AcademyHealth: Annual Research Meeting

SEATTLE – Although the patient-centered medical home has been touted as the future of primary care, clinic staffers may not be so sure.

Staff skepticism and resistance were the leading obstacles cited by administrators and workers who were surveyed within 6 months of starting to transform their practices (which included 20 clinics for Medicaid and uninsured patients) to medical homes, according to a study presented at the annual research meeting of AcademyHealth.

"People are concerned that this is just a fad, just the latest thing we’ll do for 2 years and nobody else will care about it and we’ll stop doing it," said one CEO respondent.

Workers wonder if it’s just "another flavor of the month," said another.

The 20 clinics are part of the Safety Net Medical Home Initiative, a 5-year transformation project headed by Quails Health with funding from the Commonwealth Fund and other sources. CEOs, medical directors, quality mangers, and others were interviewed at each clinic for 30-45 minutes. Safety Net clinics are located in Oregon, Idaho, Colorado, Pennsylvania, and Massachusetts.

"Very little research has been done about the experience of folks who are making these changes. If we can understand the process better, we can help facilitate others going through the same process," said Michael Quinn, Ph.D., psychologist and a senior researcher at the University of Chicago and the lead investigator for the study.

Staff resistance came up 119 times during the 98 semistructured interviews; about as often, however, those surveyed said that their clinics also anticipated benefits from the medical home efforts. Those anticipated benefits, Dr. Quinn said, can be used to counter the doubts.

One clinician respondent advised looking "at real data to show how you are affecting things. Make sure [staffers] get rapid feedback to keep everything going."

Proving the Worth of Medical Homes

Quick-turn data are key. For example, instead of waiting months to show the staff that hemoglobin A_1c levels are improving, a CEO could show the staff a reduction in no-show rates over a month or two as the clinic expands its hours into evenings and weekends.

Patient satisfaction surveys are another quick option; patients are bound to appreciate easier access and the assurance that even if they don’t see their own doctor, they’ll see someone on their doctor’s team who is familiar with their case, Dr. Quinn said.

If it’s too early for even quick-turn data, field trips are another option that survey respondents recommended. "[I] would have made a point to take more staff to see a clinic that’s doing it right earlier. We did a few weeks ago, and it changed attitudes of staff and increased buy-in," one CEO responded.

It’s also important to let skeptics know that as part of a medical home, they can expect to work in a more-supportive environment and to make fuller use of their license, Dr. Quinn said.

"Nurses are excited about the opportunity to work at the top of their license, getting to work to their fullest potential, which makes them happy," one medical director noted.

As with any change, it’s important to include everybody in the decision making as much as possible, regardless of their position in the office hierarchy.

"No directives from above; that’s been the best thing we’ve ever learned. [Get] buy-in from the bottom up and [get] people to understand why we’re doing things," said one CEO.

With such approaches, "everybody can really catch some of the excitement about" becoming a medical home, Dr. Quinn said.

This approach has worked in at least one clinic. "Even reception is buying into the idea that they’re part of an organization, not just here for a job. People don’t mind staying as late; they know the patient needs it," a provider there said.

In the survey, limited staffing, inadequate electronic medical record systems and insufficient financial support were also cited as medical home obstacles, but far less often than were staff skepticism and resistance.

Dr. Quinn said he has no disclosures. The study was funded by the Commonwealth Fund and the National Institute of Diabetes and Digestive and Kidney Diseases.

SEATTLE – Although the patient-centered medical home has been touted as the future of primary care, clinic staffers may not be so sure.

Staff skepticism and resistance were the leading obstacles cited by administrators and workers who were surveyed within 6 months of starting to transform their practices (which included 20 clinics for Medicaid and uninsured patients) to medical homes, according to a study presented at the annual research meeting of AcademyHealth.

"People are concerned that this is just a fad, just the latest thing we’ll do for 2 years and nobody else will care about it and we’ll stop doing it," said one CEO respondent.

Workers wonder if it’s just "another flavor of the month," said another.

The 20 clinics are part of the Safety Net Medical Home Initiative, a 5-year transformation project headed by Quails Health with funding from the Commonwealth Fund and other sources. CEOs, medical directors, quality mangers, and others were interviewed at each clinic for 30-45 minutes. Safety Net clinics are located in Oregon, Idaho, Colorado, Pennsylvania, and Massachusetts.

"Very little research has been done about the experience of folks who are making these changes. If we can understand the process better, we can help facilitate others going through the same process," said Michael Quinn, Ph.D., psychologist and a senior researcher at the University of Chicago and the lead investigator for the study.

Staff resistance came up 119 times during the 98 semistructured interviews; about as often, however, those surveyed said that their clinics also anticipated benefits from the medical home efforts. Those anticipated benefits, Dr. Quinn said, can be used to counter the doubts.

One clinician respondent advised looking "at real data to show how you are affecting things. Make sure [staffers] get rapid feedback to keep everything going."

Proving the Worth of Medical Homes

Quick-turn data are key. For example, instead of waiting months to show the staff that hemoglobin A_1c levels are improving, a CEO could show the staff a reduction in no-show rates over a month or two as the clinic expands its hours into evenings and weekends.

Patient satisfaction surveys are another quick option; patients are bound to appreciate easier access and the assurance that even if they don’t see their own doctor, they’ll see someone on their doctor’s team who is familiar with their case, Dr. Quinn said.

If it’s too early for even quick-turn data, field trips are another option that survey respondents recommended. "[I] would have made a point to take more staff to see a clinic that’s doing it right earlier. We did a few weeks ago, and it changed attitudes of staff and increased buy-in," one CEO responded.

It’s also important to let skeptics know that as part of a medical home, they can expect to work in a more-supportive environment and to make fuller use of their license, Dr. Quinn said.

"Nurses are excited about the opportunity to work at the top of their license, getting to work to their fullest potential, which makes them happy," one medical director noted.

As with any change, it’s important to include everybody in the decision making as much as possible, regardless of their position in the office hierarchy.

"No directives from above; that’s been the best thing we’ve ever learned. [Get] buy-in from the bottom up and [get] people to understand why we’re doing things," said one CEO.

With such approaches, "everybody can really catch some of the excitement about" becoming a medical home, Dr. Quinn said.

This approach has worked in at least one clinic. "Even reception is buying into the idea that they’re part of an organization, not just here for a job. People don’t mind staying as late; they know the patient needs it," a provider there said.

In the survey, limited staffing, inadequate electronic medical record systems and insufficient financial support were also cited as medical home obstacles, but far less often than were staff skepticism and resistance.

Dr. Quinn said he has no disclosures. The study was funded by the Commonwealth Fund and the National Institute of Diabetes and Digestive and Kidney Diseases.

SEATTLE – Although the patient-centered medical home has been touted as the future of primary care, clinic staffers may not be so sure.

Staff skepticism and resistance were the leading obstacles cited by administrators and workers who were surveyed within 6 months of starting to transform their practices (which included 20 clinics for Medicaid and uninsured patients) to medical homes, according to a study presented at the annual research meeting of AcademyHealth.

"People are concerned that this is just a fad, just the latest thing we’ll do for 2 years and nobody else will care about it and we’ll stop doing it," said one CEO respondent.

Workers wonder if it’s just "another flavor of the month," said another.

The 20 clinics are part of the Safety Net Medical Home Initiative, a 5-year transformation project headed by Quails Health with funding from the Commonwealth Fund and other sources. CEOs, medical directors, quality mangers, and others were interviewed at each clinic for 30-45 minutes. Safety Net clinics are located in Oregon, Idaho, Colorado, Pennsylvania, and Massachusetts.

"Very little research has been done about the experience of folks who are making these changes. If we can understand the process better, we can help facilitate others going through the same process," said Michael Quinn, Ph.D., psychologist and a senior researcher at the University of Chicago and the lead investigator for the study.

Staff resistance came up 119 times during the 98 semistructured interviews; about as often, however, those surveyed said that their clinics also anticipated benefits from the medical home efforts. Those anticipated benefits, Dr. Quinn said, can be used to counter the doubts.

One clinician respondent advised looking "at real data to show how you are affecting things. Make sure [staffers] get rapid feedback to keep everything going."

Proving the Worth of Medical Homes

Quick-turn data are key. For example, instead of waiting months to show the staff that hemoglobin A_1c levels are improving, a CEO could show the staff a reduction in no-show rates over a month or two as the clinic expands its hours into evenings and weekends.

Patient satisfaction surveys are another quick option; patients are bound to appreciate easier access and the assurance that even if they don’t see their own doctor, they’ll see someone on their doctor’s team who is familiar with their case, Dr. Quinn said.

If it’s too early for even quick-turn data, field trips are another option that survey respondents recommended. "[I] would have made a point to take more staff to see a clinic that’s doing it right earlier. We did a few weeks ago, and it changed attitudes of staff and increased buy-in," one CEO responded.

It’s also important to let skeptics know that as part of a medical home, they can expect to work in a more-supportive environment and to make fuller use of their license, Dr. Quinn said.

"Nurses are excited about the opportunity to work at the top of their license, getting to work to their fullest potential, which makes them happy," one medical director noted.

As with any change, it’s important to include everybody in the decision making as much as possible, regardless of their position in the office hierarchy.

"No directives from above; that’s been the best thing we’ve ever learned. [Get] buy-in from the bottom up and [get] people to understand why we’re doing things," said one CEO.

With such approaches, "everybody can really catch some of the excitement about" becoming a medical home, Dr. Quinn said.

This approach has worked in at least one clinic. "Even reception is buying into the idea that they’re part of an organization, not just here for a job. People don’t mind staying as late; they know the patient needs it," a provider there said.

In the survey, limited staffing, inadequate electronic medical record systems and insufficient financial support were also cited as medical home obstacles, but far less often than were staff skepticism and resistance.

Dr. Quinn said he has no disclosures. The study was funded by the Commonwealth Fund and the National Institute of Diabetes and Digestive and Kidney Diseases.

SEATTLE – After years of growth, the demand for complementary and alternative medicine seems to have leveled off.

Between 2002 and 2008, the total number of ambulatory visits to complementary and alternative medicine (CAM) providers in the United States, including acupuncturists, homeopathists, and chiropractors, decreased 4% from 126 million to 121 million, according to a Medical Expenditure Panel Survey analysis by the Center for Health Policy Research at Dartmouth Medical School, Hanover, N.H.

"This is the first nationally representative study to suggest CAM provider services may be reaching maturity in the U.S.," the researchers concluded at the annual research meeting of AcademyHealth.

"Everyone made big assumptions that CAM is increasing, but it doesn’t seem to be increasing. It appears to be pretty flat, whether you look at per-user or total number of visits or expenditures for illness management," said Dr. Matthew Davis, a chiropractor at the medical school.

The majority of CAM visits are for chiropractic care, but visits to chiropractors have fallen from about 110 million in 2005 to just under 100 million in 2008.

When asked what could be behind the results, Dr. Davis noted that CAM’s popularity historically runs in cycles. Also, he noted that overall spending on elective health care has been down during the recession.

Even so, a significant amount of money is still spent on CAM services, and it’s increased from about $8 billion in 2002 to $8.6 billion in 2008, even as overall visits have declined. Chiropractic care accounts for most of the increase, while spending on acupuncture, massage therapy, and other modalities has remained largely stable, according to the study.

Study Shows Distinct Focus of CAM Spending 

In a second study, Dr. Davis and his colleagues found that spending on CAM is concentrated in a minority of users, with about 25% accounting for 72% of spending. The results are based on an analysis of the 2007 National Health Interview Survey, which included questions about 18 kinds of CAM.

That’s similar to traditional medicine, but in traditional medicine, it’s a minority of older, sicker individuals who account for a majority of spending. In contrast, it seems the worried-well account for much of the spending on CAM.

After adjusting for age, sex, education, marital status, and race, the investigators found that self-reported health status was not associated with CAM spending among the almost 3,000 people surveyed. "Heavier spenders" – those who spent $520-$10,000 in 2007 – "aren’t any sicker than light spenders," those who spent less than $87. "We found very little if any relationship between the two," said Dr. Davis. About 11% in both the heavy and light spending groups reported fair to poor health.

Heavy users tend to be a little older and are more likely to be female. These people have an interest in staying well and spend money on health services. "Also, [CAM spending] probably has to do with empowerment. We live in a culture where people like to take care of their own health, and I think CAM offers that to some people," Dr. Davis said.

The Dartmouth researchers estimated that in 2007 the top 10% of users, accounting for almost half of expenditures that year, spent a mean of $2,392.

Among other findings for 2007: $165 million was spent on homeopathy, $271 million on naturopathy, $103 million on traditional healers, $19 million on ayurveda, $567 million on herbals and other nonvitamin supplements, $32 million on chelation, and $74 million on hypnosis.

Overall, CAM accounts for less than 1% of total health care spending in the U.S., and, unlike traditional medicine, largely "remains a cottage industry," Dr. Davis said.

Dr. Davis reported no relevant disclosures. The studies were funded by the National Center for Complementary and Alternative Medicine.

SEATTLE – After years of growth, the demand for complementary and alternative medicine seems to have leveled off.

Between 2002 and 2008, the total number of ambulatory visits to complementary and alternative medicine (CAM) providers in the United States, including acupuncturists, homeopathists, and chiropractors, decreased 4% from 126 million to 121 million, according to a Medical Expenditure Panel Survey analysis by the Center for Health Policy Research at Dartmouth Medical School, Hanover, N.H.

"This is the first nationally representative study to suggest CAM provider services may be reaching maturity in the U.S.," the researchers concluded at the annual research meeting of AcademyHealth.

"Everyone made big assumptions that CAM is increasing, but it doesn’t seem to be increasing. It appears to be pretty flat, whether you look at per-user or total number of visits or expenditures for illness management," said Dr. Matthew Davis, a chiropractor at the medical school.

The majority of CAM visits are for chiropractic care, but visits to chiropractors have fallen from about 110 million in 2005 to just under 100 million in 2008.

When asked what could be behind the results, Dr. Davis noted that CAM’s popularity historically runs in cycles. Also, he noted that overall spending on elective health care has been down during the recession.

Even so, a significant amount of money is still spent on CAM services, and it’s increased from about $8 billion in 2002 to $8.6 billion in 2008, even as overall visits have declined. Chiropractic care accounts for most of the increase, while spending on acupuncture, massage therapy, and other modalities has remained largely stable, according to the study.

Study Shows Distinct Focus of CAM Spending 

In a second study, Dr. Davis and his colleagues found that spending on CAM is concentrated in a minority of users, with about 25% accounting for 72% of spending. The results are based on an analysis of the 2007 National Health Interview Survey, which included questions about 18 kinds of CAM.

That’s similar to traditional medicine, but in traditional medicine, it’s a minority of older, sicker individuals who account for a majority of spending. In contrast, it seems the worried-well account for much of the spending on CAM.

After adjusting for age, sex, education, marital status, and race, the investigators found that self-reported health status was not associated with CAM spending among the almost 3,000 people surveyed. "Heavier spenders" – those who spent $520-$10,000 in 2007 – "aren’t any sicker than light spenders," those who spent less than $87. "We found very little if any relationship between the two," said Dr. Davis. About 11% in both the heavy and light spending groups reported fair to poor health.

Heavy users tend to be a little older and are more likely to be female. These people have an interest in staying well and spend money on health services. "Also, [CAM spending] probably has to do with empowerment. We live in a culture where people like to take care of their own health, and I think CAM offers that to some people," Dr. Davis said.

The Dartmouth researchers estimated that in 2007 the top 10% of users, accounting for almost half of expenditures that year, spent a mean of $2,392.

Among other findings for 2007: $165 million was spent on homeopathy, $271 million on naturopathy, $103 million on traditional healers, $19 million on ayurveda, $567 million on herbals and other nonvitamin supplements, $32 million on chelation, and $74 million on hypnosis.

Overall, CAM accounts for less than 1% of total health care spending in the U.S., and, unlike traditional medicine, largely "remains a cottage industry," Dr. Davis said.

Dr. Davis reported no relevant disclosures. The studies were funded by the National Center for Complementary and Alternative Medicine.

SEATTLE – After years of growth, the demand for complementary and alternative medicine seems to have leveled off.

Between 2002 and 2008, the total number of ambulatory visits to complementary and alternative medicine (CAM) providers in the United States, including acupuncturists, homeopathists, and chiropractors, decreased 4% from 126 million to 121 million, according to a Medical Expenditure Panel Survey analysis by the Center for Health Policy Research at Dartmouth Medical School, Hanover, N.H.

"This is the first nationally representative study to suggest CAM provider services may be reaching maturity in the U.S.," the researchers concluded at the annual research meeting of AcademyHealth.

"Everyone made big assumptions that CAM is increasing, but it doesn’t seem to be increasing. It appears to be pretty flat, whether you look at per-user or total number of visits or expenditures for illness management," said Dr. Matthew Davis, a chiropractor at the medical school.

The majority of CAM visits are for chiropractic care, but visits to chiropractors have fallen from about 110 million in 2005 to just under 100 million in 2008.

When asked what could be behind the results, Dr. Davis noted that CAM’s popularity historically runs in cycles. Also, he noted that overall spending on elective health care has been down during the recession.

Even so, a significant amount of money is still spent on CAM services, and it’s increased from about $8 billion in 2002 to $8.6 billion in 2008, even as overall visits have declined. Chiropractic care accounts for most of the increase, while spending on acupuncture, massage therapy, and other modalities has remained largely stable, according to the study.

Study Shows Distinct Focus of CAM Spending 

In a second study, Dr. Davis and his colleagues found that spending on CAM is concentrated in a minority of users, with about 25% accounting for 72% of spending. The results are based on an analysis of the 2007 National Health Interview Survey, which included questions about 18 kinds of CAM.

That’s similar to traditional medicine, but in traditional medicine, it’s a minority of older, sicker individuals who account for a majority of spending. In contrast, it seems the worried-well account for much of the spending on CAM.

After adjusting for age, sex, education, marital status, and race, the investigators found that self-reported health status was not associated with CAM spending among the almost 3,000 people surveyed. "Heavier spenders" – those who spent $520-$10,000 in 2007 – "aren’t any sicker than light spenders," those who spent less than $87. "We found very little if any relationship between the two," said Dr. Davis. About 11% in both the heavy and light spending groups reported fair to poor health.

Heavy users tend to be a little older and are more likely to be female. These people have an interest in staying well and spend money on health services. "Also, [CAM spending] probably has to do with empowerment. We live in a culture where people like to take care of their own health, and I think CAM offers that to some people," Dr. Davis said.

The Dartmouth researchers estimated that in 2007 the top 10% of users, accounting for almost half of expenditures that year, spent a mean of $2,392.

Among other findings for 2007: $165 million was spent on homeopathy, $271 million on naturopathy, $103 million on traditional healers, $19 million on ayurveda, $567 million on herbals and other nonvitamin supplements, $32 million on chelation, and $74 million on hypnosis.

Overall, CAM accounts for less than 1% of total health care spending in the U.S., and, unlike traditional medicine, largely "remains a cottage industry," Dr. Davis said.

Dr. Davis reported no relevant disclosures. The studies were funded by the National Center for Complementary and Alternative Medicine.

SEATTLE – State health insurance exchanges, being designed for 2014 implementation under the Patient Protection and Affordable Care Act, will bring an influx of older, chronically ill people into the medical system, among others, according to Kaiser Family Foundation projections.

Of the 24 million people the Congressional Budget Office estimates will purchase coverage through exchanges by 2019, Kaiser predicts almost 40% will have gone without a checkup for at least 2 years, and have no usual source of care. About 30% will have had no interaction with the health care system for at least a year.

Projected enrollees are also likely to be in poorer health than other insurance populations, but have fewer chronic diagnoses. "It’s quite possible the future exchange population is going to have pent-up medical needs," said Anthony Damico, a foundation analyst and one of the report’s authors.

The Affordable Care Act calls for health insurance exchanges in all states by January 2014, to help people and small employers purchase insurance. People with incomes between 138% and 400% of the federal poverty level will get subsidies in the form of tax credits to help them afford coverage.

Kaiser’s projections, based on the 2007 Medical Expenditure Panel Survey, attempt to define what the exchange population will look like in 2019. "We thought it would be of value to [learn] more about some of the characteristics of who this population is likely to be," to help planners decide how exchanges should be structured, among other reasons, Mr. Damico said at the annual research meeting of AcademyHealth.

The projections also give clinicians an idea of what to expect as the exchanges roll out. A key priority "will be getting [enrollees] set up with primary care physicians. It’s [also] going to be important to get [enrollees] diagnosed quickly," he said, and monitor whether individuals in the exchanges continue to have difficulty getting care.

About 13% of the adults that Kaiser expects to enroll in exchanges report fair or poor health, a significantly greater share than what current privately insured individuals report.

Kaiser predicts that adult enrollees will be about age 40 years on average and will have median incomes of about 235% of the federal poverty level. Just over half are likely to be male, about half will be married, and perhaps almost a quarter will be unemployed. The foundation also predicts that about 40% will be minorities, 15% will be children, and almost a quarter will speak a language other than English at home.

In all, "the projected 2019 exchange population is relatively older, less educated, lower income, and more racially diverse than current privately insured populations," the report noted. And they will be in worse health.

Kaiser estimated that 65% of those entering exchanges will have been previously uninsured. Most of the rest will have lost employer-based insurance, switched from employer-based coverage, or lost Medicaid coverage because of new income-based requirements that limit eligibility to those at or below 138% of the federal poverty level.

Average annual medical costs for exchange adults will range between $3,139 and $3,568, in 2007 dollars, an amount that’s in line with expenditures for adults in employer-sponsored insurance plans, according to the report.

"One key component of exchange stability will be to keep the healthier folks in the exchanges. Administrators and policy makers and insurers are really going to have to focus on the effectiveness of the subsidies," Mr. Damico said.

"The presence of subsidies may provide an incentive" for employers "to drop coverage and push their employees into purchasing health insurance through the exchanges, particularly if those employees are less healthy," the report warned.

Mr. Damico said he had no relevant financial disclosures.

SEATTLE – State health insurance exchanges, being designed for 2014 implementation under the Patient Protection and Affordable Care Act, will bring an influx of older, chronically ill people into the medical system, among others, according to Kaiser Family Foundation projections.

Of the 24 million people the Congressional Budget Office estimates will purchase coverage through exchanges by 2019, Kaiser predicts almost 40% will have gone without a checkup for at least 2 years, and have no usual source of care. About 30% will have had no interaction with the health care system for at least a year.

Projected enrollees are also likely to be in poorer health than other insurance populations, but have fewer chronic diagnoses. "It’s quite possible the future exchange population is going to have pent-up medical needs," said Anthony Damico, a foundation analyst and one of the report’s authors.

The Affordable Care Act calls for health insurance exchanges in all states by January 2014, to help people and small employers purchase insurance. People with incomes between 138% and 400% of the federal poverty level will get subsidies in the form of tax credits to help them afford coverage.

Kaiser’s projections, based on the 2007 Medical Expenditure Panel Survey, attempt to define what the exchange population will look like in 2019. "We thought it would be of value to [learn] more about some of the characteristics of who this population is likely to be," to help planners decide how exchanges should be structured, among other reasons, Mr. Damico said at the annual research meeting of AcademyHealth.

The projections also give clinicians an idea of what to expect as the exchanges roll out. A key priority "will be getting [enrollees] set up with primary care physicians. It’s [also] going to be important to get [enrollees] diagnosed quickly," he said, and monitor whether individuals in the exchanges continue to have difficulty getting care.

About 13% of the adults that Kaiser expects to enroll in exchanges report fair or poor health, a significantly greater share than what current privately insured individuals report.

Kaiser predicts that adult enrollees will be about age 40 years on average and will have median incomes of about 235% of the federal poverty level. Just over half are likely to be male, about half will be married, and perhaps almost a quarter will be unemployed. The foundation also predicts that about 40% will be minorities, 15% will be children, and almost a quarter will speak a language other than English at home.

In all, "the projected 2019 exchange population is relatively older, less educated, lower income, and more racially diverse than current privately insured populations," the report noted. And they will be in worse health.

Kaiser estimated that 65% of those entering exchanges will have been previously uninsured. Most of the rest will have lost employer-based insurance, switched from employer-based coverage, or lost Medicaid coverage because of new income-based requirements that limit eligibility to those at or below 138% of the federal poverty level.

Average annual medical costs for exchange adults will range between $3,139 and $3,568, in 2007 dollars, an amount that’s in line with expenditures for adults in employer-sponsored insurance plans, according to the report.

"One key component of exchange stability will be to keep the healthier folks in the exchanges. Administrators and policy makers and insurers are really going to have to focus on the effectiveness of the subsidies," Mr. Damico said.

"The presence of subsidies may provide an incentive" for employers "to drop coverage and push their employees into purchasing health insurance through the exchanges, particularly if those employees are less healthy," the report warned.

Mr. Damico said he had no relevant financial disclosures.

SEATTLE – State health insurance exchanges, being designed for 2014 implementation under the Patient Protection and Affordable Care Act, will bring an influx of older, chronically ill people into the medical system, among others, according to Kaiser Family Foundation projections.

Of the 24 million people the Congressional Budget Office estimates will purchase coverage through exchanges by 2019, Kaiser predicts almost 40% will have gone without a checkup for at least 2 years, and have no usual source of care. About 30% will have had no interaction with the health care system for at least a year.

Projected enrollees are also likely to be in poorer health than other insurance populations, but have fewer chronic diagnoses. "It’s quite possible the future exchange population is going to have pent-up medical needs," said Anthony Damico, a foundation analyst and one of the report’s authors.

The Affordable Care Act calls for health insurance exchanges in all states by January 2014, to help people and small employers purchase insurance. People with incomes between 138% and 400% of the federal poverty level will get subsidies in the form of tax credits to help them afford coverage.

Kaiser’s projections, based on the 2007 Medical Expenditure Panel Survey, attempt to define what the exchange population will look like in 2019. "We thought it would be of value to [learn] more about some of the characteristics of who this population is likely to be," to help planners decide how exchanges should be structured, among other reasons, Mr. Damico said at the annual research meeting of AcademyHealth.

The projections also give clinicians an idea of what to expect as the exchanges roll out. A key priority "will be getting [enrollees] set up with primary care physicians. It’s [also] going to be important to get [enrollees] diagnosed quickly," he said, and monitor whether individuals in the exchanges continue to have difficulty getting care.

About 13% of the adults that Kaiser expects to enroll in exchanges report fair or poor health, a significantly greater share than what current privately insured individuals report.

Kaiser predicts that adult enrollees will be about age 40 years on average and will have median incomes of about 235% of the federal poverty level. Just over half are likely to be male, about half will be married, and perhaps almost a quarter will be unemployed. The foundation also predicts that about 40% will be minorities, 15% will be children, and almost a quarter will speak a language other than English at home.

In all, "the projected 2019 exchange population is relatively older, less educated, lower income, and more racially diverse than current privately insured populations," the report noted. And they will be in worse health.

Kaiser estimated that 65% of those entering exchanges will have been previously uninsured. Most of the rest will have lost employer-based insurance, switched from employer-based coverage, or lost Medicaid coverage because of new income-based requirements that limit eligibility to those at or below 138% of the federal poverty level.

Average annual medical costs for exchange adults will range between $3,139 and $3,568, in 2007 dollars, an amount that’s in line with expenditures for adults in employer-sponsored insurance plans, according to the report.

"One key component of exchange stability will be to keep the healthier folks in the exchanges. Administrators and policy makers and insurers are really going to have to focus on the effectiveness of the subsidies," Mr. Damico said.

"The presence of subsidies may provide an incentive" for employers "to drop coverage and push their employees into purchasing health insurance through the exchanges, particularly if those employees are less healthy," the report warned.

Mr. Damico said he had no relevant financial disclosures.

SEATTLE – State health insurance exchanges, being designed for 2014 implementation under the Patient Protection and Affordable Care Act, will bring an influx of older, chronically ill people into the medical system, among others, according to Kaiser Family Foundation projections.

Of the 24 million people the Congressional Budget Office estimates will purchase coverage through exchanges by 2019, Kaiser predicts almost 40% will have gone without a checkup for at least 2 years, and have no usual source of care. About 30% will have had no interaction with the health care system for at least a year.

Projected enrollees are also likely to be in poorer health than other insurance populations, but have fewer chronic diagnoses. "It’s quite possible the future exchange population is going to have pent-up medical needs," said Anthony Damico, a foundation analyst and one of the report’s authors.

The Affordable Care Act calls for health insurance exchanges in all states by January 2014, to help people and small employers purchase insurance. People with incomes between 138% and 400% of the federal poverty level will get subsidies in the form of tax credits to help them afford coverage.

Kaiser’s projections, based on the 2007 Medical Expenditure Panel Survey, attempt to define what the exchange population will look like in 2019. "We thought it would be of value to [learn] more about some of the characteristics of who this population is likely to be," to help planners decide how exchanges should be structured, among other reasons, Mr. Damico said at the annual research meeting of AcademyHealth.

The projections also give clinicians an idea of what to expect as the exchanges roll out. A key priority "will be getting [enrollees] set up with primary care physicians. It’s [also] going to be important to get [enrollees] diagnosed quickly," he said, and monitor whether individuals in the exchanges continue to have difficulty getting care.

About 13% of the adults that Kaiser expects to enroll in exchanges report fair or poor health, a significantly greater share than what current privately insured individuals report.

Kaiser predicts that adult enrollees will be about age 40 years on average and will have median incomes of about 235% of the federal poverty level. Just over half are likely to be male, about half will be married, and perhaps almost a quarter will be unemployed. The foundation also predicts that about 40% will be minorities, 15% will be children, and almost a quarter will speak a language other than English at home.

In all, "the projected 2019 exchange population is relatively older, less educated, lower income, and more racially diverse than current privately insured populations," the report noted. And they will be in worse health.

Kaiser estimated that 65% of those entering exchanges will have been previously uninsured. Most of the rest will have lost employer-based insurance, switched from employer-based coverage, or lost Medicaid coverage because of new income-based requirements that limit eligibility to those at or below 138% of the federal poverty level.

Average annual medical costs for exchange adults will range between $3,139 and $3,568, in 2007 dollars, an amount that’s in line with expenditures for adults in employer-sponsored insurance plans, according to the report.

"One key component of exchange stability will be to keep the healthier folks in the exchanges. Administrators and policy makers and insurers are really going to have to focus on the effectiveness of the subsidies," Mr. Damico said.

"The presence of subsidies may provide an incentive" for employers "to drop coverage and push their employees into purchasing health insurance through the exchanges, particularly if those employees are less healthy," the report warned.

Mr. Damico said he had no relevant financial disclosures.

SEATTLE – State health insurance exchanges, being designed for 2014 implementation under the Patient Protection and Affordable Care Act, will bring an influx of older, chronically ill people into the medical system, among others, according to Kaiser Family Foundation projections.

Of the 24 million people the Congressional Budget Office estimates will purchase coverage through exchanges by 2019, Kaiser predicts almost 40% will have gone without a checkup for at least 2 years, and have no usual source of care. About 30% will have had no interaction with the health care system for at least a year.

Projected enrollees are also likely to be in poorer health than other insurance populations, but have fewer chronic diagnoses. "It’s quite possible the future exchange population is going to have pent-up medical needs," said Anthony Damico, a foundation analyst and one of the report’s authors.

The Affordable Care Act calls for health insurance exchanges in all states by January 2014, to help people and small employers purchase insurance. People with incomes between 138% and 400% of the federal poverty level will get subsidies in the form of tax credits to help them afford coverage.

Kaiser’s projections, based on the 2007 Medical Expenditure Panel Survey, attempt to define what the exchange population will look like in 2019. "We thought it would be of value to [learn] more about some of the characteristics of who this population is likely to be," to help planners decide how exchanges should be structured, among other reasons, Mr. Damico said at the annual research meeting of AcademyHealth.

The projections also give clinicians an idea of what to expect as the exchanges roll out. A key priority "will be getting [enrollees] set up with primary care physicians. It’s [also] going to be important to get [enrollees] diagnosed quickly," he said, and monitor whether individuals in the exchanges continue to have difficulty getting care.

About 13% of the adults that Kaiser expects to enroll in exchanges report fair or poor health, a significantly greater share than what current privately insured individuals report.

Kaiser predicts that adult enrollees will be about age 40 years on average and will have median incomes of about 235% of the federal poverty level. Just over half are likely to be male, about half will be married, and perhaps almost a quarter will be unemployed. The foundation also predicts that about 40% will be minorities, 15% will be children, and almost a quarter will speak a language other than English at home.

In all, "the projected 2019 exchange population is relatively older, less educated, lower income, and more racially diverse than current privately insured populations," the report noted. And they will be in worse health.

Kaiser estimated that 65% of those entering exchanges will have been previously uninsured. Most of the rest will have lost employer-based insurance, switched from employer-based coverage, or lost Medicaid coverage because of new income-based requirements that limit eligibility to those at or below 138% of the federal poverty level.

Average annual medical costs for exchange adults will range between $3,139 and $3,568, in 2007 dollars, an amount that’s in line with expenditures for adults in employer-sponsored insurance plans, according to the report.

"One key component of exchange stability will be to keep the healthier folks in the exchanges. Administrators and policy makers and insurers are really going to have to focus on the effectiveness of the subsidies," Mr. Damico said.

"The presence of subsidies may provide an incentive" for employers "to drop coverage and push their employees into purchasing health insurance through the exchanges, particularly if those employees are less healthy," the report warned.

Mr. Damico said he had no relevant financial disclosures.

SEATTLE – State health insurance exchanges, being designed for 2014 implementation under the Patient Protection and Affordable Care Act, will bring an influx of older, chronically ill people into the medical system, among others, according to Kaiser Family Foundation projections.

Of the 24 million people the Congressional Budget Office estimates will purchase coverage through exchanges by 2019, Kaiser predicts almost 40% will have gone without a checkup for at least 2 years, and have no usual source of care. About 30% will have had no interaction with the health care system for at least a year.

Projected enrollees are also likely to be in poorer health than other insurance populations, but have fewer chronic diagnoses. "It’s quite possible the future exchange population is going to have pent-up medical needs," said Anthony Damico, a foundation analyst and one of the report’s authors.

The Affordable Care Act calls for health insurance exchanges in all states by January 2014, to help people and small employers purchase insurance. People with incomes between 138% and 400% of the federal poverty level will get subsidies in the form of tax credits to help them afford coverage.

Kaiser’s projections, based on the 2007 Medical Expenditure Panel Survey, attempt to define what the exchange population will look like in 2019. "We thought it would be of value to [learn] more about some of the characteristics of who this population is likely to be," to help planners decide how exchanges should be structured, among other reasons, Mr. Damico said at the annual research meeting of AcademyHealth.

The projections also give clinicians an idea of what to expect as the exchanges roll out. A key priority "will be getting [enrollees] set up with primary care physicians. It’s [also] going to be important to get [enrollees] diagnosed quickly," he said, and monitor whether individuals in the exchanges continue to have difficulty getting care.

About 13% of the adults that Kaiser expects to enroll in exchanges report fair or poor health, a significantly greater share than what current privately insured individuals report.

Kaiser predicts that adult enrollees will be about age 40 years on average and will have median incomes of about 235% of the federal poverty level. Just over half are likely to be male, about half will be married, and perhaps almost a quarter will be unemployed. The foundation also predicts that about 40% will be minorities, 15% will be children, and almost a quarter will speak a language other than English at home.

In all, "the projected 2019 exchange population is relatively older, less educated, lower income, and more racially diverse than current privately insured populations," the report noted. And they will be in worse health.

Kaiser estimated that 65% of those entering exchanges will have been previously uninsured. Most of the rest will have lost employer-based insurance, switched from employer-based coverage, or lost Medicaid coverage because of new income-based requirements that limit eligibility to those at or below 138% of the federal poverty level.

Average annual medical costs for exchange adults will range between $3,139 and $3,568, in 2007 dollars, an amount that’s in line with expenditures for adults in employer-sponsored insurance plans, according to the report.

"One key component of exchange stability will be to keep the healthier folks in the exchanges. Administrators and policy makers and insurers are really going to have to focus on the effectiveness of the subsidies," Mr. Damico said.

"The presence of subsidies may provide an incentive" for employers "to drop coverage and push their employees into purchasing health insurance through the exchanges, particularly if those employees are less healthy," the report warned.

Mr. Damico said he had no relevant financial disclosures.

SEATTLE – State health insurance exchanges, being designed for 2014 implementation under the Patient Protection and Affordable Care Act, will bring an influx of older, chronically ill people into the medical system, among others, according to Kaiser Family Foundation projections.

Of the 24 million people the Congressional Budget Office estimates will purchase coverage through exchanges by 2019, Kaiser predicts almost 40% will have gone without a checkup for at least 2 years, and have no usual source of care. About 30% will have had no interaction with the health care system for at least a year.

Projected enrollees are also likely to be in poorer health than other insurance populations, but have fewer chronic diagnoses. "It’s quite possible the future exchange population is going to have pent-up medical needs," said Anthony Damico, a foundation analyst and one of the report’s authors.

The Affordable Care Act calls for health insurance exchanges in all states by January 2014, to help people and small employers purchase insurance. People with incomes between 138% and 400% of the federal poverty level will get subsidies in the form of tax credits to help them afford coverage.

Kaiser’s projections, based on the 2007 Medical Expenditure Panel Survey, attempt to define what the exchange population will look like in 2019. "We thought it would be of value to [learn] more about some of the characteristics of who this population is likely to be," to help planners decide how exchanges should be structured, among other reasons, Mr. Damico said at the annual research meeting of AcademyHealth.

The projections also give clinicians an idea of what to expect as the exchanges roll out. A key priority "will be getting [enrollees] set up with primary care physicians. It’s [also] going to be important to get [enrollees] diagnosed quickly," he said, and monitor whether individuals in the exchanges continue to have difficulty getting care.

About 13% of the adults that Kaiser expects to enroll in exchanges report fair or poor health, a significantly greater share than what current privately insured individuals report.

Kaiser predicts that adult enrollees will be about age 40 years on average and will have median incomes of about 235% of the federal poverty level. Just over half are likely to be male, about half will be married, and perhaps almost a quarter will be unemployed. The foundation also predicts that about 40% will be minorities, 15% will be children, and almost a quarter will speak a language other than English at home.

In all, "the projected 2019 exchange population is relatively older, less educated, lower income, and more racially diverse than current privately insured populations," the report noted. And they will be in worse health.

Kaiser estimated that 65% of those entering exchanges will have been previously uninsured. Most of the rest will have lost employer-based insurance, switched from employer-based coverage, or lost Medicaid coverage because of new income-based requirements that limit eligibility to those at or below 138% of the federal poverty level.

Average annual medical costs for exchange adults will range between $3,139 and $3,568, in 2007 dollars, an amount that’s in line with expenditures for adults in employer-sponsored insurance plans, according to the report.

"One key component of exchange stability will be to keep the healthier folks in the exchanges. Administrators and policy makers and insurers are really going to have to focus on the effectiveness of the subsidies," Mr. Damico said.

"The presence of subsidies may provide an incentive" for employers "to drop coverage and push their employees into purchasing health insurance through the exchanges, particularly if those employees are less healthy," the report warned.

Mr. Damico said he had no relevant financial disclosures.

SEATTLE – State health insurance exchanges, being designed for 2014 implementation under the Patient Protection and Affordable Care Act, will bring an influx of older, chronically ill people into the medical system, among others, according to Kaiser Family Foundation projections.

Of the 24 million people the Congressional Budget Office estimates will purchase coverage through exchanges by 2019, Kaiser predicts almost 40% will have gone without a checkup for at least 2 years, and have no usual source of care. About 30% will have had no interaction with the health care system for at least a year.

Projected enrollees are also likely to be in poorer health than other insurance populations, but have fewer chronic diagnoses. "It’s quite possible the future exchange population is going to have pent-up medical needs," said Anthony Damico, a foundation analyst and one of the report’s authors.

The Affordable Care Act calls for health insurance exchanges in all states by January 2014, to help people and small employers purchase insurance. People with incomes between 138% and 400% of the federal poverty level will get subsidies in the form of tax credits to help them afford coverage.

Kaiser’s projections, based on the 2007 Medical Expenditure Panel Survey, attempt to define what the exchange population will look like in 2019. "We thought it would be of value to [learn] more about some of the characteristics of who this population is likely to be," to help planners decide how exchanges should be structured, among other reasons, Mr. Damico said at the annual research meeting of AcademyHealth.

The projections also give clinicians an idea of what to expect as the exchanges roll out. A key priority "will be getting [enrollees] set up with primary care physicians. It’s [also] going to be important to get [enrollees] diagnosed quickly," he said, and monitor whether individuals in the exchanges continue to have difficulty getting care.

About 13% of the adults that Kaiser expects to enroll in exchanges report fair or poor health, a significantly greater share than what current privately insured individuals report.

Kaiser predicts that adult enrollees will be about age 40 years on average and will have median incomes of about 235% of the federal poverty level. Just over half are likely to be male, about half will be married, and perhaps almost a quarter will be unemployed. The foundation also predicts that about 40% will be minorities, 15% will be children, and almost a quarter will speak a language other than English at home.

In all, "the projected 2019 exchange population is relatively older, less educated, lower income, and more racially diverse than current privately insured populations," the report noted. And they will be in worse health.

Kaiser estimated that 65% of those entering exchanges will have been previously uninsured. Most of the rest will have lost employer-based insurance, switched from employer-based coverage, or lost Medicaid coverage because of new income-based requirements that limit eligibility to those at or below 138% of the federal poverty level.

Average annual medical costs for exchange adults will range between $3,139 and $3,568, in 2007 dollars, an amount that’s in line with expenditures for adults in employer-sponsored insurance plans, according to the report.

"One key component of exchange stability will be to keep the healthier folks in the exchanges. Administrators and policy makers and insurers are really going to have to focus on the effectiveness of the subsidies," Mr. Damico said.

"The presence of subsidies may provide an incentive" for employers "to drop coverage and push their employees into purchasing health insurance through the exchanges, particularly if those employees are less healthy," the report warned.

Mr. Damico said he had no relevant financial disclosures.

SEATTLE – State health insurance exchanges, being designed for 2014 implementation under the Patient Protection and Affordable Care Act, will bring an influx of older, chronically ill people into the medical system, among others, according to Kaiser Family Foundation projections.

Of the 24 million people the Congressional Budget Office estimates will purchase coverage through exchanges by 2019, Kaiser predicts almost 40% will have gone without a checkup for at least 2 years, and have no usual source of care. About 30% will have had no interaction with the health care system for at least a year.

Projected enrollees are also likely to be in poorer health than other insurance populations, but have fewer chronic diagnoses. "It’s quite possible the future exchange population is going to have pent-up medical needs," said Anthony Damico, a foundation analyst and one of the report’s authors.

The Affordable Care Act calls for health insurance exchanges in all states by January 2014, to help people and small employers purchase insurance. People with incomes between 138% and 400% of the federal poverty level will get subsidies in the form of tax credits to help them afford coverage.

Kaiser’s projections, based on the 2007 Medical Expenditure Panel Survey, attempt to define what the exchange population will look like in 2019. "We thought it would be of value to [learn] more about some of the characteristics of who this population is likely to be," to help planners decide how exchanges should be structured, among other reasons, Mr. Damico said at the annual research meeting of AcademyHealth.

The projections also give clinicians an idea of what to expect as the exchanges roll out. A key priority "will be getting [enrollees] set up with primary care physicians. It’s [also] going to be important to get [enrollees] diagnosed quickly," he said, and monitor whether individuals in the exchanges continue to have difficulty getting care.

About 13% of the adults that Kaiser expects to enroll in exchanges report fair or poor health, a significantly greater share than what current privately insured individuals report.

Kaiser predicts that adult enrollees will be about age 40 years on average and will have median incomes of about 235% of the federal poverty level. Just over half are likely to be male, about half will be married, and perhaps almost a quarter will be unemployed. The foundation also predicts that about 40% will be minorities, 15% will be children, and almost a quarter will speak a language other than English at home.

In all, "the projected 2019 exchange population is relatively older, less educated, lower income, and more racially diverse than current privately insured populations," the report noted. And they will be in worse health.

Kaiser estimated that 65% of those entering exchanges will have been previously uninsured. Most of the rest will have lost employer-based insurance, switched from employer-based coverage, or lost Medicaid coverage because of new income-based requirements that limit eligibility to those at or below 138% of the federal poverty level.

Average annual medical costs for exchange adults will range between $3,139 and $3,568, in 2007 dollars, an amount that’s in line with expenditures for adults in employer-sponsored insurance plans, according to the report.

"One key component of exchange stability will be to keep the healthier folks in the exchanges. Administrators and policy makers and insurers are really going to have to focus on the effectiveness of the subsidies," Mr. Damico said.

"The presence of subsidies may provide an incentive" for employers "to drop coverage and push their employees into purchasing health insurance through the exchanges, particularly if those employees are less healthy," the report warned.

Mr. Damico said he had no relevant financial disclosures.

SEATTLE – Patient-centered medical homes will improve care and reduce costs only if patients use them.

To make that happen, a California demonstration project, the Health Care Coverage Initiative, had to deny claims for nonurgent care when patients sought help outside of their medical home, according to researchers from the University of California, Los Angeles, Health Policy Research Center.

The HCCI is a Medicaid demonstration project that provides care for low income, uninsured adults.

"You’re talking about a population that has historically been underserved. When they get sick, they go to the [emergency department]; that’s what they’ve done their whole lives. One of major challenges was convincing people that they have [their own] doctor and should go to that doctor when they’re sick," said Gerald Kominski, Ph.D., the center’s associate director.

He and his colleagues analyzed claims data for more than 37,700 enrollees in Orange County, where the policy was tried. In the year before the claims were denied, about 60% of outpatient primary care visits were at patients’ medical homes. "Folks were not being turned away" when they sought care elsewhere, said Anna Davis, MPH, a senior research associate at the center.

That number increased to about 80% in the year after the policy took effect; the change was driven by those who hadn’t been using their assigned homes.

"Primary care visits were almost six times as likely to be [medical home] adherent" once nonadherent claims were denied, Ms. Davis said.

The likelihood of any emergency department visits being followed by admission and the likelihood of any inpatient stay both declined significantly after the policy change, she added.

Primary care use of the medical home also increased after the policy change, and specialty and urgent care decreased.

"Enforcing adherence to the medical home may be a way to strengthen the impact of the medical home model. It’s likely to lead to reductions in cost, particularly among low-income populations," she said.

About half the patients in the study were older than age 50 years and had two or more chronic conditions. To be eligible for the demonstration project, they had to have incomes below 200% of the federal poverty level.

Every patient was assigned a primary care provider when they enrolled in HCCI, and they were allowed to change their provider every 6 months. They were informed of the claims-denial policy by letter; the same letter explained that they would have a copayment of $5 for office visits and $25 for emergency department visits.

The researchers haven’t looked yet to see what impact the changes had on enrollee health, but "we did look at ambulatory care sensitive inpatient admissions and didn’t see any significant findings," Ms. Davis said.

Dr. Kominski and Ms. Davis said they have no relevant disclosures.

SEATTLE – Patient-centered medical homes will improve care and reduce costs only if patients use them.

To make that happen, a California demonstration project, the Health Care Coverage Initiative, had to deny claims for nonurgent care when patients sought help outside of their medical home, according to researchers from the University of California, Los Angeles, Health Policy Research Center.

The HCCI is a Medicaid demonstration project that provides care for low income, uninsured adults.

"You’re talking about a population that has historically been underserved. When they get sick, they go to the [emergency department]; that’s what they’ve done their whole lives. One of major challenges was convincing people that they have [their own] doctor and should go to that doctor when they’re sick," said Gerald Kominski, Ph.D., the center’s associate director.

He and his colleagues analyzed claims data for more than 37,700 enrollees in Orange County, where the policy was tried. In the year before the claims were denied, about 60% of outpatient primary care visits were at patients’ medical homes. "Folks were not being turned away" when they sought care elsewhere, said Anna Davis, MPH, a senior research associate at the center.

That number increased to about 80% in the year after the policy took effect; the change was driven by those who hadn’t been using their assigned homes.

"Primary care visits were almost six times as likely to be [medical home] adherent" once nonadherent claims were denied, Ms. Davis said.

The likelihood of any emergency department visits being followed by admission and the likelihood of any inpatient stay both declined significantly after the policy change, she added.

Primary care use of the medical home also increased after the policy change, and specialty and urgent care decreased.

"Enforcing adherence to the medical home may be a way to strengthen the impact of the medical home model. It’s likely to lead to reductions in cost, particularly among low-income populations," she said.

About half the patients in the study were older than age 50 years and had two or more chronic conditions. To be eligible for the demonstration project, they had to have incomes below 200% of the federal poverty level.

Every patient was assigned a primary care provider when they enrolled in HCCI, and they were allowed to change their provider every 6 months. They were informed of the claims-denial policy by letter; the same letter explained that they would have a copayment of $5 for office visits and $25 for emergency department visits.

The researchers haven’t looked yet to see what impact the changes had on enrollee health, but "we did look at ambulatory care sensitive inpatient admissions and didn’t see any significant findings," Ms. Davis said.

Dr. Kominski and Ms. Davis said they have no relevant disclosures.

SEATTLE – Patient-centered medical homes will improve care and reduce costs only if patients use them.

To make that happen, a California demonstration project, the Health Care Coverage Initiative, had to deny claims for nonurgent care when patients sought help outside of their medical home, according to researchers from the University of California, Los Angeles, Health Policy Research Center.

The HCCI is a Medicaid demonstration project that provides care for low income, uninsured adults.

"You’re talking about a population that has historically been underserved. When they get sick, they go to the [emergency department]; that’s what they’ve done their whole lives. One of major challenges was convincing people that they have [their own] doctor and should go to that doctor when they’re sick," said Gerald Kominski, Ph.D., the center’s associate director.

He and his colleagues analyzed claims data for more than 37,700 enrollees in Orange County, where the policy was tried. In the year before the claims were denied, about 60% of outpatient primary care visits were at patients’ medical homes. "Folks were not being turned away" when they sought care elsewhere, said Anna Davis, MPH, a senior research associate at the center.

That number increased to about 80% in the year after the policy took effect; the change was driven by those who hadn’t been using their assigned homes.

"Primary care visits were almost six times as likely to be [medical home] adherent" once nonadherent claims were denied, Ms. Davis said.

The likelihood of any emergency department visits being followed by admission and the likelihood of any inpatient stay both declined significantly after the policy change, she added.

Primary care use of the medical home also increased after the policy change, and specialty and urgent care decreased.

"Enforcing adherence to the medical home may be a way to strengthen the impact of the medical home model. It’s likely to lead to reductions in cost, particularly among low-income populations," she said.

About half the patients in the study were older than age 50 years and had two or more chronic conditions. To be eligible for the demonstration project, they had to have incomes below 200% of the federal poverty level.

Every patient was assigned a primary care provider when they enrolled in HCCI, and they were allowed to change their provider every 6 months. They were informed of the claims-denial policy by letter; the same letter explained that they would have a copayment of $5 for office visits and $25 for emergency department visits.

The researchers haven’t looked yet to see what impact the changes had on enrollee health, but "we did look at ambulatory care sensitive inpatient admissions and didn’t see any significant findings," Ms. Davis said.

Dr. Kominski and Ms. Davis said they have no relevant disclosures.

SEATTLE – Patient-centered medical homes will improve care and reduce costs only if patients use them.

To make that happen, a California demonstration project, the Health Care Coverage Initiative, had to deny claims for nonurgent care when patients sought help outside of their medical home, according to researchers from the University of California, Los Angeles, Health Policy Research Center.

The HCCI is a Medicaid demonstration project that provides care for low income, uninsured adults.

"You’re talking about a population that has historically been underserved. When they get sick, they go to the [emergency department]; that’s what they’ve done their whole lives. One of major challenges was convincing people that they have [their own] doctor and should go to that doctor when they’re sick," said Gerald Kominski, Ph.D., the center’s associate director.

He and his colleagues analyzed claims data for more than 37,700 enrollees in Orange County, where the policy was tried. In the year before the claims were denied, about 60% of outpatient primary care visits were at patients’ medical homes. "Folks were not being turned away" when they sought care elsewhere, said Anna Davis, MPH, a senior research associate at the center.

That number increased to about 80% in the year after the policy took effect; the change was driven by those who hadn’t been using their assigned homes.

"Primary care visits were almost six times as likely to be [medical home] adherent" once nonadherent claims were denied, Ms. Davis said.

The likelihood of any emergency department visits being followed by admission and the likelihood of any inpatient stay both declined significantly after the policy change, she added.

Primary care use of the medical home also increased after the policy change, and specialty and urgent care decreased.

"Enforcing adherence to the medical home may be a way to strengthen the impact of the medical home model. It’s likely to lead to reductions in cost, particularly among low-income populations," she said.

About half the patients in the study were older than age 50 years and had two or more chronic conditions. To be eligible for the demonstration project, they had to have incomes below 200% of the federal poverty level.

Every patient was assigned a primary care provider when they enrolled in HCCI, and they were allowed to change their provider every 6 months. They were informed of the claims-denial policy by letter; the same letter explained that they would have a copayment of $5 for office visits and $25 for emergency department visits.

The researchers haven’t looked yet to see what impact the changes had on enrollee health, but "we did look at ambulatory care sensitive inpatient admissions and didn’t see any significant findings," Ms. Davis said.

Dr. Kominski and Ms. Davis said they have no relevant disclosures.

SEATTLE – Patient-centered medical homes will improve care and reduce costs only if patients use them.

To make that happen, a California demonstration project, the Health Care Coverage Initiative, had to deny claims for nonurgent care when patients sought help outside of their medical home, according to researchers from the University of California, Los Angeles, Health Policy Research Center.

The HCCI is a Medicaid demonstration project that provides care for low income, uninsured adults.

"You’re talking about a population that has historically been underserved. When they get sick, they go to the [emergency department]; that’s what they’ve done their whole lives. One of major challenges was convincing people that they have [their own] doctor and should go to that doctor when they’re sick," said Gerald Kominski, Ph.D., the center’s associate director.

He and his colleagues analyzed claims data for more than 37,700 enrollees in Orange County, where the policy was tried. In the year before the claims were denied, about 60% of outpatient primary care visits were at patients’ medical homes. "Folks were not being turned away" when they sought care elsewhere, said Anna Davis, MPH, a senior research associate at the center.

That number increased to about 80% in the year after the policy took effect; the change was driven by those who hadn’t been using their assigned homes.

"Primary care visits were almost six times as likely to be [medical home] adherent" once nonadherent claims were denied, Ms. Davis said.

The likelihood of any emergency department visits being followed by admission and the likelihood of any inpatient stay both declined significantly after the policy change, she added.

Primary care use of the medical home also increased after the policy change, and specialty and urgent care decreased.

"Enforcing adherence to the medical home may be a way to strengthen the impact of the medical home model. It’s likely to lead to reductions in cost, particularly among low-income populations," she said.

About half the patients in the study were older than age 50 years and had two or more chronic conditions. To be eligible for the demonstration project, they had to have incomes below 200% of the federal poverty level.

Every patient was assigned a primary care provider when they enrolled in HCCI, and they were allowed to change their provider every 6 months. They were informed of the claims-denial policy by letter; the same letter explained that they would have a copayment of $5 for office visits and $25 for emergency department visits.

The researchers haven’t looked yet to see what impact the changes had on enrollee health, but "we did look at ambulatory care sensitive inpatient admissions and didn’t see any significant findings," Ms. Davis said.

Dr. Kominski and Ms. Davis said they have no relevant disclosures.

SEATTLE – Patient-centered medical homes will improve care and reduce costs only if patients use them.

To make that happen, a California demonstration project, the Health Care Coverage Initiative, had to deny claims for nonurgent care when patients sought help outside of their medical home, according to researchers from the University of California, Los Angeles, Health Policy Research Center.

The HCCI is a Medicaid demonstration project that provides care for low income, uninsured adults.

"You’re talking about a population that has historically been underserved. When they get sick, they go to the [emergency department]; that’s what they’ve done their whole lives. One of major challenges was convincing people that they have [their own] doctor and should go to that doctor when they’re sick," said Gerald Kominski, Ph.D., the center’s associate director.

He and his colleagues analyzed claims data for more than 37,700 enrollees in Orange County, where the policy was tried. In the year before the claims were denied, about 60% of outpatient primary care visits were at patients’ medical homes. "Folks were not being turned away" when they sought care elsewhere, said Anna Davis, MPH, a senior research associate at the center.

That number increased to about 80% in the year after the policy took effect; the change was driven by those who hadn’t been using their assigned homes.

"Primary care visits were almost six times as likely to be [medical home] adherent" once nonadherent claims were denied, Ms. Davis said.

The likelihood of any emergency department visits being followed by admission and the likelihood of any inpatient stay both declined significantly after the policy change, she added.

Primary care use of the medical home also increased after the policy change, and specialty and urgent care decreased.

"Enforcing adherence to the medical home may be a way to strengthen the impact of the medical home model. It’s likely to lead to reductions in cost, particularly among low-income populations," she said.

About half the patients in the study were older than age 50 years and had two or more chronic conditions. To be eligible for the demonstration project, they had to have incomes below 200% of the federal poverty level.

Every patient was assigned a primary care provider when they enrolled in HCCI, and they were allowed to change their provider every 6 months. They were informed of the claims-denial policy by letter; the same letter explained that they would have a copayment of $5 for office visits and $25 for emergency department visits.

The researchers haven’t looked yet to see what impact the changes had on enrollee health, but "we did look at ambulatory care sensitive inpatient admissions and didn’t see any significant findings," Ms. Davis said.

Dr. Kominski and Ms. Davis said they have no relevant disclosures.

SEATTLE – Patients having heart attacks are more likely to die if their nearest emergency department is temporarily refusing new patients, according to a study that linked heart attack outcomes to hospital diversion logs in four California counties, and that was presented at the annual research meeting of AcademyHealth.

Acute MI death rates are about 3% higher if the closest ED is on 12 or more hours of diversion on the day of the heart attack.

Treatment delays could be the reason, but patients in the study were typically accepted by another ED within a mile. Another possible explanation is that diverted patients were less likely to end up at EDs with readily available and potentially lifesaving catheterization labs, said lead investigator Yu-Chu Shen, Ph.D., an economist at the Naval Postgraduate School in Monterey, Calif.

She and her colleague found a nonsignificant trend toward increased mortality for diversion periods shorter than 12 hours, as well as "an increase of 0.2 percentage points for every hour increase in diversion. This is the first multisite, multicounty study that really quantifies the association" between diversion and acute MI mortality "on a large scale," Dr. Shen said.

The findings are based on Medicare claims data for 11,625 acute MI patients in Los Angeles, San Francisco, San Mateo, and Santa Clara counties who were treated in 2000-2005 at about 150 EDs. The researchers compared mortality outcomes when patients were able to be treated at the nearest ED vs. outcomes when their nearest ED was on diversion, typically because there were no inpatient beds available for new admissions or the catheterization lab was full.

The approximately 3%, statistically significant increase in death rates when hospitals were on 12 or more hours of diversion held true across 30- and 90-day mortality, as well as 9- and 12-month mortality.

For instance, 15% of the 3,541 patients who were able to be admitted to their nearest ED died within 30 days of their heart attack; 19% of the 2,060 whose nearest ED was on 12 or more hours of diversion died within a month, which translated to a regression-adjusted increase of 3.24% (95% confidence interval, 0.60-5.88).

Similarly, when patients’ nearest EDs were accepting new patients, 87% were admitted to a hospital with a catheterization lab; when the nearest hospital was on at least 12 hours of diversion, the number fell to 78%, Dr. Shen said (JAMA 2011;305:2440-7).

The message for physicians is to "do everything you can to keep [the ED] open," said Dr. Edward Livingston, chairman of the GI and endocrine surgery division at the University of Texas, Dallas.

"Hospitals have different thresholds for closing. Some close at the drop of a hat; others wait until they absolutely" have no choice. "Everybody [seems to have] their own criteria, but it’s really in the patient\'s best interest for hospitals to do everything possible to stay open," said Dr. Livingston, also a contributing editor at JAMA, which published the study online ahead of print to coincide with Dr. Shen’s presentation.

"We chose to publish [the study] because we think it’s an important observation. This shows a broad spectrum of hospitals in different kinds of environments with the same problem. That suggests it is a truly systemic problem, and not just a problem of one particular facility or region," which has been suggested in the past, he said.

And it’s a problem with no easy solutions, he and Dr. Shen agreed, because diversion touches on issues of resource allocation, hospital design, health care markets, competition, and other matters.

But in the short term, there "may need to be criteria that we all agree on for what makes you close. We all ought to agree that those thresholds should be really high," Dr. Livingston said.

To mitigate the adverse health outcomes associated with hospitals on diversion, "the key is increasing flow through emergency departments by moving patients who have been admitted to the hospital out of the [ED] to inpatient areas," Dr. Sandra Schneider said in a statement. A task force of emergency physicians also recommended that hospitals discharge most hospital patients before noon to make more inpatient beds available to emergency patients, and that hospitals make an effort to schedule elective and surgical cases more evenly throughout the week. Dr. Schneider is president of the American College of Emergency Physicians.

Dr. Shen said she has no disclosures. Dr. Livingston said he is a consultant for Texas Instruments. The study was funded by the Robert Wood Johnson Foundation, the National Institutes of Health, and the University of California, San Francisco.

SEATTLE – Patients having heart attacks are more likely to die if their nearest emergency department is temporarily refusing new patients, according to a study that linked heart attack outcomes to hospital diversion logs in four California counties, and that was presented at the annual research meeting of AcademyHealth.

Acute MI death rates are about 3% higher if the closest ED is on 12 or more hours of diversion on the day of the heart attack.

Treatment delays could be the reason, but patients in the study were typically accepted by another ED within a mile. Another possible explanation is that diverted patients were less likely to end up at EDs with readily available and potentially lifesaving catheterization labs, said lead investigator Yu-Chu Shen, Ph.D., an economist at the Naval Postgraduate School in Monterey, Calif.

She and her colleague found a nonsignificant trend toward increased mortality for diversion periods shorter than 12 hours, as well as "an increase of 0.2 percentage points for every hour increase in diversion. This is the first multisite, multicounty study that really quantifies the association" between diversion and acute MI mortality "on a large scale," Dr. Shen said.

The findings are based on Medicare claims data for 11,625 acute MI patients in Los Angeles, San Francisco, San Mateo, and Santa Clara counties who were treated in 2000-2005 at about 150 EDs. The researchers compared mortality outcomes when patients were able to be treated at the nearest ED vs. outcomes when their nearest ED was on diversion, typically because there were no inpatient beds available for new admissions or the catheterization lab was full.

The approximately 3%, statistically significant increase in death rates when hospitals were on 12 or more hours of diversion held true across 30- and 90-day mortality, as well as 9- and 12-month mortality.

For instance, 15% of the 3,541 patients who were able to be admitted to their nearest ED died within 30 days of their heart attack; 19% of the 2,060 whose nearest ED was on 12 or more hours of diversion died within a month, which translated to a regression-adjusted increase of 3.24% (95% confidence interval, 0.60-5.88).

Similarly, when patients’ nearest EDs were accepting new patients, 87% were admitted to a hospital with a catheterization lab; when the nearest hospital was on at least 12 hours of diversion, the number fell to 78%, Dr. Shen said (JAMA 2011;305:2440-7).

The message for physicians is to "do everything you can to keep [the ED] open," said Dr. Edward Livingston, chairman of the GI and endocrine surgery division at the University of Texas, Dallas.

"Hospitals have different thresholds for closing. Some close at the drop of a hat; others wait until they absolutely" have no choice. "Everybody [seems to have] their own criteria, but it’s really in the patient\'s best interest for hospitals to do everything possible to stay open," said Dr. Livingston, also a contributing editor at JAMA, which published the study online ahead of print to coincide with Dr. Shen’s presentation.

"We chose to publish [the study] because we think it’s an important observation. This shows a broad spectrum of hospitals in different kinds of environments with the same problem. That suggests it is a truly systemic problem, and not just a problem of one particular facility or region," which has been suggested in the past, he said.

And it’s a problem with no easy solutions, he and Dr. Shen agreed, because diversion touches on issues of resource allocation, hospital design, health care markets, competition, and other matters.

But in the short term, there "may need to be criteria that we all agree on for what makes you close. We all ought to agree that those thresholds should be really high," Dr. Livingston said.

To mitigate the adverse health outcomes associated with hospitals on diversion, "the key is increasing flow through emergency departments by moving patients who have been admitted to the hospital out of the [ED] to inpatient areas," Dr. Sandra Schneider said in a statement. A task force of emergency physicians also recommended that hospitals discharge most hospital patients before noon to make more inpatient beds available to emergency patients, and that hospitals make an effort to schedule elective and surgical cases more evenly throughout the week. Dr. Schneider is president of the American College of Emergency Physicians.

Dr. Shen said she has no disclosures. Dr. Livingston said he is a consultant for Texas Instruments. The study was funded by the Robert Wood Johnson Foundation, the National Institutes of Health, and the University of California, San Francisco.

SEATTLE – Patients having heart attacks are more likely to die if their nearest emergency department is temporarily refusing new patients, according to a study that linked heart attack outcomes to hospital diversion logs in four California counties, and that was presented at the annual research meeting of AcademyHealth.

Acute MI death rates are about 3% higher if the closest ED is on 12 or more hours of diversion on the day of the heart attack.

Treatment delays could be the reason, but patients in the study were typically accepted by another ED within a mile. Another possible explanation is that diverted patients were less likely to end up at EDs with readily available and potentially lifesaving catheterization labs, said lead investigator Yu-Chu Shen, Ph.D., an economist at the Naval Postgraduate School in Monterey, Calif.

She and her colleague found a nonsignificant trend toward increased mortality for diversion periods shorter than 12 hours, as well as "an increase of 0.2 percentage points for every hour increase in diversion. This is the first multisite, multicounty study that really quantifies the association" between diversion and acute MI mortality "on a large scale," Dr. Shen said.

The findings are based on Medicare claims data for 11,625 acute MI patients in Los Angeles, San Francisco, San Mateo, and Santa Clara counties who were treated in 2000-2005 at about 150 EDs. The researchers compared mortality outcomes when patients were able to be treated at the nearest ED vs. outcomes when their nearest ED was on diversion, typically because there were no inpatient beds available for new admissions or the catheterization lab was full.

The approximately 3%, statistically significant increase in death rates when hospitals were on 12 or more hours of diversion held true across 30- and 90-day mortality, as well as 9- and 12-month mortality.

For instance, 15% of the 3,541 patients who were able to be admitted to their nearest ED died within 30 days of their heart attack; 19% of the 2,060 whose nearest ED was on 12 or more hours of diversion died within a month, which translated to a regression-adjusted increase of 3.24% (95% confidence interval, 0.60-5.88).

Similarly, when patients’ nearest EDs were accepting new patients, 87% were admitted to a hospital with a catheterization lab; when the nearest hospital was on at least 12 hours of diversion, the number fell to 78%, Dr. Shen said (JAMA 2011;305:2440-7).

The message for physicians is to "do everything you can to keep [the ED] open," said Dr. Edward Livingston, chairman of the GI and endocrine surgery division at the University of Texas, Dallas.

"Hospitals have different thresholds for closing. Some close at the drop of a hat; others wait until they absolutely" have no choice. "Everybody [seems to have] their own criteria, but it’s really in the patient\'s best interest for hospitals to do everything possible to stay open," said Dr. Livingston, also a contributing editor at JAMA, which published the study online ahead of print to coincide with Dr. Shen’s presentation.

"We chose to publish [the study] because we think it’s an important observation. This shows a broad spectrum of hospitals in different kinds of environments with the same problem. That suggests it is a truly systemic problem, and not just a problem of one particular facility or region," which has been suggested in the past, he said.

And it’s a problem with no easy solutions, he and Dr. Shen agreed, because diversion touches on issues of resource allocation, hospital design, health care markets, competition, and other matters.

But in the short term, there "may need to be criteria that we all agree on for what makes you close. We all ought to agree that those thresholds should be really high," Dr. Livingston said.

To mitigate the adverse health outcomes associated with hospitals on diversion, "the key is increasing flow through emergency departments by moving patients who have been admitted to the hospital out of the [ED] to inpatient areas," Dr. Sandra Schneider said in a statement. A task force of emergency physicians also recommended that hospitals discharge most hospital patients before noon to make more inpatient beds available to emergency patients, and that hospitals make an effort to schedule elective and surgical cases more evenly throughout the week. Dr. Schneider is president of the American College of Emergency Physicians.

Dr. Shen said she has no disclosures. Dr. Livingston said he is a consultant for Texas Instruments. The study was funded by the Robert Wood Johnson Foundation, the National Institutes of Health, and the University of California, San Francisco.

SEATTLE – Patients having heart attacks are more likely to die if their nearest emergency department is temporarily refusing new patients, according to a study that linked heart attack outcomes to hospital diversion logs in four California counties, and that was presented at the annual research meeting of AcademyHealth.

Acute MI death rates are about 3% higher if the closest ED is on 12 or more hours of diversion on the day of the heart attack.

Treatment delays could be the reason, but patients in the study were typically accepted by another ED within a mile. Another possible explanation is that diverted patients were less likely to end up at EDs with readily available and potentially lifesaving catheterization labs, said lead investigator Yu-Chu Shen, Ph.D., an economist at the Naval Postgraduate School in Monterey, Calif.

She and her colleague found a nonsignificant trend toward increased mortality for diversion periods shorter than 12 hours, as well as "an increase of 0.2 percentage points for every hour increase in diversion. This is the first multisite, multicounty study that really quantifies the association" between diversion and acute MI mortality "on a large scale," Dr. Shen said.

The findings are based on Medicare claims data for 11,625 acute MI patients in Los Angeles, San Francisco, San Mateo, and Santa Clara counties who were treated in 2000-2005 at about 150 EDs. The researchers compared mortality outcomes when patients were able to be treated at the nearest ED vs. outcomes when their nearest ED was on diversion, typically because there were no inpatient beds available for new admissions or the catheterization lab was full.

The approximately 3%, statistically significant increase in death rates when hospitals were on 12 or more hours of diversion held true across 30- and 90-day mortality, as well as 9- and 12-month mortality.

For instance, 15% of the 3,541 patients who were able to be admitted to their nearest ED died within 30 days of their heart attack; 19% of the 2,060 whose nearest ED was on 12 or more hours of diversion died within a month, which translated to a regression-adjusted increase of 3.24% (95% confidence interval, 0.60-5.88).

Similarly, when patients’ nearest EDs were accepting new patients, 87% were admitted to a hospital with a catheterization lab; when the nearest hospital was on at least 12 hours of diversion, the number fell to 78%, Dr. Shen said (JAMA 2011;305:2440-7).

The message for physicians is to "do everything you can to keep [the ED] open," said Dr. Edward Livingston, chairman of the GI and endocrine surgery division at the University of Texas, Dallas.

"Hospitals have different thresholds for closing. Some close at the drop of a hat; others wait until they absolutely" have no choice. "Everybody [seems to have] their own criteria, but it’s really in the patient\'s best interest for hospitals to do everything possible to stay open," said Dr. Livingston, also a contributing editor at JAMA, which published the study online ahead of print to coincide with Dr. Shen’s presentation.

"We chose to publish [the study] because we think it’s an important observation. This shows a broad spectrum of hospitals in different kinds of environments with the same problem. That suggests it is a truly systemic problem, and not just a problem of one particular facility or region," which has been suggested in the past, he said.

And it’s a problem with no easy solutions, he and Dr. Shen agreed, because diversion touches on issues of resource allocation, hospital design, health care markets, competition, and other matters.

But in the short term, there "may need to be criteria that we all agree on for what makes you close. We all ought to agree that those thresholds should be really high," Dr. Livingston said.

To mitigate the adverse health outcomes associated with hospitals on diversion, "the key is increasing flow through emergency departments by moving patients who have been admitted to the hospital out of the [ED] to inpatient areas," Dr. Sandra Schneider said in a statement. A task force of emergency physicians also recommended that hospitals discharge most hospital patients before noon to make more inpatient beds available to emergency patients, and that hospitals make an effort to schedule elective and surgical cases more evenly throughout the week. Dr. Schneider is president of the American College of Emergency Physicians.

Dr. Shen said she has no disclosures. Dr. Livingston said he is a consultant for Texas Instruments. The study was funded by the Robert Wood Johnson Foundation, the National Institutes of Health, and the University of California, San Francisco.

SEATTLE – Patients having heart attacks are more likely to die if their nearest emergency department is temporarily refusing new patients, according to a study that linked heart attack outcomes to hospital diversion logs in four California counties, and that was presented at the annual research meeting of AcademyHealth.

Acute MI death rates are about 3% higher if the closest ED is on 12 or more hours of diversion on the day of the heart attack.

Treatment delays could be the reason, but patients in the study were typically accepted by another ED within a mile. Another possible explanation is that diverted patients were less likely to end up at EDs with readily available and potentially lifesaving catheterization labs, said lead investigator Yu-Chu Shen, Ph.D., an economist at the Naval Postgraduate School in Monterey, Calif.

She and her colleague found a nonsignificant trend toward increased mortality for diversion periods shorter than 12 hours, as well as "an increase of 0.2 percentage points for every hour increase in diversion. This is the first multisite, multicounty study that really quantifies the association" between diversion and acute MI mortality "on a large scale," Dr. Shen said.

The findings are based on Medicare claims data for 11,625 acute MI patients in Los Angeles, San Francisco, San Mateo, and Santa Clara counties who were treated in 2000-2005 at about 150 EDs. The researchers compared mortality outcomes when patients were able to be treated at the nearest ED vs. outcomes when their nearest ED was on diversion, typically because there were no inpatient beds available for new admissions or the catheterization lab was full.

The approximately 3%, statistically significant increase in death rates when hospitals were on 12 or more hours of diversion held true across 30- and 90-day mortality, as well as 9- and 12-month mortality.

For instance, 15% of the 3,541 patients who were able to be admitted to their nearest ED died within 30 days of their heart attack; 19% of the 2,060 whose nearest ED was on 12 or more hours of diversion died within a month, which translated to a regression-adjusted increase of 3.24% (95% confidence interval, 0.60-5.88).

Similarly, when patients’ nearest EDs were accepting new patients, 87% were admitted to a hospital with a catheterization lab; when the nearest hospital was on at least 12 hours of diversion, the number fell to 78%, Dr. Shen said (JAMA 2011;305:2440-7).

The message for physicians is to "do everything you can to keep [the ED] open," said Dr. Edward Livingston, chairman of the GI and endocrine surgery division at the University of Texas, Dallas.

"Hospitals have different thresholds for closing. Some close at the drop of a hat; others wait until they absolutely" have no choice. "Everybody [seems to have] their own criteria, but it’s really in the patient\'s best interest for hospitals to do everything possible to stay open," said Dr. Livingston, also a contributing editor at JAMA, which published the study online ahead of print to coincide with Dr. Shen’s presentation.

"We chose to publish [the study] because we think it’s an important observation. This shows a broad spectrum of hospitals in different kinds of environments with the same problem. That suggests it is a truly systemic problem, and not just a problem of one particular facility or region," which has been suggested in the past, he said.

And it’s a problem with no easy solutions, he and Dr. Shen agreed, because diversion touches on issues of resource allocation, hospital design, health care markets, competition, and other matters.

But in the short term, there "may need to be criteria that we all agree on for what makes you close. We all ought to agree that those thresholds should be really high," Dr. Livingston said.

To mitigate the adverse health outcomes associated with hospitals on diversion, "the key is increasing flow through emergency departments by moving patients who have been admitted to the hospital out of the [ED] to inpatient areas," Dr. Sandra Schneider said in a statement. A task force of emergency physicians also recommended that hospitals discharge most hospital patients before noon to make more inpatient beds available to emergency patients, and that hospitals make an effort to schedule elective and surgical cases more evenly throughout the week. Dr. Schneider is president of the American College of Emergency Physicians.

Dr. Shen said she has no disclosures. Dr. Livingston said he is a consultant for Texas Instruments. The study was funded by the Robert Wood Johnson Foundation, the National Institutes of Health, and the University of California, San Francisco.

SEATTLE – Patients having heart attacks are more likely to die if their nearest emergency department is temporarily refusing new patients, according to a study that linked heart attack outcomes to hospital diversion logs in four California counties, and that was presented at the annual research meeting of AcademyHealth.

Acute MI death rates are about 3% higher if the closest ED is on 12 or more hours of diversion on the day of the heart attack.

Treatment delays could be the reason, but patients in the study were typically accepted by another ED within a mile. Another possible explanation is that diverted patients were less likely to end up at EDs with readily available and potentially lifesaving catheterization labs, said lead investigator Yu-Chu Shen, Ph.D., an economist at the Naval Postgraduate School in Monterey, Calif.

She and her colleague found a nonsignificant trend toward increased mortality for diversion periods shorter than 12 hours, as well as "an increase of 0.2 percentage points for every hour increase in diversion. This is the first multisite, multicounty study that really quantifies the association" between diversion and acute MI mortality "on a large scale," Dr. Shen said.

The findings are based on Medicare claims data for 11,625 acute MI patients in Los Angeles, San Francisco, San Mateo, and Santa Clara counties who were treated in 2000-2005 at about 150 EDs. The researchers compared mortality outcomes when patients were able to be treated at the nearest ED vs. outcomes when their nearest ED was on diversion, typically because there were no inpatient beds available for new admissions or the catheterization lab was full.

The approximately 3%, statistically significant increase in death rates when hospitals were on 12 or more hours of diversion held true across 30- and 90-day mortality, as well as 9- and 12-month mortality.

For instance, 15% of the 3,541 patients who were able to be admitted to their nearest ED died within 30 days of their heart attack; 19% of the 2,060 whose nearest ED was on 12 or more hours of diversion died within a month, which translated to a regression-adjusted increase of 3.24% (95% confidence interval, 0.60-5.88).

Similarly, when patients’ nearest EDs were accepting new patients, 87% were admitted to a hospital with a catheterization lab; when the nearest hospital was on at least 12 hours of diversion, the number fell to 78%, Dr. Shen said (JAMA 2011;305:2440-7).

The message for physicians is to "do everything you can to keep [the ED] open," said Dr. Edward Livingston, chairman of the GI and endocrine surgery division at the University of Texas, Dallas.

"Hospitals have different thresholds for closing. Some close at the drop of a hat; others wait until they absolutely" have no choice. "Everybody [seems to have] their own criteria, but it’s really in the patient\'s best interest for hospitals to do everything possible to stay open," said Dr. Livingston, also a contributing editor at JAMA, which published the study online ahead of print to coincide with Dr. Shen’s presentation.

"We chose to publish [the study] because we think it’s an important observation. This shows a broad spectrum of hospitals in different kinds of environments with the same problem. That suggests it is a truly systemic problem, and not just a problem of one particular facility or region," which has been suggested in the past, he said.

And it’s a problem with no easy solutions, he and Dr. Shen agreed, because diversion touches on issues of resource allocation, hospital design, health care markets, competition, and other matters.

But in the short term, there "may need to be criteria that we all agree on for what makes you close. We all ought to agree that those thresholds should be really high," Dr. Livingston said.

To mitigate the adverse health outcomes associated with hospitals on diversion, "the key is increasing flow through emergency departments by moving patients who have been admitted to the hospital out of the [ED] to inpatient areas," Dr. Sandra Schneider said in a statement. A task force of emergency physicians also recommended that hospitals discharge most hospital patients before noon to make more inpatient beds available to emergency patients, and that hospitals make an effort to schedule elective and surgical cases more evenly throughout the week. Dr. Schneider is president of the American College of Emergency Physicians.

Dr. Shen said she has no disclosures. Dr. Livingston said he is a consultant for Texas Instruments. The study was funded by the Robert Wood Johnson Foundation, the National Institutes of Health, and the University of California, San Francisco.

SEATTLE – Gastric bypass did not extend the lives of older, severely obese patients in a Department of Veterans Affairs Study.

Though bariatric surgery is often assumed to extend lives, "physicians should advise patients such as those examined here that there is no survival benefit at nearly 7 years, and the longer-term survival benefit is still unknown," said lead author Matthew L. Maciejewski, Ph.D., of Duke University, Durham, N.C., and an investigator at the Center for Health Services Research in Primary Care at the Durham VA Medical Center at the annual research meeting of AcademyHealth.

He and his colleagues compared 850 VA Roux-en-Y gastric bypass patients with 41,244 nonsurgical controls. The operations were conducted between 2000 and 2006. The average age in the bypass group was 50 years and average body mass index was 47 kg/m²; 74% were men. The average age in the control group was 55 years and average BMI was 42 kg/m²; 92% were men.

At first glance, bypass patients appeared to do better after a mean follow-up of 6.7 years. Although 6.8% had died after 6 years, for instance, 15.2% had died in the control group (hazard ratio, 0.64; 95% confidence interval, 0.51-0.80).

The apparent advantage, however, diminished after covariate adjustment (HR 0.80; 95% CI 0.63-0.99), and vanished when patients were propensity matched one to one with the most similar controls based on age, sex, race, marital status, BMI, diagnosis related groups (DRG), and other factors (HR, 0.83; 95% CI, 0.61-1.14). When the investigators further adjusted for the start time, the advantage disappeared (HR, 0.94, 95% CI, 0.64-1.39).

In short, "the use of bariatric surgery, compared with usual care, was not associated with decreased mortality," Dr. Maciejewski and his colleagues concluded (JAMA 2011 June 12 [doi:10.1001/jama.2011.817]).

The results mean "you should not select people [for surgery] thinking they are going to live longer. If someone comes to you and says, ‘I want bariatric surgery because it’s going to improve my longevity,’ the answer is ‘no.’ There’s no study that definitively shows that might even be the case," said coauthor Dr. Edward Livingston, chairman of the GI and endocrine surgery division at the University of Texas Southwestern Medical School at Dallas.

Selection instead should be based on immediate concerns. Out-of-control diabetes, a patient too big to get around, sleep apnea, failing joints, and other weight-related problems make "surgery a reasonable option," said Dr. Livingston, who’s been performing bariatric surgeries since 1993.

The findings contradict previous studies suggesting a survival benefit for bariatric surgery, but those studies were largely of younger women with inherently lower obesity-related mortality risks, or foreign studies that don’t translate well to the United States, he said.

In contrast, the veterans in the study – older, obese, and comorbid – "die at a very high rate, so we expected [surgery to demonstrate] a big benefit in a short amount of time. The belief is if you take people that are really sick with diabetes, hypertension, and sleep apnea, and get a lot of weight off them, they live longer. We didn’t see it. This is the first study to show that doesn’t actually happen," he said.

The researchers have previously shown that bariatric surgery did not cut the health care costs of their cohort within 3 years (Med. Care 2010;48:989-98).

Dr. Maciejewski is paid consultant to Takeda Pharmaceuticals and Novartis and owns stock in Amgen. Dr. Livingston is a paid consultant to Texas Instruments. The study was funded by the Department of Veterans Affairs.

SEATTLE – Gastric bypass did not extend the lives of older, severely obese patients in a Department of Veterans Affairs Study.

Though bariatric surgery is often assumed to extend lives, "physicians should advise patients such as those examined here that there is no survival benefit at nearly 7 years, and the longer-term survival benefit is still unknown," said lead author Matthew L. Maciejewski, Ph.D., of Duke University, Durham, N.C., and an investigator at the Center for Health Services Research in Primary Care at the Durham VA Medical Center at the annual research meeting of AcademyHealth.

He and his colleagues compared 850 VA Roux-en-Y gastric bypass patients with 41,244 nonsurgical controls. The operations were conducted between 2000 and 2006. The average age in the bypass group was 50 years and average body mass index was 47 kg/m²; 74% were men. The average age in the control group was 55 years and average BMI was 42 kg/m²; 92% were men.

At first glance, bypass patients appeared to do better after a mean follow-up of 6.7 years. Although 6.8% had died after 6 years, for instance, 15.2% had died in the control group (hazard ratio, 0.64; 95% confidence interval, 0.51-0.80).

The apparent advantage, however, diminished after covariate adjustment (HR 0.80; 95% CI 0.63-0.99), and vanished when patients were propensity matched one to one with the most similar controls based on age, sex, race, marital status, BMI, diagnosis related groups (DRG), and other factors (HR, 0.83; 95% CI, 0.61-1.14). When the investigators further adjusted for the start time, the advantage disappeared (HR, 0.94, 95% CI, 0.64-1.39).

In short, "the use of bariatric surgery, compared with usual care, was not associated with decreased mortality," Dr. Maciejewski and his colleagues concluded (JAMA 2011 June 12 [doi:10.1001/jama.2011.817]).

The results mean "you should not select people [for surgery] thinking they are going to live longer. If someone comes to you and says, ‘I want bariatric surgery because it’s going to improve my longevity,’ the answer is ‘no.’ There’s no study that definitively shows that might even be the case," said coauthor Dr. Edward Livingston, chairman of the GI and endocrine surgery division at the University of Texas Southwestern Medical School at Dallas.

Selection instead should be based on immediate concerns. Out-of-control diabetes, a patient too big to get around, sleep apnea, failing joints, and other weight-related problems make "surgery a reasonable option," said Dr. Livingston, who’s been performing bariatric surgeries since 1993.

The findings contradict previous studies suggesting a survival benefit for bariatric surgery, but those studies were largely of younger women with inherently lower obesity-related mortality risks, or foreign studies that don’t translate well to the United States, he said.

In contrast, the veterans in the study – older, obese, and comorbid – "die at a very high rate, so we expected [surgery to demonstrate] a big benefit in a short amount of time. The belief is if you take people that are really sick with diabetes, hypertension, and sleep apnea, and get a lot of weight off them, they live longer. We didn’t see it. This is the first study to show that doesn’t actually happen," he said.

The researchers have previously shown that bariatric surgery did not cut the health care costs of their cohort within 3 years (Med. Care 2010;48:989-98).

Dr. Maciejewski is paid consultant to Takeda Pharmaceuticals and Novartis and owns stock in Amgen. Dr. Livingston is a paid consultant to Texas Instruments. The study was funded by the Department of Veterans Affairs.

SEATTLE – Gastric bypass did not extend the lives of older, severely obese patients in a Department of Veterans Affairs Study.

Though bariatric surgery is often assumed to extend lives, "physicians should advise patients such as those examined here that there is no survival benefit at nearly 7 years, and the longer-term survival benefit is still unknown," said lead author Matthew L. Maciejewski, Ph.D., of Duke University, Durham, N.C., and an investigator at the Center for Health Services Research in Primary Care at the Durham VA Medical Center at the annual research meeting of AcademyHealth.

He and his colleagues compared 850 VA Roux-en-Y gastric bypass patients with 41,244 nonsurgical controls. The operations were conducted between 2000 and 2006. The average age in the bypass group was 50 years and average body mass index was 47 kg/m²; 74% were men. The average age in the control group was 55 years and average BMI was 42 kg/m²; 92% were men.

At first glance, bypass patients appeared to do better after a mean follow-up of 6.7 years. Although 6.8% had died after 6 years, for instance, 15.2% had died in the control group (hazard ratio, 0.64; 95% confidence interval, 0.51-0.80).

The apparent advantage, however, diminished after covariate adjustment (HR 0.80; 95% CI 0.63-0.99), and vanished when patients were propensity matched one to one with the most similar controls based on age, sex, race, marital status, BMI, diagnosis related groups (DRG), and other factors (HR, 0.83; 95% CI, 0.61-1.14). When the investigators further adjusted for the start time, the advantage disappeared (HR, 0.94, 95% CI, 0.64-1.39).

In short, "the use of bariatric surgery, compared with usual care, was not associated with decreased mortality," Dr. Maciejewski and his colleagues concluded (JAMA 2011 June 12 [doi:10.1001/jama.2011.817]).

The results mean "you should not select people [for surgery] thinking they are going to live longer. If someone comes to you and says, ‘I want bariatric surgery because it’s going to improve my longevity,’ the answer is ‘no.’ There’s no study that definitively shows that might even be the case," said coauthor Dr. Edward Livingston, chairman of the GI and endocrine surgery division at the University of Texas Southwestern Medical School at Dallas.

Selection instead should be based on immediate concerns. Out-of-control diabetes, a patient too big to get around, sleep apnea, failing joints, and other weight-related problems make "surgery a reasonable option," said Dr. Livingston, who’s been performing bariatric surgeries since 1993.

The findings contradict previous studies suggesting a survival benefit for bariatric surgery, but those studies were largely of younger women with inherently lower obesity-related mortality risks, or foreign studies that don’t translate well to the United States, he said.

In contrast, the veterans in the study – older, obese, and comorbid – "die at a very high rate, so we expected [surgery to demonstrate] a big benefit in a short amount of time. The belief is if you take people that are really sick with diabetes, hypertension, and sleep apnea, and get a lot of weight off them, they live longer. We didn’t see it. This is the first study to show that doesn’t actually happen," he said.

The researchers have previously shown that bariatric surgery did not cut the health care costs of their cohort within 3 years (Med. Care 2010;48:989-98).

Dr. Maciejewski is paid consultant to Takeda Pharmaceuticals and Novartis and owns stock in Amgen. Dr. Livingston is a paid consultant to Texas Instruments. The study was funded by the Department of Veterans Affairs.