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JANUARY 2008 HOT TOPICSAre Disease Management Programs Effective?
The study reviewed past research on disease management programs, focusing on their effects on six chronic conditions: congestive heart failure, coronary artery disease, diabetes, asthma, depression, and chronic obstructive pulmonary disease. With the exception of asthma and chronic obstructive pulmonary disease, which showed inconclusive results, researchers found consistent evidence that disease management programs did improve the quality of health care. Patients with congestive heart failure and depression also consistently reported improved quality of life. However, there was no conclusive evidence that disease management leads to a net reduction of direct medical costs. The results underscore the inadequacy of the current evidence base for assessing the impact of disease management programs. Most of the evidence to date addresses small-scale programs targeting high-risk individuals, while only three studies have evaluated large, population-based interventions, implying that little is known about their effect. The authors stress the need to build a stronger evidence base with more rigorous research, such as randomized trials or well-designed observational studies that compare the outcomes of disease management interventions with those found in a comparison group. Read More »State Insurance Mandates and Consumer-Directed Health Plans Have Not Improved Access to or Affordability of Health Insurance for Small Businesses
Read the Research Brief »Links Between Work and Teen Tobacco Use
The study also found that, among teen smokers, those who worked for more than 10 hours per week tended to start smoking at younger ages than did those who did not work or who worked less than 10 hours a week. In addition, among teens who had not yet used tobacco, those who started to work between grades 10 and 11 were at least three times more likely to begin smoking than were teens who did not start working. The study showed that working very likely contributes to the smoking behaviors of teens. The authors recommend that policymakers consider a focus on the workplace as a promising venue for smoking prevention programs and antismoking policies. Read the Fact Sheet »
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Disease management programs offer systematic coordination of care for patients with chronic health problems. These increasingly popular programs have been hailed as the solution to the twin ills of the U.S. health care system: inadequate quality and high costs. In 2005, U.S. health insurance plans and employers spent about $1.2 billion on disease management, with 96 percent of the top 150 U.S. health insurance companies offering some form of disease management service. Are these programs delivering as promised? A RAND Health study led by Dr. Soeren Mattke found that these programs generally improve the quality of health care, but there is little evidence that they save money. 
Small U.S. firms often face significant barriers in providing health insurance to their employees. In 2003, only 43 percent of firms with fewer than 50 employees offered health insurance, compared with 95 percent of firms with 50 or more employees. Moreover, health insurance plans offered to small businesses tend to suffer from limitations, including high premiums and preexisting-condition clauses that exclude expensive conditions from coverage. Some insurers simply do not sell policies to small firms. Policy solutions to addressing these problems have focused on two options: (1) state mandates that limit insurers' ability to deny health insurance coverage to small firms and restrict variability in the cost of premiums and (2) consumer-directed health plans (CDHPs), which typically combine high deductibles with tax-deductible personal health savings accounts and are less costly than traditional health plans. Research funded by the Kauffman-RAND Institute for Entrepreneurship Public Policy examined the effects of these policies on small businesses. The study found that, to date, neither of these options has improved access to or the affordability of health insurance for small businesses. Although CDHPs appear to be growing in popularity, evidence suggests that small businesses are no likelier than larger ones to offer such plans. In addition, insurance reforms focused on smaller firms have not improved small-business access to health insurance and, moreover, seem to have had unintended effects—many firms appear to have adjusted their size to avoid the more highly regulated market. The study recommends exploring new policy solutions, such as small-business purchasing pools. At the same time, the evolving marketplace for CDHP-related products and services should be monitored to track CDHPs' effects on insurance offered to small businesses.
Research has shown a connection between working and increased substance use among teens. However, few of these studies have specifically focused on tobacco use. Does working for pay make teenagers more likely to smoke? A study led by RAND Health researcher Rajeev Ramchand examined this question. The researchers used longitudinal data that allowed them to follow a group of urban youth in Baltimore, MD, from first grade through the end of high school. The study found a strong association between working for pay and smoking among these teens in the 10th grade. Even after adjusting for other factors that influence teen smoking behavior, the analysis found a clear link between the amount of time teenagers worked and their current use of tobacco. 
