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Pediatric Asthma: An Opportunity In Payment Reform And Public Health


September 18th, 2014

Editor’s note: The post is informed by a case study, the third in a series made possible through the Merkin Initiative on Physician Payment Reform and Clinical Leadership, a special project to develop clinician leadership in health care delivery and financing reform. The case study will be presented on Wednesday, September 24 using a “MEDTalk” format featuring live story-telling and knowledge-sharing from patients, providers, and policymakers. 

The Clinical Challenge: A Chronic, but Manageable Illness

Asthma affects 7 million children – more than 10 percent of kids in the U.S. – and is the most common chronic childhood disease. Yet even with high levels of insurance coverage, 46 percent of pediatric patients have uncontrolled asthma. There are substantial gaps in appropriate prescribing and adherence to effective medications. In addition, a multitude of non-medical issues influence a child’s ability to control their asthma: low parental health literacy, poor quality housing, and environmental triggers such as pests, mold, and cleaning chemicals. As a result 800,000 kids visit the emergency department (ED) for asthma each year.

In 2007 (the latest year which data are available) the U.S. spent over $56 billion on asthma care, of which nearly $27 billion was spent on pediatric asthma. Medicaid is the primary payer for pediatric asthma related hospitalizations with 55 percent of the market. Better control may also mean lower medical costs, due to reductions in ED visits, admissions, and other health care utilization – patients with poorly controlled severe asthma cost nearly $5,000 more per patient per year compared to average pediatric asthmatic costs.

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A First Look At How The Affordable Care Act Is Affecting Coverage Among Parents And Children


September 9th, 2014

Following the implementation of the major coverage provisions of the Affordable Care Act (ACA) in 2014, the question arises: “How is the health law affecting uninsured children and their families?” Today, the Urban Institute released two new briefs using the Health Reform Monitoring Survey (HRMS) to begin to answer that question.

The bottom line is that between September 2013 and June of 2014, coverage increased for parents, particularly in states that have expanded Medicaid under the ACA, but no coverage changes were yet apparent for children. This early look suggests that the ACA is contributing to coverage gains for parents, which in turn should be beneficial to both them and their children.

Children’s Coverage

The report on children’s coverage from The Urban Institute and the Georgetown University Center for Children and Families found that the uninsured rate for children remained at historically low levels—close to 7 percent—but did not decline further for children under age 18 between September 2013 and June 2014. However, this national snapshot does not capture all of the fluctuations in children’s coverage that may be occurring across the country in particular states; we will have to wait for data from federal sources to have a definitive assessment of how coverage is changing at the state level.

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Whither CHIP?


August 19th, 2014

In a day all but lost to Affordable Care Act prehistory, on November 7, 2009, the House of Representatives passed the Affordable Health Care for America Act. Among the bill’s many differences with its Senate counterpart, it would have allowed the Children’s Health Insurance Program (CHIP) to expire at the end of 2013, with children covered under that program enrolled in either Medicaid or commercial Exchange plans.

On December 24, the Senate passed the Patient Protection and Affordable Care Act (ACA). Their bill extended CHIP through fiscal year 2015 while, curiously, enhancing the Federal match rate for the program beyond that date and instituting a maintenance of effort (MOE) requirement for states to keep CHIP kids covered through 2019.

At the time, drafters of the respective chamber’s versions of health reform anticipated heading to conference to negotiate and resolve their differences, with the disposition of CHIP one of the top considerations.

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Health Affairs August Issue: Variations In Health Care


August 4th, 2014

Health AffairsAugust variety issue includes a number of studies demonstrating variations in health and health care, such as differing obstetrical complication rates and disparities in care for diabetes. Other subjects in the issue include the impact of ACA coverage on young adults’ out-of-pocket costs; and how price transparency may help lower health care costs.

For mothers-to-be, huge differences in delivery complication rates among hospitals.

Four million women give birth each year in the United States. While the reported incidence of maternal pregnancy-related mortality is low (14.5 per 100,000 live births), the rate of obstetric complications is nearly 13 percent.

Laurent Glance of the University of Rochester and coauthors analyzed data for 750,000 obstetrical deliveries in 2010 from the Healthcare Cost and Utilization’s Nationwide Inpatient Sample. They found that women delivering vaginally at low-performing hospitals had twice the rate of any major complications (22.55 percent) compared to vaginal deliveries at high-performing hospitals (10.42 percent

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Immigration And The ACA: Will Differing State Systems Offer A Controlled Experiment In Extending Coverage To Immigrants?


May 7th, 2014

Immigration and health care reform remain controversial issues, and their intersection remains fraught with complexities. Immigration reform that would provide a pathway to legalization for the 11-12 million unauthorized immigrants in the country is stalled in Congress.  Some of the fundamental controversies surrounding the Affordable Care Act (ACA) have, however, been settled, and the law is well into implementation. Now is a good time to focus on how the ACA is affecting and might affect health coverage, costs, and outcomes for various populations, including immigrants.

In addition to federal support for health coverage, the ACA is also ushering in an era of increased state experimentation. The law allows states to open their own insurance marketplaces or participate in the federal marketplace, and with last year’s Supreme Court decision, to decide whether or not to expand Medicaid for low-income childless adults. The law may also open opportunities for states to experiment with coverage options for the one major group excluded from the ACA: unauthorized immigrants.

Unauthorized Immigrants and the Affordable Care Act

ACA excludes the unauthorized from the marketplaces and eligibility for federal subsidies to purchase health insurance. According to the Migration Policy institute, an estimated 7-8 million unauthorized immigrants are currently uninsured, due to low employer coverage and ineligibility for Medicaid and other public programs; the unauthorized represent between one-fifth and one-sixth of the total 40-45 million uninsured. Their uninsurance rate ranges widely from state to state, peaking at over 70 percent in a number of Southeastern and Southwestern states.

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Implementing Health Reform: A Summary Health Insurance Marketplace Enrollment Report


May 1st, 2014

On May 1, 2014, the Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE) released a summary enrollment report for the federal and state marketplaces (exchanges) for the entire 2014 open enrollment period — from October 1, 2013 to March 31, 2014, including special enrollment (SEP) activity reported through April 19, 2014. The report was accompanied by a press release, an infographic, and an addendum reporting state level data, as well as the March Medicaid and CHIP enrollment report.

The headline of the report is old news by now: Over 8 million individuals selected a qualified health plan through the federally facilitated marketplace (FFM) and state-based marketplaces (SBM) during the covered period. The Medicaid report adds that as of March, 2014, Medicaid and CHIP enrollment has grown by 4.8 million, 8.2 percent, over baseline figures from the third quarter of 2013.

Both the marketplaces and Medicaid programs saw a dramatic surge in enrollment in March. Nearly 3.8 million people selected a marketplace plan during March and April, 47 percent of the total (including 910,495 who enrolled during the April SEP). Medicaid and CHIP enrollment in March increased by 1.8 million over that that reported in February.

Age distribution. As expected, enrollees trended younger as the open enrollment period ended. The number of young adults aged 18 to 34 who selected a marketplace plan doubled during the last month, accounting for 31 percent of March and April enrollment. This surge increased the total proportion of young adult enrolled only to 28 percent, compared to 66 percent of enrollees above age 35 and 25 percent between ages 55 and 64 (with 6 percent below age 18).

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Travels In Hyperreality: What If Bipartisan ACA Fixes Were Possible?


April 23rd, 2014

Since enactment of the Affordable Care Act in March 2010, a strange, relatively unnoticed phenomenon has occurred: Congress has passed bipartisan changes to it. These amendments were generally to such esoteric components of the law that they dodged the political block-aid that otherwise surrounds it.

But what would happen if things were different? If Congress could act to change the ACA in a meaningful way, what would it do? Here we briefly review the previous sub rosa changes to launch into a broader examination of macro ACA reforms that have a fighting chance of enactment in the not too distant future.

Tinkering. Most recently, in the Medicare “doc fix” in March, both parties acted to repeal the section of the ACA that capped deductibles for small group health plans. That legislation also delayed, again, implementation of the ACA’s Medicaid cuts to disproportionate share hospitals.

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Implementing Health Reform: The Latest Affordable Care Act Coverage Numbers (Updated)


April 18th, 2014

On February 17, 2014, the White House announced that 8 million Americans have signed up for private health insurance coverage through the health insurance marketplaces, or exchanges. This significantly exceeds the White House’s original goal of 7 million enrollees. It is far more than the Congressional Budget Office’s recent projections of 6 million.

The number of actual enrollees will be smaller than this number. The CBO’s projections are for the average number of those actually enrolled in coverage over the course of a calendar year. To calculate the average number of enrollees, one must subtract from the 8 million the number of individuals who fail to pay their premiums and thus are never actually enrolled in coverage, as well as those who will drop coverage at some later point during the year. To that reduced number, then, must be added back the number who become newly covered through special enrollment periods during the remainder of the year. In the end, 6 to 7 million average enrollees is probably a reasonable estimate.

This does not, however, exhaust the number of Americans who are now covered under the Affordable Care Act. The fact sheet states that 3 million young adults are covered under their parents’ plans because of the ACA. This number is probably high, but it is clear that the ACA has dramatically increased coverage of Americans between the age of 19 and 25 — the age group most likely to lack health insurance prior to the ACA (and still).

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Health Affairs Web First: Global Health Funding In 2013 Five Times Greater Than 1990


April 8th, 2014

Development assistance for health (DAH) to low- and middle-income countries provided by donors and international agencies are given in the form of grants, low-cost loans, and goods and services. Without this assistance, some of the poorest countries would be less able to supply basic health care.

A new study, being released today as a Web First by Health Affairs, tracked the flow of development assistance for health and estimated that in 2013 it reached $31.3 billion.

Looking at past growth patterns of these international transfers of funds for health, authors Joseph Dieleman, Casey Graves, Tara Templin, Elizabeth Johnson, Ranju Baral, Katherine Leach-Kemon, Anne Haakenstad, and Christopher Murray identified a steady 6.5 percent annualized growth rate between 1990 and 2000, which nearly doubled to 11.3 percent between 2001 and 2010 with the burgeoning of many public-private partnerships. Since 2011, however, annualized growth has dramatically dropped, to 1.1 percent, due, in part, to the effect of the global economic crisis.

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Implementing Health Reform: Medicaid & CHIP February 2014 Report


April 5th, 2014

On April 4, 2014, the Centers for Medicare and Medicaid Services released their Medicaid & CHIP February 2014 Monthly Applications, Eligibility Determinations, and Enrollment Report. (Blog post here.) For the first time, the February monthly report provides meaningful data on enrollment.

Like previous reports, the report gives the total number of applications received by all reporting state agencies (2,207,513) and total number of individuals determined eligible for Medicaid and CHIP by state agencies (2,249,120). For comparison, the numbers of applications is down from initial January reports (2,266,778), but the number of determinations is up (2,436,879).

As with previous reports, however, these numbers are subject to so many qualifications as to be little use for determining growth of the Medicaid program. The data do not include numbers from New York and Washington, while Tennessee only reported CHIP data. They are also very preliminary — the January determinations figure was revised upwards by about a fifth in February.

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Continuous Coverage Improves Costs And Quality For Children And Low-Income Adults


March 13th, 2014

The termination of Medicaid and Children’s Health Insurance Program (CHIP) coverage due to short-term income changes or frequent reapplication requirements increases overall health care costs and negatively affects quality of care and quality measurement and improvement efforts. This may have a significant yet commonly overlooked impact on income-related health care disparities. By requiring at least twelve months of continuous coverage, we could prevent avoidable complications, reduce administrative burden, improve quality measurement and improvements efforts, and ultimately, reduce costs.

Current Medicaid Coverage Costs

One year of continuous adult Medicaid coverage costs, on average, 22 percent less per month than six months of coverage, and 42 percent less than just one month of coverage. That is because people who lose coverage have more emergency room visits, hospital admissions, and preventable problems such as the onset of asthma and diabetes; they also have more problems that could have been managed with ambulatory care and lower rates of cancer screening and early detection. Current re-enrollment requirements also contribute to additional administrative costs that will increase as people toggle back and forth between Medicaid/CHIP and the individual health insurance exchanges.

Less than twelve months of coverage also directly harms quality measurement and improvement efforts. Because accurate measurement requires at least twelve months of coverage, those with shorter coverage periods are excluded from performance evaluation. Most Healthcare Effectiveness Data & Information Set (HEDIS is a registered trademark of NCQA) measures, for example, require evaluation of at least twelve months of claims or record reviews to ascertain whether appropriate services were provided in a timely manner. As a result, plans and providers may not have enough people on which to report and do not get credit for high quality.

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Implementing Health Reform: A February Exchange Enrollment Report


March 12th, 2014

On March 11, 2014, the Department of Health and Human Services released its Health Insurance Marketplace March Enrollment Report covering the period of October 1, 2013 through March 1, 2014. The Report covers, that is to say, five of the six months of the 2014 open enrollment period, which ends on March 31, 2014.

As of March 1, 4,242,300 individuals had selected a health plan through the federal and state exchanges, including 1,621,239 who signed up through the state exchanges and 2,621,086 who signed up through the federal exchange. New plan selections were down somewhat in February, with 942,000 individuals selecting a plan as compared to 1,146,000 in January, but February was a short month and the January report included a few days from December, so this does not necessarily indicate a drop in momentum.

There is every reason to believe, moreover, that enrollment will climb sharply in March, the last month of open enrollment. Experience with programs with open enrollment periods, such as Medicare Part D, Massachusetts Commonwealth Care, the Children’s Health Insurance Program, and the Federal Employee Health Benefits Program indicates that people tend to put off signing up for coverage until the last moment. During the 2012 FEHBP open enrollment period, 22 percent of those who changed enrollment did so in the last two days. The administration and partner organizations are also continuing to ramp up enrollment efforts, while exchanges continue to expand capacity.

It is quite likely, therefore, that the exchanges will sign up 6 million individuals—the revised Congressional Budget Office estimate—by March 31, perhaps more. Moreover, even after March 31, millions of additional Americans will qualify for special enrollment periods, for example because they lose Medicaid or employer coverage; thus, the total number of enrollees could easily exceed CBO estimates by the end of 2014.

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Implementing Health Reform: Retroactive Premium Tax Credits And Cost-Sharing Reductions (Updated)


February 28th, 2014

As we move into the last month of the 2014 open enrollment period, the Centers on Medicare and Medicaid Services continues to make mid-course corrections. On February 27, 2014, the CMS issued a “Bulletin to Marketplaces on the Availability of Retroactive Advance Payments of the PTCs and CSRs in 2014 Due to Exceptional Circumstances.” The Bulletin makes it possible for exchanges to allow individuals to obtain advance premium tax credits (PTCs) and cost-sharing reductions (CSRs) retroactively if they have been unable to obtain eligibility determinations and to enroll in qualified health plans (QHPs) through the exchange because the exchange experienced technical difficulties during the 2014 open enrollment period.

Presumably the Bulletin is intended to assist enrollees in states like Massachusetts, Oregon, Maryland, Nevada, and Hawaii, where technical problems have made it difficult or impossible for individuals to enroll in QHPs through the exchange on a timely basis. It could also, however, apply to the federal exchange. Each exchange must apparently decide whether or not to effectuate this policy.

Under the Affordable Care Act, PTCs and CSRs are only available to individuals who enroll in a QHP through an exchange. This Bulletin does not change that. CMS continues to require individuals to be determined eligible for PTC and CSR payments and to be enrolled in a QHP through an exchange. To qualify for assistance under the Bulletin, individuals must also have applied to the exchange using a federally approved application during the open enrollment period.

However the Bulletin allows exchanges to permit individuals who have experienced “exceptional circumstances” related to technical difficulties in enrollment, such that they have not been able to have their eligibility determined and to be enrolled in a QHP through the exchange, to qualify for retroactive PTC and CSR eligibility under two circumstances.

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Cesarean Rates: A Global Perspective


February 24th, 2014

As noted in a previous Health Affairs Blog post by Katy Kozhimannil and Ezra Golberstein, there is significant variability in cesarean delivery rates across the United States, but this is also true worldwide. Worldwide cesarean delivery rates have come under scrutiny and criticism since the World Health Organization (WHO) suggested in 1985 that the optimal rate should not exceed 10 to 15 percent.

Although currently there is no expert agreement on a single optimal level, a general consensus has emerged that extremely low rates (less than 5 percent) suggest underuse and higher rates (greater than 10-15 percent) suggest overuse. Globally, the average rate sits slightly above that recommended level at 16 percent. However, the mean value masks the underlying variability that exists across countries and the different issues inherent in the variation. Of countries which report at least some cesarean deliveries, the range of use runs from 1 percent (Niger) to 52 percent (Brazil) of live child births.

Middle and High-Income Countries

Cesarean rates in middle and high-income countries have continued to increase over the last decade (most are significantly over 15 percent). The average rate among the Organisation for Economic Co-operation and Development (OECD)-member countries is 26.9 per 100 live births (range: 14.7 to 49.0). Comparatively, the United States has a very high rate of cesarean delivery (31.4 per 100 live births). In Switzerland, for example, cesarean section rates varied in 2010 from less than 20 percent to over 40 percent in a region. Within a region, the rates also varied by hospital. A study in France found more cesarean sections were performed in for-profit hospitals than in public hospitals, which treat more complicated pregnancies, suggesting that financial incentives may also play a role in explaining excess cesarean deliveries.

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When The Only Cure Is A Transplant


February 21st, 2014

On Christmas Eve 2011, protesters from a local church marched to the entrance of our hospital, Rush University Medical Center in Chicago. They demanded we provide organ transplants for sick members of their congregation. We invited them in and listened to their gut wrenching stories. George, twenty-two, was brought to the United States as a six-month-old. He developed renal failure at age sixteen while covered under the Children’s Health Insurance Program. Now he was uninsured, on dialysis and refused a transplant evaluation at the same institution that treated him as a child. Another undocumented immigrant, Martin, was twenty-six. He too was uninsured and on dialysis.

Chicago has six adult transplant centers. Initially none would evaluate George or Martin for transplantation because they were uninsured. In the Narrative Matters essay, “Undocumented Immigrants And Kidney Transplant: Costs And Controversy,” published in the February issue of Health Affairs, Vanessa Grubbs tells a similarly heartfelt story of a patient in need of a transplant: Mr. Rojas. George, Martin and Mr. Rojas are not US citizens, but it was their lack of health insurance that kept transplantation out of reach. Foreign-born immigrants always have access to a transplant evaluation (the prerequisite for organ transplant) if they have insurance or the cash to pay.

In theory, the organ allocation system in the United States is based on justice and equity. The National Organ Transplant Act (NOTA) was passed in 1984 to create a fair system of organ transplantation in the United States. A federal task force, created by the act, was charged to design an organ allocation system “based on medical criteria that are publicly stated and fairly applied.” The task force emphasized that organs should be distributed to those eligible “regardless of their ability to pay.” Both NOTA and the bylaws of the United Network for Organ Sharing, the nonprofit organization that manages the national transplant network, require that need, not financial or citizenship status, guide transplant allocation decisions. Undeniably, the system of altruistic donation is only viable if a donating individual believes organs are allocated fairly.

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GrantWatch: Zip Code Overrides DNA When It Comes to Health


February 4th, 2014

This month on GrantWatch Blog, Anne Warhover, president and CEO of the Colorado Health Foundation, expands on the recommendations released last month from the Robert Wood Johnson Foundation (RWJF)’s Commission to Build a Healthier America (of which Warhover was a commissioner). For more on the report, see the Health Affairs Blog post.

In “Zip Code Overrides DNA Code When It Comes to a Healthy Community,” Warhover looks at the impact of a person’s environment on health.

Everyone wants to live a long and healthy life. Yet one-fifth of all Americans live in environments that compromise their health—where there are no sidewalks or trails for people to walk and bike; where there are no playgrounds or parks for children to play; where crime and violence discourage not only outdoor activity, but also social interaction; and where communities lack affordable access to fresh fruits and vegetables.

In fact, when it comes to your health, your zip code matters more than genes, writes Warhover. The recommendations of the RWJF Commission raises awareness of this issue and suggests new priorities that include “investments in our youngest children, encouraging leaders in different sectors to work together to create communities where healthy decisions are possible, and broadening the mission of health care providers beyond treatment.”

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Implementing Health Reform: December Data On Medicaid And CHIP Applications And Eligibility Determinations


January 22nd, 2014

On January 22, 2014, the Centers for Medicare and Medicaid Services released the December (2013) Monthly Applications and Eligibility Determinations Report for the Medicaid and CHIP programs. The top line of this report is that 1,918,484 applications for Medicaid and CHIP were received by state Medicaid and CHIP agencies in December 2013, while 2,293,359 individuals were determined eligible for Medicaid and CHIP, for a total of 6,323,188 individuals determined eligible for Medicaid and CHIP since October 1, 2013. The bottom line is that a lot of new people are being signed up for Medicaid and CHIP — primarily in states that expanded Medicaid — but we don’t know how many more for certain..

Applications are reportedly up 14.4 percent from baseline figures for the three-month period preceding October 2013 data in states that have expanded Medicaid. More impressively, Medicaid eligibility determinations are up 73 percent in expansion states over baseline data, but only up 3 percent in states that did not expand Medicaid. Medicaid expansion states accounted for 1.2 million of the new determinations, non-expansion states for 1 million.

These numbers come with many caveats however. First, application data are only available from 46 states and the District of Columbia, not including New York, Ohio, Washington, and Pennsylvania — not insignificant states. Only 41 states reported both determinations and baseline data. Both applications and determinations data are, for most states, not limited to individuals newly eligible under the Affordable Care Act, but also include individuals in traditional Medicaid categories. The 1.9 million application number counts applications, not individuals, and an application may (and often does) include more than one individual. Four states include renewals in their application data.

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Health Affairs Web First: First-Ever Quantitative Data About The Toll Of BPA Exposure


January 22nd, 2014

The risks of exposure to Bisphenol A (BPA) have been well known for some time. While exposure to BPA in the United States affects an estimated 92.6 percent of Americans over the age of five, there are gaps in the knowledge of the health consequences of BPA exposure.

A new study, released today as a Web First by Health Affairs, presents the first estimate of the potential disease burden and costs associated with ongoing exposure to BPA. Author Leo Trasande found that $2.98 billion in annual costs are attributable to BPA-associated childhood obesity and adult coronary heart disease. Of the $2.98 billion, the study identified $1.49 billion in childhood obesity costs, the first environmentally attributable costs of child obesity to be documented. Trasande holds faculty appointments at New York University’s School of Medicine, Wagner School of Public Service, and Steinhardt School of Culture, Education and Human Development.

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Health Beyond Health Care: RWJF Commission Issues New Report


January 15th, 2014

Much of the political debate over health reform has focused on the important questions of affordable health insurance coverage and access to medical care. However, medical care is far from the most important factor influencing health, a fact that is at the core of a newly released report from the Robert Wood Johnson Foundation’s Commission to Build A Healthier America.

The Commission was initially formed in 2008 and issued 2009 recommendations concerning influences on health such as nutrition, physician activity, and tobacco use. The new report, “Time To Act: Investing in the Health of our Children and Communities,” also focuses on socioeconomic factors; specifically, it recommends increased investments in early childhood development, including universal access to quality early childhood development programs for low-income children under age 5; efforts to promote healthier neighborhoods through collaboration among the health, community development, and finance sectors; and a new orientation for health care providers toward nonmedical determinants of health and working with nonmedical professionals. The report provides examples of successful initiatives in each of these areas.

Most people think about health and health care together, said Mark McClellan of the Brookings Institution, who co-chaired the Commission with Brookings colleague Alice Rivlin, in a webcast marking the report’s release.  But “when you start looking at the evidence, looking at what’s working on the ground to actually have a meaningful impact on the health of people,” you realize that “you can’t get there just by putting more resources into health care.”

The new report signals a renewed emphasis for RWJF on addressing the broad universe of factors beyond health care that affect health. “Over the next year, our foundation is really going to invest in what we’re talking about as a culture of health — that is, how do we come together across sectors to make America healthier,” said Risa Lavizzo-Mourey, President and CEO of the foundation.. This post will briefly touch on the report’s recommendations, with more discussion to follow in the coming days via a guest post on Health Affairs Blog and our sister publication, GrantWatch Blog.

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Cesarean Rates: Shifting The Focus From Increases To Variability In Use


January 15th, 2014

At 1.3 million procedures each year, the Centers for Disease Control and Prevention (CDC) lists cesarean delivery as the most frequently-performed inpatient surgery in the U.S. Both public and private insurance programs pay more to hospitals for childbirth than for any other condition, and Medicaid programs fund nearly half of all U.S. births.

Cesarean delivery is a potentially life-saving intervention that can hasten delivery in order to avoid adverse outcomes for women or infants, but it carries distinct risks as compared with vaginal delivery, including infant respiratory illness and maternal complications in future pregnancies. Cesarean rates increased dramatically from 20.7 percent in 1996 to an all-time high of 32.9 percent in 2009, but have since remained stable. New data from the CDC indicate a shift in gestational age for cesarean births between 2009 and 2011, with a decrease in births at 38 weeks gestation and an increase in births at 39 weeks, consistent with the increasing policy focus on avoiding non-indicated delivery before 39 weeks gestation. The use of cesareans is changing, and clinicians, policymakers, and researchers should now shift from a sole focus on the “relentless rise” to additionally considering unwarranted variations in cesarean rates.

What We Know

Three notable patterns emerge from the available data on cesarean rates. 1) Cesarean rates are highly variable; 2) changes in cesarean rates are not correlated with changes in infant mortality; and 3) prior research shows that patient and clinical factors do not account for variation in cesarean use.

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