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Health Management & Policy

HMP Research Centers

Center for Value-Based Insurance Design

Engages in the design, evaluation, and promotion of health insurance products created to achieve improvements in health outcomes while managing costs faced by patients and employers.

Griffith Leadership Center

Supports healthcare activities involving Michigan faculty and working healthcare organizations, provides "action-learning" opportunities and mentor-preceptor relationships for Michigan students, and promotes leadership and best-practice initiatives.

Center for Law, Ethics, and Health (CLEH)

Established to examine the law’s influence on the nation’s two health systems: the health care delivery system, which is concerned with individual health outcomes; and the public health system, which is designed to protect the health of communities.

HMP Faculty Research

Adler-Milstein, Julia; Green, Carol E.; Bates, David W. "A Survey Analysis Suggests That Electronic Health Records Will Yield Revenue Gains for Some Practices and Losses for Many", Health Affairs, March 2013.

Health care providers remain uncertain about how they will fare financially if they adopt electronic health record (EHR) systems. We used survey data from forty-nine community practices in a large EHR pilot, the Massachusetts eHealth Collaborative, to project five-year returns on investment. We found that the average physician would lose $43,743 over five years; just 27 percent of practices would have achieved a positive return on investment; and only an additional 14 percent of practices would have come out ahead had they received the $44,000 federal meaningful-use incentive.

The largest difference between practices with a positive return on investment and those with a negative return was the extent to which they used their EHRs to increase revenue, primarily by seeing more patients per day or by improved billing that resulted in fewer rejected claims and more accurate coding. Almost half of the practices did not realize savings in paper medical records because they continued to keep records on paper. We conclude that current meaningful use incentives alone may not ensure that most practices, particularly smaller ones, achieve a positive return on investment from EHR adoption. Policies that provide additional support, such as expanding the regional extension center program, could help ensure that practices make the changes required to realize a positive return on investment from EHRs.

Eisenberg, Daniel; Hunt, Justin; Speer, Nicole. "Mental Health in American Colleges and Universities: Variation Across Student Subgroups and Across Campuses", Journal of Nervous & Mental Disease, January 2013, Vol. 201, Issue 1, pp. 60-67.

We estimated the prevalence and correlates of mental health problems among college students in the United States. In 2007 and 2009, we administered online surveys with brief mental health screens to random samples of students at 26 campuses nationwide. We used sample probability weights to adjust for survey nonresponse. A total of 14,175 students completed the survey, corresponding to a 44% participation rate. The prevalence of positive screens was 17.3% for depression, 4.1% for panic disorder, 7.0% for generalized anxiety, 6.3% for suicidal ideation, and 15.3% for nonsuicidal self-injury. Mental health problems were significantly associated with sex, race/ethnicity, religiosity, relationship status, living on campus, and financial situation. The prevalence of conditions varied substantially across the campuses, although campus-level variation was still a small proportion of overall variation in student mental health. The findings offer a starting point for identifying individual and contextual factors that may be useful to target in intervention strategies.

Greer, Scott L. “Evaluation of the Health Board Elections and Alternative Pilots”, Research Findings, December 20, 2012.

This report presents the findings from the evaluation of NHS Scotland Health Board electoral and alternative pilot projects arising from the Health Boards (Membership and Elections) (Scotland) Act 2009. The Act follows several other measures in Scotland which have aimed to increase public involvement and accountability in NHS decision making. Two NHS boards, Dumfries and Galloway and Fife held elections for 10 and 12 members respectively. Two other boards, Grampian and Lothian explored alternative ways of recruiting and selecting two new appointed members each. The evaluation report describes the selection of candidates including voter turnout in the direct elections; characteristics of candidates; the impact of elections and alternative pilots on for example public engagement and NHS board dynamics; costs associated with direct elections and alternative pilots; and the advantages and disadvantages of different models of public engagement and accountability in health decision making.

Eisenberg, Daniel; Golberstein, Ezra; Whitlock, Janis L.; Downs, Marilyn F. "Social Contagion of Mental Health: Evidence from College Roommates", Health Economics, published online, October 11, 2012.

From a policy standpoint, the spread of health conditions in social networks is important to quantify, because it implies externalities and possible market failures in the consumption of health interventions. Recent studies conclude that happiness and depression may be highly contagious across social ties. The results may be biased, however, because of selection and common shocks. We provide unbiased estimates by using exogenous variation from college roommate assignments. Our findings are consistent with no significant overall contagion of mental health and no more than small contagion effects for specific mental health measures, with no evidence for happiness contagion and modest evidence for anxiety and depression contagion. The weakness of the contagion effects cannot be explained by avoidance of roommates with poor mental health or by generally low social contact among roommates. We also find that similarity of baseline mental health predicts the closeness of roommate relationships, which highlights the potential for selection biases in studies of peer effects that do not have a clearly exogenous source of variation. Overall, our results suggest that mental health contagion is lower, or at least more context specific, than implied by the recent studies in the medical literature.

Jarman, Holly and Truby, Katherine. "Traveling for Treatment: A Comparative Analysis of Patient Mobility Debates in the European Union and United States", Journal of Comparative Policy Analysis: Research and Practice, 2012.

Global debates about the future of medical travel, often driven by perspectives from the large US health market, growing health tourism sectors in middle income states, and global commercial health providers, are focused on the rising costs of care. From this perspective, increasing medical travel is seen primarily as a way to alleviate pressure on medical prices.

But individual healthcare costs are not the only factor that US policymakers, in the face of increasing numbers of patients exiting the US healthcare system, should consider. By examining the European Union case, where individual healthcare costs do not so readily dominate the policy debate, and duplicative, rather than primary or complementary exit is more prominent, we can gain a fuller understanding of the problems associated with patient mobility. There remain several key outstanding questions, such as how to manage health system capacity, how to measure the quality of care abroad and ensure continuity of care back home, and how to promote equal access to care in a rapidly changing marketplace.

Dimick, J.B.; Scheske, J.; and Lemak, C.H. "Leadership Development in Surgery" (commentary). Archives of Surgery, 2012, Vol. 147 No. 10, pp. 944-945.

Norton, Edward C.; Morgen M., Wang; Jason J., Coyne; Kasey, Kleinman; Lawrence C. "Rank Reversal in Indirect Comparisons." Value in Health, 2012.

When a direct comparison of two or more treatments within the same study is not possible, researchers must instead make indirect comparisons of those treatments across different trials. The central point of this article is that when indirectly comparing two or more treatments, the choice of how to express results may directly affect the conclusion. In other words, when sorting treatments by effect size (which we refer to as ranking), the choice between RR, RD, and OR matters. We describe these three measures and show when indirect comparisons using any of the measures will be different from the others. We illustrate our results with intuition, examples, graphs, and mathematical proofs. We are unaware of previous description of this phenomenon, which we call rank reversal.

We explain our main points in the context of an indirect comparison meta-analysis, whereby two treatments (let's call them A and B) are each compared with a control (called C) in separate studies. The goal is to use the information in these two separate studies to indirectly compare treatments A and B, and thereby rank their effectiveness. For example, compared with a placebo, is the desirable outcome more likely when a patient takes drug A rather than drug B? The answer to this question is important for both practice and policy. As we explain, answering this question is not always straightforward. When compared with their respective placebos, drug A may be preferred to drug B when measured by an RR, but drug B may be preferred to drug A when measured by an OR, even though both OR and RR are measures of relative effectiveness.

We prove that rankings are not always consistent across these risk measures, describe under what circumstances the rankings are the same or different, explain how uncertainty affects the main results, introduce software that can help identify problems, discuss implications, and recommend best practice for research and policy. When the study design is such that the results could be expressed in terms of either RRs or ORs, the burden is on the researcher to specify a conceptual framework to make that choice.

Grazier, K.L. "Risk-adjusted Payment and Performance Assessment for Primary Care" (commentary). Medical Care, 2012.

Capoccia, V., Grazier, K.L., Toal, C., Ford II, J., Gustafson, D. H. "Massachusetts's Experience Suggests Coverage Alone Is Insufficient To Increase Addiction Disorders Treatment." Health Affairs, 2012.

The Affordable Care Act is aimed at extending health insurance to more than thirty million Americans, including many with untreated substance use disorders. Will those who need addiction treatment receive it once they have insurance?

To answer that question, we examined the experience of Massachusetts, which implemented its own universal insurance law in 2007. As did the Affordable Care Act, the Massachusetts reform incorporated substance abuse services into the essential benefits to be provided all residents. Prior to the law's enactment, the state estimated that a half-million residents needed substance abuse treatment. Our mixed-methods exploratory study thus asked whether expanded coverage in Massachusetts led to increased addiction treatment, as indicated by admissions, services, or revenues. In fact, we observed relatively stable use of treatment services two years before and two years after the state enacted its universal health care law. Among other factors, our study noted that the percentage of uninsured patients with substance abuse issues remains relatively high--and that when patients did become insured, requirements for copayments on their care deterred treatment. Our analysis suggests that expanded coverage alone is insufficient to increase treatment use. Changes in eligibility, services, financing, system design, and policy may also be required.

Stensland, M.; Watson, P.; Grazier, K.L. "An Examination of Costs, Charges, and Payments for Inpatient Psychiatric Treatment in Community Hospitals Psychiatric Services, Psychiatric Services." Journal of the American Psychiatric Association, 2012.

Hospitalization is a critical component of treatment for individuals with serious and persistent mental illness. Despite its resource intensity, the costs of inpatient psychiatric hospitalizations in the United States are not well understood. The objective of this research was to provide cost estimates for inpatient psychiatric care.

Consistent with past research, the results suggest that previous attempts to control pricing may have led to unintended consequences, including a large gap between charges and reimbursed amounts, potential cost shifting between payers, and potentially extended lengths of stay to offset reduced per diems. The lack of transparency in pricing makes it challenging to estimate the cost to society for a day of psychiatric hospitalization.

Hall, A.G.; Landry, A.Y.; Lemak, C.H.; Duncan. R.P. "Incentives for Healthy Behaviors: Experience from Florida Medicaid's Enhanced Benefit Rewards Program." Journal of Primary Care and Community Health, 2012.

Engaging individuals in their own health care proves challenging for policy makers, health plans, and providers. Florida Medicaid introduced the Enhanced Benefits Rewards (EBR) program in 2006, providing financial incentives as rewards to beneficiaries who engage in health care seeking and healthy behaviors. This study analyzed beneficiary survey data from 2009 to determine predictors associated with awareness of and participation in the EBR program.

Non-English speakers, those in a racial and ethnic minority group, those with less than a high school education, and those with limited or no connection to a health care provider were associated with lower awareness of the program. Among those aware of the program, these factors were also associated with reduced likelihood of engaging in the program. Individuals in fair or poor health were also less likely to engage in an approved behavior. Individuals who speak Spanish at home and those without a high school diploma were more likely than other groups to spend their earned program credits.

Findings underscore the fact that initial engagement in such a program can prove challenging as different groups are not equally likely to be aware of or participate in an approved activity or redeem a credit. Physicians may play important roles in encouraging participation in programs to incentivize healthy behaviors.

Cohen, G.R.; Erb, N.; Lemak, C.H. "Physician Practice Responses to Financial Incentive Programs: Exploring the Concept of Implementation Mechanisms." Annual Review of Health Care Management: Strategy and Policy Perspectives on Reforming Health Systems. Advances in Health Care Management 13, 2012, pp. 29-58.

The purpose of this study was to develop a framework for studying financial incentive program implementation mechanisms, the means by which physician practices and physicians translate incentive program goals into their specific office setting. Understanding how new financial incentives fit with the structure of physician practices and individual providers' work may shed some insight on the variable effects of physician incentives documented in numerous reviews and meta-analyses.

Although uncommonly included in evaluations, evidence from 26 articles reveals financial incentive program sponsors and participants utilized a variety of strategies to facilitate communication about program goals and intentions, to provide feedback about participants' progress, and to assist-practices in providing recommended services. Despite diversity in programs' geographic locations, clinical targets, scope, and market context, sponsors and participants deployed common strategies. While these methods largely pertained to communication between program sponsors and participants and the provision of information about performance through reports and registries, they also included other activities such as efforts to engage patients and ways to change staff roles.

Our results underscore the effects implementation mechanisms may have on how practices incorporate new programs into existing systems of care which implicates both the potential rewards from small changes as well as the resources which may be required to obtain buy-in and support. We identify gaps in previous research regarding actual changes occurring in physician practices in response to physician incentive programs. We offer suggestions for future evaluation by proposing a framework for understanding implementation. Our model will assist future scholars in translating site-specific experiences with incentive programs into more broadly relevant guidance for practices by facilitating comparisons across seemingly disparate programs.

Buchmueller, T. C.; Grazier, K.L.; Hirth, R.H.; Okeke, E. "The Price Sensitivity of Medicare Beneficiaries: a Regression Discontinuity Approach", Health Economics, 2012.

We use four years of data from the retiree health benefits program of the University of Michigan to estimate the effect of price on the health plan choices of Medicare beneficiaries. During the period of our analysis, changes in the University's premium contribution rules led to substantial price changes. A key feature of this 'natural experiment' is that individuals who had retired before a certain date were exempted from having to pay any premium contributions. This 'grandfathering' creates quasi-experimental variation that is ideal for estimating the effect of price. Using regression discontinuity methods, we compare the plan choices of individuals who retired just after the grandfathering cutoff date and were therefore exposed to significant price changes to the choices of a 'control group' of individuals who retired just before that date and therefore did not experience the price changes. The results indicate a statistically significant effect of price, with a $10 increase in monthly premium contributions leading to a 2 to 3 percentage point decrease in a plan's market share.