Practically Speaking
Winter 2017

2016 Greater Value Portfolio Awards

Donaghue is delighted to be working with the Rx Foundation for the 2016 Greater Value Portfolio program, which has funded four exciting research projects for a total of $2,167,756.

The Rx Foundation funds innovative people and projects to improve healthcare quality and access in the U.S. Jennie Riley, Rx Foundation Coordinator and Secretary to the Board of Trustees said that “The Rx Foundation welcomed the opportunity to partner with Donaghue in considering a strong group of proposals that demonstrated potential for both impact and scalability within the health system.”

The Greater Value Portfolio program supports research projects that demonstrate and test new approaches to increasing value in health care delivery. In 2016, 115 letters of intent were reviewed by a small group of subject matter experts, including staff from Donaghue and the Rx Foundation. The topic of improving the value in our health care system is a broad one, and the ideas that were submitted were wide-ranging. In general, we received LOIs on ideas that focused on health care consumers, on changes to specific areas clinical care delivery, and on changes to systems that extend beyond health care.

The four Greater Value Portfolio award winners selected in 2016 and their research topics are described below.

Scott Halpern, MD, PhD
University of Pennsylvania
“Behavioral Economic Approaches to Improve Palliative Care for Critically Ill Patients”
The well-described mismatch between the care seriously ill patients want and the care they receive stems, in part, from clinicians’ failures to engage patients’ in discussions about their goals and preferences in a timely manner. For example, ICU clinicians struggle to adhere to recommendations that they discuss prognosis and palliative options with patients and caregivers. We propose a pragmatic, stepped-wedge, cluster randomized trial testing the effectiveness of two electronic health record interventions designed to increase ICU clinicians’ engagement of critically ill patients and caregivers in discussions about alternative treatment options, including care focused on comfort. We hypothesize that patient centered outcomes can be improved without raising costs by simply requiring ICU clinicians to document a prognostic estimate (Intervention A) and to provide justification if they choose not to offer patients the option of comfort-oriented care (Intervention B). The primary outcome of our study is a composite measure of in-hospital mortality and length of stay, which we have previously developed and shown to be patient-centered. Secondary outcomes include nurse-assessed quality of death, other clinical outcomes, palliative care process measures, and costs.

Ateev Mehrotra, MD, MPH
Harvard School of Medicine
“Just Google It: What Is the Impact of Health Care Price Information Being More Accessible to
The growing interest nationally in price transparency is motivated by the wide variation in prices seen across providers and the increasing out-of-pocket cost burden on patients. The hope is that patients will use price transparency initiatives to identify lower-cost providers and save money. Unfortunately existing price transparency initiatives have largely been unsuccessful. The websites are rarely used because patients find them difficult to find and navigate. The goal of my research is to evaluate the impact of making provider price data easily accessible on the Internet through a unique partnership between Google, Harvard, and the State of New Hampshire. New Hampshire has a relatively sophisticated price transparency website, but it is rarely used. By early 2017 Google will display the price information on New Hampshire’s website when a relevant search is made by a user in New Hampshire. Our study has three aims: measure utilization and engagement of the price data by Google users; survey New Hampshire residents to evaluate whether the initiative increases their ability to find relevant price data; and use health plan claims to evaluate whether making price data more easily available led more New Hampshire residents to shift to lower-cost providers. This research will add to our understanding of how to encourage price transparency and price shopping, while also having a practical positive benefit to New Hampshire residents for whom price information will become easier to find.

Sophia Jan, MD, MSHP
The Feinstein Institute for Medical Research
“Long Term Care and Future Planning for Adults with Intellectual/Developmental Disabilities”
Most adults with intellectual/developmental disabilities outlive their parents. Unfortunately, the publicly-funded long-term care delivery system — which includes home health care, adult daycares, and nursing homes — cannot keep up with demand. Most families recognize the need to develop long-term care plans. Yet few do, leading to crises, emotional trauma, and at its worst, inappropriate or unwanted and costly placement in nursing home settings. Identifying individuals at highest risk for emergent placement and intervention targets for long-term care planning can significantly improve the quality of life, independence, and personal choice of adults with intellectual/developmental disabilities while also improving the impact of public funding and effectiveness of existing long-term care support services.

Partnering with a social services agency and focusing on intellectual/developmental disabilities adults 18-64 years, an age at which many long-term care decisions are initiated, our specific aims are the following:

  • Develop a predictive model identifying adults with intellectual/developmental disabilities at greatest risk for institutional placement through a retrospective cohort of Medicaid and Medicare-eligible enrollees with intellectual/developmental disabilities in five large states
  • Identify long-term care planning activities among racially-diverse aging caregivers living with adults with intellectual/developmental disabilities through a community-based cross-sectional survey in one city
  • Identify strategies to promote long-term care planning through focus groups of racially-diverse aging family caregivers who are positive and negative outliers of long-term care planning
  • Develop and test a long-term care planning tool to help adults with intellectual/developmental disabilities and family caregivers understand projected health needs and plan ways to remain in their own homes when crises occur

David Meltzer, MD, PhD
University of Chicago
“Longitudinal Effects of the Comprehensive Care Physician Program”
Health care costs and adverse health outcomes are concentrated in a small fraction of the population at increased risk of hospitalization. Hospitalized patients often experience discontinuities between inpatient and outpatient care that increase costs and impair outcomes. This has been especially true as hospitalists have increasingly provided hospital care instead of traditional primary care physicians, who no longer typically have enough patients in the hospital to make it economically viable for them to see hospitalized patients.

With funding from the Center for Medicare and Medicaid Innovation since 2012, we have recruited 2,000 patients for a randomized trial to test whether Medicare patients at increased risk of hospitalization experience better outcomes if they can receive inpatient and outpatient care from the same physician. We make this possible by having a group of comprehensive care physicians who care for a small panel of patients at increased risk of hospitalization so that they have enough patients in the hospital each morning to justify their daily presence there while having a small enough panel of patients that they can provide them with primary care despite only having clinic in the afternoons. Our preliminary results suggest substantially improved care experience, outcomes, and costs with comprehensive care physicians’ over 18 months, but longer follow-up is needed. The goal of this study is to conduct this long-term follow up to assess whether outcomes improve and total resource use declines over four years if patients receive inpatient and outpatient care from a comprehensive care physician compared to different inpatient and outpatient physicians.