Cost of Health Care
09 Jun Assigning Low Income Medicare Enrollees to Least Expensive Plan May Save Billions
MedicalResearch.com Interview with: Yuting Zhang, Ph.D. Associate professor Graduate School of Public Health Department of Health Policy and Management. University of Pittsburgh MedicalResearch: What are the main findings of the study? Dr. Zhang: Since 2006, the government has randomly assigned low-income enrollees to stand-alone Part D plans, based upon the region in which they live. If low-income Medicare Part D enrollees were assigned to the least expensive plan instead of a random plan, the government and beneficiaries could save more than $5 billion in the first year.09 Jun Insurance Status May Predict Cancer Outcome in Young Adults
Posted at 11:48h
in Author Interviews, Cancer Research, Cost of Health Care, Journal Clinical Oncology
MedicalResearch Interview with:
Ayal A. Aizer, MD, MHS
Harvard Radiation Oncology Program
Boston, MA
MedicalResearch: What are the main findings of the study?
Dr. Aizer: We studied Americans between the ages of 20-40 using the SEER Database (a national cancer registry) and found that patients who had insurance were more likely to present with localized (curable) versus metastatic (generally incurable) cancer. Patients with localized tumors were more likely to receive the appropriate treatment and, most importantly, survived longer than patients without insurance. Our analysis accounted for demographic and socioeconomic differences between patients who were insured versus uninsured. Our results indicate that insurance status is a powerful predictor of outcome among young adults with cancer. The Affordable Care Act, which will likely improve insurance coverage nationally, may yield improved cancer outcomes among Americans.
07 Jun Cuts In Medicaid Disproportionate Share Funding Challenge Safety-Net Hospitals
MedicalResearch.com Interview with
Katherine Neuhausen, MD, MPH
Director of Delivery System Transformation, Office of Health Innovation
Clinical Assistant Professor, Department of Family Medicine and Population Health
Virginia Commonwealth University
MedicalResearch: What are the main findings of the study?
Dr. Neuhausen: Medicaid Disproportionate Share Hospital (DSH) payments keep safety-net hospitals financially viable because these hospitals play such a critical role caring for the uninsured and Medicaid patients, providing trauma care and other vital community services, and training future health providers. The Affordable Care Act (ACA) reduces these DSH payments because the ACA's authors assumed that safety-net hospitals would receive increased revenue from Medicaid expansion and therefore, have less need for DSH payments. However, we found that California’s DSH need will actually increase because of medical cost inflation, low Medicaid payment rates, and the high number of people who will remain uninsured. As a result, the DSH reductions will create funding gaps that must be filled to ensure the financial stability of safety-net hospitals. The financial outlook for California’s safety-net hospitals is still much better under ACA than it would have been without the ACA. In the absence of the ACA, California’s public hospitals would have had an additional $1.5 billion in costs for uncompensated care for the uninsured and would be facing a financial crisis.
22 May Dramatic Increase In Hospitalizations For Atrial Fibrillation As Population Ages
MedicalResearch.com Interview with: Nileshkumar J. Patel MD Staten Island University Hospital Staten Island, NY, 10304 and Abhishek J. Deshmukh MD University of Arkansas Little Rock, AR MedicalResearch: What are the main findings of the study? Answer: We analyzed data from almost 4 million hospitalizations for atrial fibrillation (AF) from more than 1,200 hospitals across 45 states in last decade, and found that - Hospitalization rates for atrial fibrillation have increased exponentially among US adults during the past 10 years, particularly in those 65 years or older. - The most frequent coexisting conditions were hypertension (59.99%), diabetes (21.47%) and chronic pulmonary disease (20.01%). - In terms of geographic distribution of admissions, the hospitals in the South constitute (38.5%) the highest percentage of atrial fibrillation hospitalizations, followed by Midwest (24.9%), Northeast (22.2%) and West (14.4%). - Overall in-hospital mortality was 1%. The mortality rate was highest in >80 years age group (1.93%) and patients with concomitant heart failure (8.2%). - The percentage of patients discharged to nursing facility increased from 8.1% in 2000 to 11.5% in 2010 and need for home health care increased from 6.7% to 13.1%. Approximately one fourth of the patients (25.83%) were discharged to long-term care institution if atrial fibrillation hospitalization was complicated by acute ischemic stroke. - Mean cost of AF hospitalization increased significantly from $6,410 in 2001 to $8,439 in 2010 (24.04% increase, p <0.001) even after adjusting for inflation. This represents an absolute increment in annual national cost from approximate 2.15 billion dollars in 2001 to 3.46 billion dollars in 2010. The mean cost of care was highest if AF hospitalization was associated with heart failure ($33,161) and valvular disorders ($28,030).21 May Childhood Asthma: Higher Out-of-Pocket Costs May Cause Some Parents to Avoid Care
MedicalResearch.com Interview with:
Vicki Fung, Ph.D.
Assistant Professor
Department of Medicine, Harvard Medical School
Mongan Institute for Health Policy, Massachusetts General Hospital
MedicalResearch: What are the main findings of the study?
Dr. Fung: We found that lower income parents of children with asthma were more likely to delay or avoid taking their children to a doctor's office visit or to the emergency room if they had to pay higher out-of-pocket costs for care; they were also more likely to report borrowing money to pay for asthma care.
15 May US Health Care Age and Gender Spending Trends
MedicalResearch.com Interview with: David Lassman Statistician in the National Health Statistics Group, Office of the Actuary Centers for Medicare and Medicaid Services (CMS) Baltimore, Maryland. MedicalResearch: What types of health care spending are included in this report? Answer: In the past, the CMS Office of the Actuary provided periodic updates of health care spending by age and more recently by gender. This report, for the first time, provides a time series of spending by age (five categories – 0-18, 19-44, 45-64, 65-84, and 85+) and gender. We also show spending by three major age categories – children (0-18), working age adults (19-64), and the elderly (age 65 and over). We present data for personal health care only which consists of all the medical goods and services used to treat or prevent a specific disease or condition in a specific person. We provide estimates for the even years between 2002 and 2010. These age and gender estimates are controlled to the most recent Historical National Health Expenditure Accounts.13 May Neighborhood Socioeconomic Status Impact On Medicare Rating for Heart Failure
Posted at 21:48h
in AHA Journals, Author Interviews, Health Care Systems, Hospital Readmissions, Medicare
MedicalResearch.com Interview with:
Alex Blum, MD MPH FAAP
Chief Medical Officer
Evergreen Health, Baltimore MD 21211
MedicalResearch.com: What are the main findings of the study?
Dr. Blum: Accounting for the social risk of patients using a measure of neighborhood socioeconomic status (SES), did not alter the hospital rankings for congestive heart failure (CHF) readmission rates.
07 May Mortality Dropped After Massachusetts Health Care Reform
Posted at 10:28h
in Annals Internal Medicine, Author Interviews, Cost of Health Care, Health Care Systems
MedicalResearch.com Interview with:
Benjamin D. Sommers, MD, PhD
Assistant Professor of Health Policy & Economics
Harvard School of Public Health / Brigham & Women's Hospital
Boston, MA 02115
MedicalResearch.com: What are the main findings of the study?
Dr. Sommers: We find that over the first four years since Massachusetts' 2006 comprehensive health reform law, all-cause mortality in the state fell by 2.9%, compared to a similar population of adults living in counties outside Massachusetts that did not expand insurance during this period. We also found that the law reduced the number of adults in Massachusetts without insurance, reduced cost-related barriers to care, increased use of outpatient visits, and led to improvement in self-reported health. Overall, we estimate that the health reform law prevented over 320 deaths per year in the state - or one life saved per 830 adults gaining health insurance. Mortality rates declined primarily due to fewer deaths from causes amenable to health care, such as cancer, infections, and heart disease. We also found that the health benefits were largest for people living in poor counties in the state, areas with higher percentage of uninsured adults before the law was passed, and for minorities.
02 May Follow Your Heart Program Reduced Hospital Readmissions Following Heart Surgery
Posted at 23:10h
in Annals Thoracic Surgery, Author Interviews, Cost of Health Care, Hospital Readmissions, Pharmacology
MedicalResearch.com Interview with:
Michael H. Hall, MD
North Shore-LIJ Health System
MedicalResearch: What are the key points of your research?
Dr. Hall: Our study was designed to improve care transition from the hospital to home after coronary bypass surgery. The innovative program (Follow Your Heart), implemented at one of our system hospitals, involves sending cardiac surgery nurse practitioners (NPs) who cared for the patients in the hospital to the homes of discharged patients for at least two visits in the first two weeks after discharge. Their goal is to provide continuity of care for patients that they know from the hospital setting and to provide robust medication management, coordinate community services, and be a communications hub for hospital and community providers (primary care, cardiology, and community nurse home visit services). The nurse practitioners interact with community resources to ensure understanding and satisfaction of the patients’ needs prior to hand-off to those resources after two weeks. Our nurse practitioners utilize encrypted smart phones to provide reports to all appropriate providers and can even send pictures of incisions to the surgeon when necessary.
28 Apr Type 2 Diabetes: Telephone-Based Peer Support Improved Risk Factors
MedicalResearch.com Interview with:
Juliana C. N. Chan, MBChB MD FHKAM FRCP
Professor Juliana Chan is Professor of Medicine and Therapeutics, Director, Hong Kong Institute of Diabetes and Obesity and International Diabetes Federation Centre of Education at the Chinese University of Hong Kong, Prince of Wales Hospital and Chief Executive Officer of Asia Diabetes Foundation Hong Kong.
MedicalResearch.com: What are the main findings of the study?
Dr. Chan: In this 1-year randomized study, we asked the question whether type 2 diabetic patients receiving team-based integrated care augmented by information technology would further improve in their glycemic control if given additional peer support through the telephone. All patients underwent comprehensive risk assessment guided by the web-based JADE portal which generated personalized risk report with attained treatment targets and decision support. After 1 year, all patients improved significantly in all risk factors including A1c with improved treatment adherence, self efficacy and psychological wellbeing. Although the peer support group did not further improve in A1c, short-stay hospitalization rates were substantially reduced by 50% , especially amongst those with emotional distress. These patients accounted for 20% of the intervention group, in whom peer support further reduced psychological distress and treatment non-adherence.
26 Apr Prostate Cancer: Cost Savings from Active Surveillance
MedicalResearch.com Interview with: Alice Dragomir, MSc, PhD Assistant Professor, Urology/Surgery, McGill University Scientist, RI-MUHC MedicalResearch.com: What are the main findings of the study? Authors’ response: Our study demonstrates that for eligible patients, active surveillance could offer not only the known clinical advantages from the patient’s perspective, but also economic benefits from the health care system’s perspective. At the national level, the cost savings of an annual cohort of incident prostate cancers managed with active surveillance over a first year and 5 years of follow-up could be substantial. These are estimated at $96 million.23 Apr Bone Mineral Density: What is Impact of Change in Physician Reimbursement?
MedicalResearch.com Interview with: Susan Jaglal, PhD Senior Scientist Toronto Rehabilitation Institute University of Toronto, Toronto, Ontario MedicalResearch.com: What are the main findings of the study? Dr. Jaglal: Bone Mineral Density (BMD) tests are used to both diagnose osteoporosis and assess and individual’s risk of fracture. While the tests play an important role in bone health, they are sometimes ordered inappropriately. For example, while women age 40-44 are typically not at risk of fragility fracture or in need of Bone Mineral Density testing, these individuals received almost half the Bone Mineral Density tests performed in Ontario in 2007/2008. Policy changes have been made in recent years in an effort to curb unnecessary testing of low risk individuals in both the United States and Canada. Policy efforts in Ontario included a 2008 fee schedule change that limited repeated testing among low-risk patients and included a new fee code for a “baseline” tests. Patients were limited to 1 baseline test in their lifetime. The goal of the present study was to determine the impact of this fee schedule change on Bone Mineral Density testing rates. The study was based on an analysis of provincial administrative data including physician billings, hospital discharges, and emergency department visits. Results demonstrated that while fee schedule changes were associated with a decrease in BMD testing rates, the decreases affected both low and high-risk patients. Most decreases were seen in testing rates of low-risk women. However, the associated decrease in testing among high-risk patients (e.g., those over 65 or with a recent fracture) is concerning, as high-risk patients benefit from screening and monitoring of Bone Mineral Density.14 Apr Stroke: Fragmentation of Care Leads To More CT Scans, Higher Costs
Posted at 10:14h
in AHA Journals, Author Interviews, Cost of Health Care, CT Scanning, Dartmouth, NIH, Stroke
MedicalResearch.com Interview with: Kimon Bekelis, MD Department of Neurosurgery Dartmouth-Hitchcock Medical CenterDr. Bekelis MedicalResearch.com: What are the main findings of the study? Dr. Bekelis: We demonstrated extensive regional and racial variation in the utilization of head CT scans in the first year after ischemic stroke. Increased use paralleled spending in corresponding Hospital Referral Regions. Greater...
11 Apr Quality Intervention Program To Reduce Unnecessary Radiology Follow-Up Imaging
MedicalResearch.com Interview with:
Jamie Hui, MD
Center for Health Services Research
Virginia Mason Medical Center
Seattle, Washington
MedicalResearch.com: What are the main findings of the study?
Dr. Hui: Through a quality improvement intervention aimed at how radiologists report on findings in female pelvic ultrasound examinations, we were able to decrease the number of unnecessary recommendations for follow-up imaging of benign adnexal cysts, preventing duress for these women.
09 Apr Why Do Some Patients Fail To Get Their Prescriptions Filled?
Posted at 15:46h
in Annals Internal Medicine, Author Interviews, Compliance, Cost of Health Care, McGill, Pharmacology
MedicalResearch.com Interview with:
Robyn Tamblyn BScN Msc PhD
James McGill Chair
Departments of Medicine and Epidemiology and Biostatistics
McGill University and Scientific Director
Institute of Health Services and Policy Research
Canadian Institutes of Health Research
MedicalResearch.com: What are the main findings of the study?
Dr. Tamblyn: Higher drug costs are associated with a higher probability of primary non-adherence, whereas better follow-up by the prescribing physician, and a policy to provide medication at no cost for the very poor increase the likelihood of adherence
08 Apr Diabetes: Patients Still Face High Out of Pocket Expenses
MedicalResearch.com Interview with: Dr. Rui Li Division of Diabetes Translation Centers for Disease Control and Prevention Atlanta, GA MedicalResearch.com: What are the main findings of the study? Answer: The proportion of people with diabetes facing high out-of-pocket (OOP) burden declined between 2001 and 2011. Although insurance and income related disparities have declined, almost one-fourth of all people with diabetes still face a high out-of-pocket burden.07 Apr Number of Low Income Uninsured Higher In States Not Expanding Medicaid
MedicalResearch.com Interview
Sandra L. Decker, Ph.D.
Distinguished Consultant
Centers for Disease Control and Prevention
National Center for Health Statistics
Hyattsville, MD 20782
MedicalResearch.com: What are the main findings of the study?
Dr. Decker: One of the main findings is that the percent of the low income population that is uninsured is higher in states not expanding Medicaid than those expanding. The low income uninsured in non-expansion states are more likely to report having or having had certain health conditions such as hypertension, cancer, stroke, emphysema, or a heart condition than those in expansion states.
02 Apr Hospital Costs, Length of Stay Increase with Workload of Hospitalists
MedicalResearch.com Interview with:
Daniel J. Elliott, M.D., MSCE, FACP
Associate Chair of Research
Department of Medicine and Research Scholar
Value Institute, Christiana Care Health System
MedicalResearch.com: What are the main findings of the study?
Dr. Elliott: The optimal workload for hospitalists has been a question since the earliest days of hospital medicine. However there has been very little empirical evidence to understand the relationship between workload and outcomes.
The objective of our study was to determine the association of daily workload for hospitalists on the efficiency, quality, and cost of care. We analyzed data from a single private practice hospitalist group at a community-based health system between February 2008 and January 2011. Our research showed that both length of stay and cost increased for patients as hospitalist workload increased.
At the same time, our research showed that workload did not affect patient satisfaction as measured by HCAHPS scores or quality and safety outcomes including admissions, rapid response team activation and mortality.
17 Mar Headache Imaging Costs $1 Billion Dollars Per Year
Posted at 23:06h
in Author Interviews, Cost of Health Care, JAMA, Pain Research, Pharmacology, Radiology, University of Michigan
MedicalResearch.com Interview Invitation with:
Dr. Brian C. Callaghan MD
Department of Neurology
University of Michigan Health System, Ann Arbor
MedicalResearch.com: What are the main findings of the study?
Dr. Callaghan: The main findings are that we order headache neuroimaging (MRIs and CTs) frequently, this accounts for approximately $1 billion dollars annually, and the number of tests ordered is only increasing with time.
12 Mar Massachusetts Health Care Reform and the Working Poor
MedicalResearch.com Interview with: Liane J. Tinsley, MPH Associate Research Scientist Department of Epidemiology New England Research Institutes, Inc. Watertown, MA 02472 MedicalResearch.com: What are the main findings of the study? Answer: For this study, we analyzed health insurance data from a cohort of community-dwelling individuals between the ages of 30-79 at baseline, in Boston, MA. Massachusetts health care reform legislation, including the expansion of Medicaid, resulted in substantial overall gains in coverage in our study population. Despite being targeted by the law, the working poor (those currently working for pay, either part- or full-time and earning less than 200% of the US federal poverty threshold for household size) continued to report lower rates of insurance coverage following reform (13.3% without insurance), compared to the both non-working poor (4.7% without insurance) and the not poor (5.0% without insurance).03 Mar Gaining Prescription Drug Insurance Reduced Inpatient Medicare Payments
MedicalResearch.com Interview with: Prof. Robert Kaestner University of Illinois at Chicago - Institute of Government and Public Affairs Chicago, IL 60607 and National Bureau of Economic Research 365 Fifth Avenue, 5th Floor New York, NY 10016-4309 MedicalResearch.com: What are the main findings of the study? Prof. Kaestner: Gaining prescription drug insurance through Medicare Part D was associated with...
25 Feb Acute Coronary Syndrome: Genotyping Guided Antiplatelet Therapy After Stent Surgery
Posted at 03:23h
in Annals Internal Medicine, Author Interviews, Cost of Health Care, Heart Disease, UCSF
MedicalResearch.com Interview with:
Dhruv S. Kazi, MD, MSc, MS
Assistant Adjunct Professor
Division of Cardiology San Francisco General Hospital
Department of Medicine, and
Department of Epidemiology and Biostatistics
University of California San Francisco
MedicalResearch.com: What is the background of your study?
Dr. Kazi: When we first asked the research question -what is the role of genotyping among patients receiving a stent for ACS, we quickly realized that there were no RCTs that had directly compared ticagrelor with prasugrel. But in our opinion, that was precisely the reason to build a model and systematically synthesize the available literature. There are nearly half a million PCIs for ACS in the US each year, and each time, the physician and patients have to examine the trade-offs between the various alternatives. What our model does is that it explicates the trade-offs - makes them transparent, and quantifies them. So patients and physicians can make an informed decision on what is the optimal therapy for them.
18 Feb Expanded Health Insurance: Hospital Services Use by Young Adults with Behavioral Diagnoses
Posted at 21:53h
in Cost of Health Care, Dartmouth, Health Care Systems, Mental Health Research, Yale
MedicalResearch.com Interview with:
Ellen R. Meara
Associate Professor of The Dartmouth Institute
Adjunct Associate Professor in Economics & Nelson A. Rockefeller Center for Public Policy, Dartmouth College
MedicalResearch.com: What are the main findings of this study?
Answer: When insurance coverage for young adults rose by over 15 percentage points following Massachusetts' 2006 health reform, use of inpatient care for mental illness and substance use disorders fell and emergency department visits for these conditions grew more slowly for 19 to 25 year olds in Massachusetts relative to other states. Also, their care was much more likely to be paid for by private or public insurance insurers.
13 Feb EHR: Electronic Health Records and Cost Challenges to Implementation
MedicalResearch.com Interview with;
Dr Sarah Slight, School of Medicine
Pharmacy and Health, Wolfson Research Institute
University of Durham, United Kingdom.
MedicalResearch.com: What are the main findings of the study?
Dr. Slight: Our study identified four main cost categories associated with the implementation of EHR systems, namely: infrastructure (e.g., hardware and software), personnel (e.g., project management and training teams), estates / facilities (e.g., furniture and fittings), and other (e.g., consumables and training materials). Many factors were felt to impact on these costs, with different hospitals choosing varying amounts and types of infrastructure, diverse training approaches for staff, and different software applications to integrate with the new system.
22 Jan Transfers of Hospitalized Patients and Insurance Status
Posted at 01:00h
in Annals Internal Medicine, Author Interviews, Cost of Health Care, Health Care Systems, University of Pittsburgh
MedicalResearch.com Interview with:
Janel Hanmer, MD, PhD
University of Pittsburgh Medical Center
Montefiore Hospital
Pittsburgh, PA 15213
MedicalResearch.com: What are the main findings of the study?
Dr. Hanmer: We used the National Inpatient Sample - a sample of about 20% of US community hospitals with all discharges from those hospitals - to examine if insurance status is associated with transfer from one hospital to another. We were looking at patients who were already admitted to the hospital, not the patients who presented to the Emergency Department. We selected the five most common general medicine admissions for adults aged 18 to 64. We found that uninsured patients were less likely to be transferred than privately insured patients in four of the five conditions (about 20-40% less likely). We also found that women were less likely than men to be transferred in five of the conditions (about 35 to 40% less likely).
08 Jan Acute Stroke: Cost Effectiveness of Thrombolysis Therapy
MedicalResearch.com Interview with
Dr. James Sheppard
MRC Research Fellow
Department of Primary Care Health Sciences
University of Oxford
MedicalResearch.com: What are the main findings of the study?
Dr. Sheppard: The aim of our study was to develop a decision-tree model which estimates the cost-effectiveness and potential implementation costs of a series of interventions which increase thrombolysis rates in acute stroke. The model examined all possible acute stroke patient pathways and was based on real life patient data. We found all proposed interventions to be cost saving whilst increasing patient quality of life after stroke. We estimate that, assuming a "willingness-to-pay" of USD $30,000 per quality adjusted life year gained, the potential budget available to deliver interventions which improve acute stroke care range from USD $50,000 to USD $144,000.
19 Dec Costs of Health Care: Teaching Medical Residents How to Provide Cost-Conscious Care
Posted at 00:04h
in Author Interviews, Cost of Health Care, Education, JAMA, University of Pennsylvania
MedicalResearch.com Interview with:
Mitesh Patel, MD, MBA
RWJF Clinical Scholar, University of Pennsylvania
Mitesh Patel, MD, MBA is a Robert Wood Johnson Clinical Scholar the University of Pennsylvania and primary care physician at the Philadelphia VA Medical Center
MedicalResearch.com: What are the main findings of the study?
Dr. Patel: We evaluated survey responses from nearly 300 internal medicine residency programs directors to assess whether residency programs were teaching residents the fundamental concepts of practicing high-value, cost-conscious care. We found that 85% of program directors feel that graduate medical education has a responsibility to help curtail the rising costs of health care. Despite this, about 6 out of every 7 internal medicine residency programs have not yet adopted a formal curriculum teaching new physicians these important concepts.
05 Dec Antiretroviral Therapy: Survival Benefits in South Africa
MedicalResearch.com Interview with: Michael D. April, MD, DPhil San Antonio Uniformed Services Health Education Consortium.Department Harvard Medical School The Medical Practice Evaluation Center MedicalResearch.com: What are the main findings of this study? Dr. April: Using a mathematical model, this study quantified the survival benefits associated with antiretroviral therapy to HIV-infected people in South Africa since 2004. Our results highlight the astounding benefits of treatment. In short, antiretroviral therapy has saved 2.8 million years of life in South Africa to date and is projected to save an additional 15.1 million years of life by 2030.27 Nov Primary Care: The Impact of Cost Displays on Laboratory Test Ordering
MedicalResearch.com Interview with:
Thomas D. Sequist, MD, MPH,
Atrius Health
MedicalResearch.com: What are the main findings of the study?
Dr. Sequist: Our study, the Impact of Cost Displays on Primary Care Physician Laboratory Test Ordering published in the Journal of General Internal Medicine found that when the costs of certain lab tests were displayed electronically in real time, the rate at which physicians ordered tests decreased. It was conducted among 215 primary care physicians working for Atrius Health, an alliance of six non-profit medical groups and a home health and hospice agency in Massachusetts, where an integrated electronic health record system is used. Physicians in the intervention group received real-time information on laboratory costs for 27 individual tests when they placed their electronic orders, while the control group did not. What we found was a significant decrease in the ordering rates of both high and low cost range tests by physicians to whom the costs of the tests were displayed electronically in real-time. This included a decrease in ordering rates for four of the 21 lower cost laboratory tests, and one of six higher cost laboratory tests.
In addition, physicians were generally very receptive to the intervention. A majority (81 percent) reported that the exercise increased their knowledge regarding costs of care and requesting real-time cost information on an expanded set of health care services.