of plans they offer, how much their employees contribute to the cost of coverage, whether they participate in a purchasing alliance and whether they provide quality information to their employees. HSC collaborated with RAND on the Employer Survey.
- Site Visits. Researchers examine the forces affecting health care organizations and how they are responding by interviewing 50 to 80 health care leaders in 12 sites: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich; Little Rock, Ark.; Miami; Northern New Jersey; Orange County, Calif; Phoenix; Seattle; and Syracuse, N.Y. The interviews generally cover hospital systems, employers, benefits consultants, health plans, medical groups, safety net providers and consumer groups.
- CTS-Related Research. Other RWJF initiatives related to the CTS include: RAND researchers Beth McGlynn and Steve Asch’s work to analyze the quality of care in HSC’s 12 communities; efforts by UCLA/RAND researchers, including Kenneth Wells, Audrey Burman and Roland Sturm, to examine how public policies and markets affect access to substance abuse and mental health services; RAND researchers Stephen Long and Susan Marquis’ analysis of employment-based health insurance; and research by Stephen Shortell at the University of California at Berkeley analyzing physician organizations. National in scope, focused at the local level The Community Tracking Study (CTS)
SC’s
mission is to inform policy discussions about how changes in national and local
health care markets affect people’s healthcare. HSC collects and analyzes data
from those who finance, deliver and receive health care services. HSC provides
timely, objective and incisive analyses on health care developments of national
significance, thereby enhancing policy makers’ capability to improve health and
health care.
HSC
Vision
SC
is committed to becoming the leading health policy research organization devoted
to understanding developments in health care markets and communities and the effect
on people’s health care.
HSC’s new mission focuses the organization’s purpose and clearly identifies its
primary audience—policy makers. The mission statement, coupled with HSC’s vision,
has already guided HSC leaders and staff as they map out a research agenda and
make data collection design decisions.
The most important HSC strategic planning goals are as follows:
- Establish key policy research areas and provide both narrow analyses and
broader syntheses of relevant topics.
- Private insurance coverage
- Access to care for the uninsured
- Managed care and markets
- Make HSC’s rich and varied data— already widely available to researchers— more accessible to policy makers and the news media.
- Manage research planning and dissemination of findings strategically to have maximum impact on health policy.
Key Policy Area 1 - Private Insurance Coverage
or nine of the last 10 years and during the longest economic
expansion in American history, the number of Americans without health insurance
has increased. Today, there are almost 43 million uninsured people— nearly 10
million more than a decade ago. In the near term, rising premiums will likely
drive the number of uninsured even higher and affect the kind of coverage people
have and how much they have to pay for it.
Incremental coverage proposals at the state and federal levels are numerous and
gathering some steam, including tax credits targeted at employers and the individual
market and expansion of public programs. HSC will continue to draw on its understanding
of consumers, employers, providers and health plans to assess the current and
future behavior of these groups and how they interact with respect to insurance
coverage.
Recent and planned HSC analyses on this topic are numerous and varied. Selected
examples follow: Why don’t people take advantage of employer-sponsored insurance
offered to them? How have small firms’ offer and take-up rates changed over time
and why? Where should tax credits be targeted—individuals, families or employers?
How effective would a tax credit be in communities with high uninsurance rates
or in areas where the uninsured are less healthy?
As the economy falters and labor markets loosen, employers already are changing
or paring back health benefits and shifting costs to employees. HSC researchers
have tracked—and will continue to track—changes in types of insurance coverage,
benefit design and who bears the cost of coverage. As HSC did with defined contributions,
it will strive to anticipate possible new models of insurance and their implications,
particularly how costs, risk and responsibility for decisions are shared between
employers and employees.
Related Publications by HSC Staff
Inquiry, Vol. 37, No. 1 Spring 2001What Accounts for Variation in Uninsurance Rates Across Communities?
by Peter J. Cunningham and Paul B. Ginsburg Issue Brief No. 36 April 2001
Tax Credits and Purchasing Pools: Will this Marriage Work?
by Sally Trude and Paul B. Ginsburg Issue Brief No. 32 October 2000
Are Defined Contributions a New Direction for Employer-Sponsored Coverage?
by Sally Trude and Paul B. Ginsburg
|
Speaking about various defined-contribution schemes, HSC
senior researcher Sally Trude warns, “Older and sicker workers may be
unable to obtain or afford health insurance.”
—Medicine & Health, November 13, 2000
|
Key Policy Area 2 - Access to Care for the Uninsured
Rising numbers of uninsured will increase the burden on safety net providers. These hospitals, community health centers and other organizations are stretched thin already and are facing financial pressures from managed care and cuts in federal subsidies. Through site visits and the CTS Household Survey, HSC monitors the capacity and financial viability of the safety net as markets become more competitive, insurance expansions are implemented and innovative ways to provide uncompensated care— such as through managed care—are put in place. Drawing on the CTS Physician Survey, HSC also examines the role doctors play in providing charity care and how that care may be evolving under managed care and other market forces. How might a Bush Administration initiative— that includes an expansion of the safety net through community health centers and tax credits—enhance coverage while improving access to care for those who remain uninsured? Earlier HSC research suggests that expansions in insurance coverage are more effective in improving access for the uninsured than expanding direct care services. HSC is continuing research in this area by examining variation across markets in the use of insurance expansions versus directly supporting the safety net and assessing the effectiveness of these different approaches. The results of these and related studies will provide policy makers with a clearer picture of how successful the mixed approach may be in improving access, or whether it reinforces the existing two-tier system of care. As these changes unfold, ongoing tracking of uninsured persons’ ability to access care will provide a strong indicator of whether the safety net, while frail, remains largely intact HSC’s current research suggests—or is fraying and putting people in jeopardy. Related Publications by HSC Staff Issue Brief No.38 May 2001Emergency Room Diversions: A Symptom of Hospitals Under Stress
by Linda R. Brewster, Liza S. Rudell and Cara S. Lesser Issue Brief No. 34 January 2001
Race, Ethnicity and Preventive Services: No Gains for Hispanics
by J. Lee Hargraves Data Bulletin No. 19 October 2000
Some Communities Make Progress in Reducing Children's Uninsurance
by Michael H. Park and Peter J. Cunningham
|
"The most troubling trend is the increase in uninsured
low-income parents who, unlike their children, do not have access to public
programs," said Peter Cunningham, author of a study on the uninsured
that showed a significant increase in the percentage of uninsured working
parents - from 31 percent to 35 percent between 1997 and 1999.
—Associated Press, April 24, 2000
|
Key Policy Area 3 - Managed Care and Markets
anaged care is increasingly regulated, in part because of
consumer concerns about how cost-containment techniques affect quality. HSC research
has tracked the extent of such techniques and examined how they may be affecting
care delivery and consumer and physician perceptions of quality. Contrary to the
anecdotes, HSC researchers have found few differences in access and use of services
among types of managed care plans and between managed care and indemnity insurance.
At the same time, HSC found that negative perceptions about HMOs taint people’s
ratings of their health care.
Drawing on successive rounds of site visits, HSC has tracked the evolution of
managed care and helped policy makers to understand implications of the consumer
backlash that is now dismantling the original vision. In the future, HSC will
document whether consumer satisfaction improves as plans relax care management
and whether physicians have less trouble obtaining needed services for patients—or
more problems, as may be the case for hospital services.
Burgeoning health care information on the Internet, the rising tide of aging baby
boomers who promise to be far more demanding consumers and other factors portend
a new age of consumerism in health care. It is interesting to note that HSC research
has found that consumers are not all that knowledgeable about how their health
plans work. HSC surveys will continue to track how consumer access to information
may affect patient-physician interactions and, from doctors’ perspective, the
cost and quality of care.
Market changes—including instability in health plan provider networks, consolidation
among providers and insurers and the loosening of managed care—could lead to a
range of policy responses or a decision to back away from regulation. For example,
greater market consolidation of plans or hospitals may lead to antitrust actions
or attempts to limit rate increases. On the other hand, some aspects of proposed
federal patient protection legislation may be moot as plans move to provide better
access to specialists and discard preauthorization requirements.
Related Publications by HSC Staff
Health Affairs, Vol. 20, No. 2 March/April 2001 Do Consumers Know How Their Health Plan Works?
by Peter J. Cunningham, Charles Denk and Michael Sinclair Issue Brief No. 35 February 2001
Back to the Future? New Cost and Access Challenges Emerge: Initial Findings from HSC’s Recent Site Visits
by Cara S. Lesser and Paul B. Ginsburg Issue Brief No. 30 September 2000
Health Care Perceptions and Experiences: It’s Not Whether You Are in an HMO, It’s Whether You Think You Are
by James D. Reschovsky and J. Lee Hargraves
|
"We have been through a lot, and we're not any closer
to a long-term resolution of the system's fundamental problems,"
says Paul Ginsburg, president of a Washington, D.C., think tank called
the Center for Studying Health Systems Change.
—The Wall Street Journal, February 21, 2001 |
Making HSC's Data More Accessible
ith each successive round, HSC’s multiple surveys and site
visit data grow in value because they document changes in health care over a longer
period. By gathering information from all the major actors— consumers, purchasers,
health plans, physicians and hospitals—in the same markets, HSC can reveal to
policy makers the various dynamics and perspectives shaping health care at the
community and national levels.
HSC has made CTS survey data available quickly to researchers in public-use files
accessible over its Web site, generally within a year. Now, HSC is taking the
step to make survey data available to a broader audience through regular, descriptive
trend reports on key indicators largely related to its three main policy areas.
For private insurance coverage, HSC will issue regular reports on who does and
does not have coverage, offering behavior of employers, employee take-up of insurance
and other factors. For access to care for the uninsured, there will be reports
on an array of access measures, racial and ethnic disparities and other topics.
And for managed care and markets, HSC will issue reports on access and quality
under managed care, prevalence of care management techniques and other indicators.
These reports will serve to put emerging issues on policy makers’ radar screens
and confirm or refute anecdotes—guiding policy makers about whether intervention
is warranted.
HSC also will take steps to better acquaint the policy research community with
the CTS and is considering ways to create additional data files that are more
accessible to policy makers and the news media.
Strategically Managing Research and Dissemination for Maximum Policy Impact
SC is committed to strategically managing and disseminating
its research for maximum policy impact. As part of this commitment, HSC will deepen
existing relationships and build new ones with congressional and agency staff,
industry associations and consumer groups to help anticipate emerging policy topics
and discern information gaps about current issues. These interactions, both through
formal forums, such as speaking engagements and congressional testimony, and informal
exchanges, such as briefings and discussions about market trends and related policy,
are guiding HSC in developing research that helps policy makers come up with practical,
real-world solutions to health care problems and challenges.
Over the last two years, the HSC Users’ Advisory Committee—which includes prominent
experts from leading consumer and employer groups, policy organizations and industry
associations— has provided important guidance in developing HSC’s research agenda.
In addition to this committee, many other less formal relationships with policy
makers, and relationships with policy research colleagues at MPR, are helping
to link HSC’s research to the policy community. HSC will work over the coming
years to make those connections even stronger.
Finally, HSC will continue working closely with journalists who serve as a critical
filter for policy makers inundated with health policy research. Over the last
few years, the media increasingly have turned to HSC as an honest broker of information,
viewing it as an organization that is not beholden to special interests or an
ideological point of view. Both news coverage of HSC and visits to HSC’s Web site—www.hschange.org—are
up significantly.
The key strategic planning goals— establishing a policy research focus in three
main areas, making data more accessible and widely available and managing the
research and dissemination process for maximum policy impact—represent the cornerstone
of HSC’s future and promise to make the organization an even more important resource
for the policy community.
More About HSC | Supporting RWJF's Mission
...informing and supporting
long with other grantees, HSC informs the research and program
activities at RWJF, helping to support the Foundation’s overall mission to improve
the health and health care of all Americans. HSC is a major component of RWJF’s
Health Tracking initiative, which features a network of research organizations
studying various facets of the changing health care system at the national and
local levels. Specifically, HSC’s research contributes to understanding what is
working well in the American health care system and what is failing, both at the
national level and in communities across the country.
The Foundation concentrates grant-making support in three broad areas: access
to care, substance abuse and chronic care. These also are areas covered by the
network of organizations associated with HSC’s Community Tracking Study (see
p. 11). To accomplish its overall goals, RWJF supports research and evaluation,
training and education, program demonstrations and communications.
James Knickman, vice president for evaluation and research, and Robert
Hughes, vice president, initiated the network of organizations focused on
tracking change and nurtured its development over the last six years. Both continue
to play a leadership role with respect to the research network. Along with them,
Maureen Michael, program officer, provides leadership to the project and
is responsible for managing the network day to day. Paul Tarini, senior
communications officer, provides public affairs counsel to the project, and Rona
Henry, senior financial officer, provides financial oversight. HSC is among
the many projects under RWJF’s Health Care Group led by Risa Lavizzo-Mourey,
M.D., senior vice president and director.
HSC Staff
Paul B. Ginsburg, Ph.D., PresidentPeter Kemper, Ph.D., Vice President
Joy M. Grossman, Ph.D., Associate Director
Ann C. Greiner, M.C.P., Director of Public Affairs Peter J. Cunningham, Ph.D., Senior Health Researcher
Jack Hadley, Ph.D., Visiting Scholar
James D. Reschovsky, Ph.D., Senior Health Researcher
Jeffrey J. Stoddard, M.D., Senior Physician Researcher
Sally Trude, Ph.D., Senior Health Researcher
Alwyn Cassil, Public Affairs Manager
Kelly J. Devers, Ph.D., Health Researcher
J. Lee Hargraves, Ph.D., Health Researcher
Cara S. Lesser, M.P.P., Health Researcher
Ha T. Tu, M.P.A., Health Researcher
Laurie E. Felland, M.S., Health Research Analyst
Leslie A. Jackson, M.H.S., Health Research Analyst
Tad Lee, Public Affairs Specialist
Marie C. Reed, M.H.S., Health Research Analyst
Elizabeth A. Schaefer, M.A., Health Research Analyst Andrea Benoit, Health Research Assistant
Elizabeth Eagan, Health Research Assistant
Liza S. Rudell, Health Research Assistant
Ashley C. Short, Health Research Assistant
Bradley C. Strunk, Health Research Assistant
Kara Miller, Project Assistant Teresa Armstrong, Manager of Administration
Robin Clemente, Executive Assistant
Roland Edwards, Senior Public Affairs Coordinator
Donna Lovelace, Research Coordinator
Bridget O'Leary, Executive Secretary
Mukarrama Terrell, Public Affairs Assistant
Selected Staff Biographies
Paul B. Ginsburg, Ph.D., president, is nationally recognized for his work in health economics and health policy, especially health care market changes and cost trends. He previously served as executive director of the Physician Payment Review Commission and as deputy assistant director of the Congressional Budget Office. Ginsburg earned his doctorate in economics from Harvard University. Peter Kemper, Ph.D., vice president, has been principal investigator of the Community Tracking Study since HSC’s inception. He is a nationally recognized expert on care of the elderly and the effects of managed care. He was formerly director of the long-term care division of the Agency for Health Care Policy and Research, now the Agency for Healthcare Research and Quality (AHRQ), and director of the Madison, Wis., office of MPR. Kemper received his doctorate in economics from Yale University. Joy M. Grossman, Ph.D., associate director, oversees HSC’s data collection and research activities. Her research specialties are health plan and provider competition and managed care. She previously was a health policy analyst at the Prospective Payment Assessment Commission and an investment banker. Grossman received her doctorate in economics from the University of California at Berkeley. Ann C. Greiner, M.C.P., director of public affairs, oversees HSC’s publications, conferences and outreach activities. Previously, she was an assistant vice president at the National Committee for Quality Assurance, directing communications and marketing efforts, and served as a research associate at the Economic Policy Institute. Greiner holds a master’s degree in urban planning from the Massachusetts Institute of Technology. Peter J. Cunningham, Ph.D., senior health researcher, specializes in access, the uninsured and safety net issues. Previously, he was a researcher at AHRQ, where he worked on the National Medical Expenditure Survey. Cunningham received his doctorate in sociology from Purdue University. Jack Hadley, Ph.D., visiting scholar, is a principal research associate at the Urban Institute’s Health Policy Center. He is a past president of the Association for Health Services Research and a former editor of Inquiry. His work with HSC focuses on studies of the health insurance market and physician behavior. Hadley received his doctorate in economics from Yale University. James D. Reschovsky, Ph.D., senior health researcher, leads HSC’s research efforts in health care delivery and quality. His research focuses on health care, insurance and managed care issues. Previously, he held academic positions at Michigan State University and Cornell University and was a research fellow at AHRQ. Reschovsky received his doctorate in public policy studies from the University of Michigan. Jeffrey J. Stoddard, M.D., senior physician researcher, specializes in service delivery, physician and children’s issues. A practicing pediatrician, he previously held a faculty position at the University of Wisconsin Medical School. Stoddard received his medical degree from the University of Wisconsin Medical School and completed his pediatric residency at The Johns Hopkins Hospital. He also completed a postdoctoral fellowship sponsored by the Pew Health Policy Program at the University of California at San Francisco. Sally Trude, Ph.D., senior health researcher, specializes in managed care and physician issues. Previously, she was a senior analyst at the Medicare Payment Advisory Commission and the Physician Payment Review Commission and a health policy analyst at RAND. Trude received her doctorate in public policy analysis from RAND. Alwyn Cassil, public affairs manager, handles HSC’s media relations and publications. Previously, she was a press officer at the U.S. Department of Health and Human Services’ Office of Inspector General and Health Care Financing Administration and Washington editor of AHA News, the weekly newspaper published by the American Hospital Association. She received a bachelor’s degree in journalism from the University of Florida. Kelly J. Devers, Ph.D., health researcher, specializes in managed care, provider organizations and competition. She also has expertise in qualitative and mixed-methods research. Previously, she was a senior research fellow at AHRQ. Devers received her doctorate in sociology from Northwestern University and completed a postdoctoral fellowship at the University of California at Berkeley and San Francisco. J. Lee Hargraves, Ph.D., health researcher, specializes in patient and consumer assessments of health care and quality of medical care. He was a senior survey scientist at the Picker Institute, where he was an investigator on AHRQ’s Consumer Assessment of Health Plans (CAHPS) project. Hargraves received his doctorate in sociology from Boston College. Cara S. Lesser, M.P.P., health researcher, directs HSC’s site visit work and specializes in market change issues. Previously, she was a senior research associate at the Institute for Health Policy Studies at the University of California at San Francisco. Lesser received her master’s degree in public policy from the University of California at Berkeley. Ha T. Tu, M.P.A., Health researcher, focuses on service delivery issues. She was an economic consultant to the Center for Health Policy Studies in Columbia, Md., and the Health Care Financing Administration. Tu holds a master’s degree in applied economics from Princeton University.Recent HSC Publications
Issue Briefs
30 Health Care Perceptions and Experiences: It’s Not Whether You Are in an HMO, It’s Whether You Think You Are by James D. Reschovsky and J. Lee Hargraves 31 Wall Street Comes to Washington: Market Watchers Evaluate the Health Care System 32 Are Defined Contributions a New Direction for Employer-Sponsored Coverage? by Sally Trude and Paul B. Ginsburg 33 At the Brink: How Harvard Pilgrim Got in Trouble by Linda R. Brewster and Paul B. Ginsburg 34 Race, Ethnicity and Preventive Services: No Gains for Hispanics by J. Lee Hargraves 35 Back to the Future? New Cost and Access Challenges Emerge: Initial Findings from HSC’s Recent Site Visits by Cara S. Lesser and Paul B. Ginsburg 36 Tax Credits and Purchasing Pools: Will this Marriage Work? by Sally Trude and Paul B. Ginsburg 37 Defined Contributions: The Search for a New Vision 38 Emergency Room Diversions: A Symptom of Hospitals Under Stress by Linda R. Brewster, Liza S. Rudell and Cara S. Lesser 39 Provider Network Instability: Implications for Choice, Costs and Continuity of Care by Ashley C. Short, Glen P. Mays and Timothy K. Lake 40 Health Plan-Provider Showdowns on the Rise by Bradley C. Strunk, Kelly J. Devers and Robert E. HurleyData Bulletins
19 Some Communities Make Progress in Reducing Children's Uninsurance by Michael H. Park and Peter J. Cunningham. 20 Tracking Health Care Costs: An Upswing in Premiums and Costs Underlying Health InsuranceCommunity Reports
1 Indianpolis, Ind., Provider Systems Thrive in Robust Economy 2 Cleveland, Ohio, Increased Consolidation Raises Concerns 3 Seattle, Wash., Market Instability Puts Future of HMO's in Question 4 Phoenix, Ariz., Rapid Population Growth Attracts National Firms 5 Syracuse, N.Y., Insurers Consolidate, Hospitals Struggle Financially 6 Lansing, Mich., Highly Consolidate, Market Poses Cost Control Challenges 7 Greenville, S.C., Hospitals Compete for More Competition 8 Little Rock, Ark., Hopes Dim for More Competition 9 Orange County, Califk., HMO Model Shaken but Remains Intact 10 Miami, Fla., Hospitals Profit from Aggressive Negotiations 11 Boston, Mass., upcoming Summer 2001 12 Northern New Jersey, upcoming Summer 2001Journal Articles and Book by HSC Staff and Collaborators
Understanding Health System Change: Local Markets, National Trends, edited by Paul B. Ginsburg and Cara S. Lesser. Chicago, IL: Health Administration Press, June 2001. “What Accounts for Variations in Uninsur-ance Rates Across Communities?” Peter J. Cunningham and Paul B. Ginsburg. Inquiry, Vol. 37, No. 1 (Spring 2001). “Do Consumers Know How Their Health Plan Works?” Peter J. Cunningham, Charles Denk and Michael Sinclair. Health Affairs, Vol. 20, No. 2 (March/April 2001). “Trends in Out-of-Pocket Spending by Insured American Workers, 1990-1997,” Jon R. Gabel, Paul B. Ginsburg, Jeremy D. Pickreign and James D. Reschovsky. Health Affairs, Vol. 20, No. 2 (March/April 2001). “Physicians’ Assessments of the Ability to Provide High Quality Care in a Changing Health Care System,” James D. Reschovsky, Marie Reed, David Blumenthal and Bruce Landon, Medical Care, Vol. 39, No. 3 (2001). “Tracking Health Care Costs: Inflation Is Back,” Christopher Hogan, Paul B. Ginsburg and Jon R. Gabel. Health Affairs, Vol. 19, No. 6 (November/December 2000). “Update on the Nation’s Health Care System: Results from Tracking Change in 12 Communities,” Cara S. Lesser and Paul B. Ginsburg. Health Affairs, Vol. 19, No. 6 (November/December 2000). “Withering on the Vine: The Decline of Indemnity Insurance,” Jon R. Gabel, Paul B. Ginsburg, Heidi H. Whitmore and Jeremy D. Pickreign. Health Affairs, Vol. 19, No. 5 (September/October 2000).HSC and MPR
ince its founding, HSC has been a sister organization to Mathematica
Policy Research, Inc. Both organizations share a strong commitment to producing
objective, high-quality policy research and providing sound information for decision
makers. MPR has conducted some of the most important evaluations of key federal,
state and local public programs and demonstrations. These studies have focused
on issues across the lifespan, from children’s health and welfare to long-term
care for the elderly.
In addition to sharing values, both organizations are housed in the same Washington,
D.C., location and have a common administrative infrastructure, including contracting,
human resources, library services, accounting/payroll and facilities management.
MPR also has offices in Princeton, N.J., Cambridge, Mass., and Columbia, Md.
MPR staff are key contributors to HSC’s data collection and analysis work. Specifically,
MPR conducts the CTS Household Survey and Insurance Followback Survey on behalf
of HSC and oversees management of the Physician Survey. In addition, HSC draws
on MPR staff for specialized assistance, including Frank Potter, senior
statistician, for statistical support, and Richard Strouse, vice president,
for overall survey management and design support. Finally, MPR researchers are
actively participating in HSC’s third round of site visits.
HSC and Mathematica, Inc.
Mathematica, Inc., is the employee-owned parent company of MPR and HSC, and certain officers of Mathematica, Inc., are affiliated with HSC. Charles Metcalf, Ph.D., President, Mathematica, Inc.Don F. Lara, Senior Vice President and Director of Administration, Mathematica, Inc., and Vice President, HSC
Jay B. Style, M.B.A., Vice President, Controller and Treasurer, Mathematica, Inc., and Vice President, HSC
Patrick Mooney, Vice President and Director of Human Resources, Mathematica, Inc., and Vice President, HSC
HSC Board of Directors
SC is guided by a board that includes members of Mathematica’s
board of directors and key MPR staff.
Anita Summers, Emeritus Professor of Public Policy and Management, University
of Pennsylvania; Chair
Harold Beebout, Senior Vice President, Mathematica, Inc.
George Carcagno, Executive Vice President, Mathematica, Inc.
Paul B. Ginsburg, President, HSC
Peter Kemper, Vice President, HSC
Stuart Kerachsky, Senior Vice President and Director of Research, Mathematica
Policy Research, Inc.
Charles Metcalf, President, Mathematica, Inc.
Margo Rosenbach, Vice President, Mathematica Policy Research, Inc. Donald Steinwachs, Professor and Chair, Department of Health Policy and Management; Director, Health Services Research and Development Center, The Johns Hopkins University Craig Thornton, Senior Fellow, Mathematica Policy Research, Inc.
HSC Advisory Committees
Users’ Group * Linda Bilheimer, Ph.D., The Robert Wood Johnson FoundationRobert A. Berenson, M.D., Health Care Financing Administration
Mary Jane England, MD, Washington Business Group on Health
Bill Gradison, Patton Boggs, LLP
Paul Griner, MD, Association of American Medical Colleges
David Helms, Ph.D., Academy for Health Services Research and Health Policy
Julia A. James, Health Policy Alternatives, Inc.
Judith Miller Jones, National Health Policy Forum
Margaret E. O’Kane, National Committee for Quality Assurance
Ronald F. Pollack, Families USA
Roger S. Taylor, MD, M.P.A., RAND
Bruce C. Vladeck, Ph.D., Mount Sinai School of Medicine
William Winkenwerder, MD, Blue Cross Blue Shield of Massachusetts Researchers’ Group * Stephen Asch, MD, RAND
David Blumenthal, MD, M.P.P., Massachusetts General Hospital
Lawrence D. Brown, Ph.D., Columbia University School of Public Health
Jon B. Christianson, Ph.D., University of Minnesota, Carlson School of Management
Mary L. Durham, Ph.D., Kaiser Permanente Center for Health Research
Stephen H. Long, Ph.D., RAND
Nicole Lurie, MD, M.S.P.H., University of Minnesota School of Medicine
Pamela Short, Ph.D., Pennsylvania State University
Stephen M. Shortell, Ph.D., University of California at Berkeley
* As of 1/1/01
Data Collection Partners
The Gallup OrganizationMathematica Policy Research, Inc.
Social and Scientific Systems, Inc.
Consultants
Bitwrench, Inc., Web ConsultantDavid Blumenthal, MD, M.P.P., Massachusetts General Hospital
Linda Brewster, M.B.A., Consultant
Jon R. Gabel, Health Research and Educational Trust, Consultant
Garrett, Yu Hussein, McCabe & Reis, LLC, Public Affairs Consultant
Christopher Hogan, Ph.D., Direct Research, LLC, Consultant
Bruce Landon, MD, MBA, Harvard Medical School, Consultant
Jane J. Stein, The Stein Group, Publications Consultant
Eben Weitzman, Ph.D., University of Massachusetts, Site Visit Data Base Consultant
Site Visit Collaborators
Lawrence D. Brown, Ph.D., Columbia UniversityLawrence P. Casalino, MD, Ph.D., University of Chicago
Jon B. Christianson, Ph.D., University of Minnesota
Debra A. Draper, Ph.D., Mathematica Policy Research, Inc.
Lance Heineccius, M.S., University of Washington
Robert E. Hurley, Ph.D., Virginia Commonwealth University
Aaron Katz, C.P.H., University of Washington
Timothy K. Lake, Ph.D., Mathematica Policy Research, Inc.
Patricia Lichiello, M.A., University of Washington
Sue Felt-Lisk, M.P.A., Mathematica Policy Research, Inc.
Glen P. Mays, Ph.D., Mathematica Policy Research, Inc.
Carolyn Watts, Ph.D., University of Washington
