Research Roundup: Whistleblowers, Spreading Best Practices, Medicare’s Growth-Limiting Strategy

British Medical Journal: The Impact Of Removing Financial Incentives From Clinical Quality Indicators: Longitudinal Analysis Of Four Kaiser Permanente Indicators – The researchers found the removal of pay-for-performance incentives "was associated with a decrease in performance of about 3% per year on average for screening for diabetic retinopathy and about 1.6% per year for cervical cancer screening" (Lester et al., 5/11). More details about the study and related news coverage are in the May 12 Morning Report.

Mathematica Policy Research: Basing Healthcare On Empirical Evidence --  This brief (.pdf) examines the projects, by various federal, state and private-sector organizations (using federal stimulus funds) that aim to foster evidence-based practice. "As major buyers of health care, states can play a prominent role in promoting evidence-based practice and minimizing burden on providers. In particular, as Medicare focuses increasingly on incentives for evidence-based practice when comparative effectiveness research strongly supports it, state policymakers can build consistent incentives in Medicaid and other state-administered programs and health plans, and also engage private insurers in these efforts. By coordinating these efforts across payers, the states can play a pivotal role in building consistent incentives to improve the quality and efficiency of care-a goal of all stakeholders in health care reform" (Bernstein, Chollet, and Peterson, May 2010).

Additional briefs in the series look at the benefits and cost-effectiveness of preventive health services and the relationship between health insurance and health outcomes.

Commonwealth Fund: Blueprint For The Dissemination Of Evidence-Based Practices In Health Care – "Despite the substantial literature on evidence-based clinical care practices that have proven effective in controlled environments and trials, a major challenge for health care systems has been to spread these advances broadly and rapidly," write the authors, who propose a blueprint for dissemination of best practices by national quality improvement campaigns. The eight key strategies to success include the need to: "highlight the evidence base and relative simplicity of recommended practices; ... develop practical implementation tools and guides for key stakeholder groups; ... create networks to foster learning opportunities; and ... incorporate monitoring and evaluation of milestones and goals" (Yuan, Nembhard, Stern et al., 5/4).

Kaiser Family Foundation: Explaining Health Reform: Medicare and the New Independent Payment Advisory Board – "This brief (.pdf) describes how the new board created under the 2010 health reform law is expected to limit the growth in Medicare spending over time. Starting in 2014, if projected per capita Medicare spending exceeds targets set in the law, the board must recommend ways to reduce Medicare spending, while maintaining quality and access to care for beneficiaries. The board's recommendations automatically take effect the next year unless Congress adopts an alternative plan to achieve an equivalent level of savings" (5/5).

George Washington University School of Public Health and Health Services (.pdf): Medical-Legal Partnerships: Addressing the Unmet Legal Needs of Health Center Patients – Medical-legal partnerships are when "health care staff at hospitals, clinics, and other sites are trained to screen for health-related legal issues, refer the patient to an affiliated lawyer or legal services team as necessary, and work with the attorney to resolve problems that impact patient health."

"While health reform greatly expands coverage for most health center patients who are uninsured, health center patients will need significant information and assistance in navigating the new rules and regulations," the authors write. "Working with social workers and other enabling service staff, attorneys can help address some of the complex social-cultural and legal needs of their patients and their families. Further, the need for legal assistance is likely to increase, particularly with significant changes in the terms of eligibility, plan enrollment, provider selection, and service delivery embodied in the newly enacted health reform law" (Shin et al., 5/4).

Kaiser Family Foundation/Georgetown University: Financing New Medicaid Coverage Under Health Reform: The Role of the Federal Government and States - This authors of this brief write: "Under the health reform law, the Medicaid program will undergo a significant expansion by 2014. Millions of low-income adults who currently cannot qualify for coverage in most states will be made eligible for Medicaid. The federal government will finance the vast majority of the new costs of coverage."

The Congressional Budget Office "estimates suggest the federal government will finance some 96 percent of the new Medicaid and CHIP costs associated with coverage initiatives under health reform, while states will finance roughly four percent ...  Working with CMS, states will need to develop systems to claim the higher federal matching rate available for newly-eligible (versus already-eligible) Medicaid beneficiaries. One practical challenge that states face is accurately determining who is eligible for Medicaid under the new rules rather than the old rules, and establishing procedures for states to claim the different matching rates for their Medicaid and CHIP populations without imposing additional barriers to enrollment" (Heberlein, Guyer and Rudowitz, 5/7).

Urban Institute: Health Insurance Coverage In The District Of Columbia: Estimates From The 2009 DC Health Insurance Survey – This chartbook (.pdf) estimates the health insurance status and options of individuals living in the District of Columbia, based on the 2009 District of Columbia Health Insurance Survey of 4,717 households. "Uninsurance was low among District residents, with 6.2% (representing about 37,000 people) reporting that they were uninsured at the time of the survey. More residents (10.6%, representing about 63,000 people) reported being uninsured at some time in the past 12 months. These rates compare favorably with the US rates of 15.1% currently uninsured," according to the report. Additionally, 55 percent of respondents reported they were insured by their employer while 38 percent reported "they were covered by a public program such as Medicare, Medicaid, or the Alliance" (Ormond, Palmer and Phadera, 4/15).

The Urban Institute also features briefs on D.C.'s insured and uninsured, as documented in the 2009 DC Health Insurance Survey (Ormond, Palmer and Phadera, 4/15).

New England Journal of Medicine: Whistle-Blowers' Experiences In Fraud Litigation Against Pharmaceutical Companies – This study examines the "motivations and experiences of whistle-blowers in cases of major health care fraud," as assessed following interviews with 26 individuals involved in federal "qui tam" cases against pharmaceutical manufacturers settled between January 2001 and March 2009. "Currently, 90% of health care fraud cases are 'qui tam' actions in which whistle-blowers with direct knowledge of the alleged fraud initiate the litigation on behalf of the government ... if [the] action leads to a financial recovery, the whistle-blower stands to collect a portion of the award," the authors note.

Nonetheless, "the strain the process places on individuals' professional and personal lives may make prospective whistle-blowers with legitimate evidence of fraud reluctant to come forward. ... the financial recovery appeared to be quite disproportionate (in both positive and negative directions) to the whistle-blower's personal investment in the case. More sophisticated approaches to determining relators' recoveries could be used to promote both equity and more responsible whistle-blowing" (Kesselheim, Studdert and Mello, 5/13).