Overuse Of Health Services Research Articles

Room to Improve Prior Authorization in Children With Complex Medical Needs

Since the 1980s, US health insurers have used prior authorization (PA) to determine whether a health care service or treatment is medically necessary before covering its cost. To initiate this process, a patient’s clinician submits an application that justifies the need for the service or treatment. The insurer then adjudicates necessity. PA was designed to mitigate overuse of expensive health services and treatments that patients may not need, thereby containing health care costs and promoting evidence-based care. PA originated largely from overuse of health services and treatments among elderly Medicare beneficiaries.1 Despite widespread use of PA among public and private insurers for adult patients, there is a paucity of information on PA in children, including the risks and benefits to children who experience it.To advance knowledge on PA in children, Constant and colleagues2 assessed the initiation of expensive biologic medications (eg, antitumor-necrosis factor α) in 190 children with inflammatory bowel disease (IBD). IBD is a complex chronic gastrointestinal condition with a relapsing and remitting disease course that can become debilitating if insufficiently treated. Biologic medications are effective in moderate and severe IBD. The per-member-per-year (PMPY) cost of biologic mediations for pediatric patients with IBD is high (∼$41 100).3 Constant and colleagues found that nearly three-fourths of children experienced PA for use of a biologic medication. Thirteen percent experienced complicated PA, which included peer-to-peer review, letter of appeal, and/or step-therapy before approval was granted. Uncomplicated and complicated PA delayed biologic initiation for IBD by over 1 and 3 weeks, respectively. Children experiencing PA had significantly higher rates of IBD exacerbation that necessitated emergency department use, hospitalization, and exposure to systemic corticosteroids.The findings from this study question the value of PA for biologic medications in children with IBD. On completion of the PA process, biologic medications were approved for all children with IBD in the study, suggesting that no unnecessary use occurred. Despite this, health might have been compromised because of the need to wait for PA approval. Although the retrospective case-control study design cannot be used to infer causal relationship between the need for PA and health outcomes, the imbalance of risk without benefit with PA for biologic medications in children with IBD in the study is evident.Reading the study by Constant and colleagues invoked recollection of myriad PA and insurer-led denial-of-care experiences for children with complex medical needs cared for in our clinical practice. We have had patients with epilepsy experience recurrent seizures while waiting on PA approval for antiepileptic medications. Patients with severe neurologic impairment have vomited and aspirated while waiting on PA for gastroesophageal reflux and gastric promotility medications. One patient hospitalized with hypoxia because of a critical airway who was scheduled for tracheotomy and a laryngotracheal separation was denied hospital coverage because the insurer perceived that the patient’s health problems did not necessitate hospital level of care. Most if not all of these patients received coverage approval by the insurer after significant time and effort justifying need was performed by the patients’ clinicians.With these experiences in mind, the findings from the study by Constant and colleagues complement the disdain expressed by many pediatric clinicians that PA is an administrative nuisance without any clear benefit to children. Multiple initiatives to reform and standardize the PA process have emerged to optimize efficiency and transparency as well as to address variation across insurers. Despite state-level legislation and national efforts from the American Medical Association,4 the burden of PA on clinicians remains heavy. US physicians reportedly spend up to 16 hours weekly on PA tasks. Forty percent of physicians hire office staff dedicated to PA.5 Labor costs for PA processing exceed $500 million annually.6Constant and colleagues remind us that pediatric clinicians have no choice currently but to remain steadfast to complete the PA process for the patients who need it to get them the medications and treatments that require PA approval. This is especially true for general pediatric, complex care, and specialty clinicians caring for large numbers of children with complex and chronic medical needs. These children are at risk for a disproportionate share of PAs to attain needed medications and medical equipment. Strong partnerships among insurers, clinicians, patients, and families are essential when designing and implementing solutions to optimize the value of PA for pediatric patients. Future quality improvement and research endeavors should distinguish and disseminate successful PA collaborations. We should all work together to ensure safe and timely access to pediatric health services and treatments, regardless of their cost.

Knowledge, attitudes and behaviors of the community about palliative care

Background: Although cancer is the disease for which people need palliative care the most, the number of diseases and conditions requiring palliative care has increased and will continue to grow. Palliative care improves health, reduces unnecessary hospitalization as well as overuse of health services. There are several barriers to palliative care access and the main are those related to the public such as: lack of public awareness of palliative care, on their benefits; cultural and social barriers.

The medical insurance system’s weakness to provide economic protection for vulnerable citizens in China: A five-year longitudinal study

ObjectivesLittle is known about the magnitude of catastrophic health expenditure (CHE) attributable to critical disease, especially in the middle-aged and elderly population. This research aimed to exploring the key aspects of how the health insurance fails to protect the middle-aged and elderly against CHE in the past five years. And propose corresponding measures to improve. MethodsData were obtained from the 2011 to 2015 China Health and Retirement Longitudinal Study. The method was adapted from WHO to calculate the catastrophic health expenditure (CHE) and impoverishment by medical expense (IME), and use Generalized Linear Mixed Models (GLMMs) to comprehensively analyze the risk factors that cause middle-aged and elderly people to fall into CHE. ResultsThe incidence of CHE of China’s middle-aged and elderly population has been rose in the five years from 2011 (10.5 %) to 2013 (17.5 %) to 2015 (19.7 %). The CHE of richest families was almost 6 times from 2011 to 2015. Urban Employee Medical Insurance Scheme, the incidence of CHE was up 10 percentage from 2011 to 2015. According to the GLMMs, families have inpatient cares as the most important factor to CHE. The incidence of CHE increased by 2.25 times compared with those who did not use inpatient services. ConclusionsThe health system needs to control the irrational growth of health expenses and reduce residents’ overuse of health services. Government should take supplementary measures to comprehensively strengthen the advantages of health insurance. Raise residents' awareness of health care, enhance citizens' physical fitness, and avoid unnecessary waste of health resources.

Making Wise Choices in Health Provision: Initial Exploration of Nurse Perceptions in Israel.

Overuse of health services drives up costs while affecting quality of care. It can also harm patients physically and psychologically through invoking duplicate testing, unnecessary procedures, and psychological stress. The purpose of this study was to understand nurses' perceptions of health care overuse. Nurses perceived that physicians' main considerations when ordering tests are to get additional data to strengthen the diagnosis and "just to be safe." Fear of litigation and patients' desires were important factors. Implementing interventions to reduce overuse will create a more efficient and effective system.

Nurses' Perceptions on the Overuse of Health Services: A Qualitative Study.

To examine whether nurses in Israel think there is overuse of health services, the reasons behind the issue, and ways to reduce the overuse. This was a qualitative study using semistructured interviews. A convenience sample of community care nurses from health clinics across Israel was interviewed. Interviews focused on common areas of overuse, outcomes of overuse, causes of overuse, and potential ways to address the issue. Interviews were recorded, transcribed, and analyzed thematically. Overuse of antibiotics, imaging, blood tests, and prenatal surveillance were cited as main areas of health service overuse. Participants stated that negative outcomes of overuse could be seen at patient, health system, and population levels. Factors influencing overuse included patient satisfaction, physician fears, and insecurities. Potential interventions included improving physicians' diagnostic confidence, increasing appointment times, providing patients with more treatment information, and implementing a unified computerized system across medical institutions. Nurses mentioned physicians and patients as main actors in influencing overuse; hence, those populations should be researched further. The health system was identified as the responsible party to address the issue. Health system leaders must consider potential barriers, and investigate interventions that match current culture and context within the health system. Nurses can play an essential role in limiting overuse and mitigating subsequent harms to patients.

Communicating information about “what not to do” to consumers

BackgroundAmericans devote more resources to health care than any other developed country, and yet they have worse health outcomes and less access. This creates a perfect set of opportunities for Consumer Reports, a nonprofit consumer advocacy and multimedia organization known for its focus on individual consumers in markets where significant amounts of misinformation is in play. Consumer Reports uses comparisons/ratings based on the best available data to “level” the market playing field. While our early efforts to inform consumers of overuse and underuse in health care were successful, we sensed there were opportunities to have greater impact. Over a 5-year period, with the help of many partners, Consumer Reports learned more about how to communicate “what not to do” to consumers, ultimately enhancing the effectiveness of this difficult message.AnalysisConsumer Reports began an in-depth examination of the overuse of health services in 2010 with an exploratory review of the cognitive psychology literature. Lessons learned from this review were used in the presentation of subsequent ratings of heart disease and cancer screening tests. Surveys showed surprising gaps in the prevention/screening knowledge of healthy, low-risk Consumer Reports subscribers aged 40 to 60 years. Of these subscribers, 44% reported engaging in heart screening tests that received the lowest ratings from the U.S. Preventive Services Task Force and from Consumer Reports. At the same time professional societies and the ABIM (American Board of Internal Medicine) Foundation created Choosing Wisely®, a campaign focused on identifying lists of health tests and treatments not to do. Consumer Reports joined the Choosing Wisely campaign as the consumer “translator” and organizer of a network of consumer organizations with access to tens of millions of consumers. Over the past year, Consumer Reports has conducted multiple qualitative evaluations of content related to overuse of health services. Ratings of cancer screening tests were released in 2013 in an article readers reported as one of the most heavily read articles in the magazine’s recent history.ConclusionsTelling consumers that more is not better is not a popular or easy message to deliver. The message is most likely to be “sticky” but is best received if it comes from trusted sources (e.g., physicians), focuses on safety when justified, is communicated in plain language, and uses both mass media and individual consumer approaches. Changing the culture of health care in an era of health reform is an essential part of the transformation needed if we are to allocate finite resources fairly in hopefully fair markets while assuring that better quality products and services at lower prices dominate.

A “Top Five” list for emergency medicine: a policy and research agenda for stewardship to improve the value of emergency care

United States health care costs are growing at an unsustainable rate; one significant contributor has been the overuse of health services. Physicians have a professional ethical obligation to serve as stewards of society’s resources and take responsibility for health care costs. We propose a framework for identifying overused services and a research and implementation agenda to guide stewardship efforts to demonstrate the value of emergency care. Examples of interventions to reduce the cost of emergency care along six value streams are discussed: laboratory tests, high-cost imaging, medication administration, intravenous fluids and medications, hospital admissions and post-discharge care. Structural and political hurdles such as the Emergency Medical and Active Labor Act mandate, medico-legal concerns, lack of provider knowledge about costs and economic conflicts are identified. A research agenda focused on identifying low value clinical actions and potential interventions for overuse reduction is detailed. A policy agenda is proposed for organized emergency medicine to convene a structured, collaborative process to identify and prioritize clinical decisions that are of little value to patients, amenable to improvement through standardization, and actionable by front-line providers. Emergency medicine cannot wait longer to identify areas of low value care, or else other groups will impose external standards on our practice. Development of a Top Five list for emergency medicine will begin to demonstrate our professional ethical commitment to our patients and health system improvement.

Nurse Executives and the National Priorities Partnership

Nurse Executives and the National Priorities Partnership

Medical malpractice - april 2011 update.

Although the malpractice crisis--the inability of health care providers to obtain affordable liability insurance--has abated in many states, medical liability costs and pressures remain a concern. In addition, the perceived threat of litigation spurs "defensive medicine"--the practice of ordering services primarily to reduce the physician's liability exposure rather than because they are medically necessary. There is wide consensus that liability pressure undermines efforts to curb overuse of health services, although there is disagreement about the magnitude of its effect. This Update reviews the evidence on the effects of medical malpractice reforms published since the Medical Malpractice: Impact of the Crisis and Effects of State Tort Reforms synthesis was released in 2006. Key findings include: Except for caps on noneconomic damages, there is little evidence that other traditional tort reforms affect medical liability costs or defensive medicine. Average awards are reduced by 20 percent to 30 percent, and premiums in states with caps on noneconomic damages rise 6 percent to 13 percent more slowly than premiums in states without caps. There is evidence that tort reforms-particularly caps on noneconomic damages-reduce health spending, but the size of the reduction is subject to debate. Because of the lack of success of many traditional tort reforms, a number of innovated tort reforms are receiving increased attention. Although they show promise in theory, they have not been widely evaluated so the evidence of their effectiveness is weak.

Controlling healthcare costs by removing waste: what American doctors can do now

Healthcare costs are unsustainable. The authors propose a solution to control costs without rationing (deliberate withholding of effective care) or payment reductions to doctors and hospitals. Three physician-led strategies comprise...

Medicare Part D—Lessons Learned and Guidance for Health-care Reform

Medicare Part D—Lessons Learned and Guidance for Health-care Reform

Intimate Partner Violence and Physical Health Consequences

Extensive research indicates that intimate partner violence (IPV) poses a significant risk to the physical health of women. IPV is associated with increased mortality, injury and disability, worse general health, chronic pain, substance abuse, reproductive disorders, and poorer pregnancy outcomes. IPV is also associated with an overuse of health services and unmet need for services, as well as strained relationships with providers. The body of IPV research has several critical gaps. There are almost no longitudinal studies of IPV and health. Most studies are clustered into a few specialties, with almost no research in the areas of allied health, dentistry, or management. A common definition of IPV is still not used. Finally, with some notable exceptions, there has been little success in moving the health care system to routinely screen women for IPV.

A prepaid healthcare scheme in rural Africa.

Healthcare providers in Africa are having to increasingly rely on the resources of the populations they serve. An 8-year experience with one of the first rural-based health insurance schemes in East Africa is described. Initial difficulties included adverse selection of members with chronic ill health, fraudulent claims and overuse of health services, leading to considerable financial losses. External technical assistance introduced member tracking and regular reports, reduced adverse selection, fraud and overuse of services to a minimum, and achieved financial stability. Local market research and a comprehensive marketing plan is essential for the overall success of an insurance plan. Health insurance in this part of Africa is likely to assist middle income earners rather than the poor.