Blog Home

Archive for the 'Disparities' Category




Study Draws Misleading Conclusions Regarding 340B Program


October 23rd, 2014

After reading Rena Conti and Peter Bach’s recent study on hospitals’ purported misuse of the 340B Drug Discount Program, published in the October issue of Health Affairs, I had two questions:  first, how are the authors substantiating their conclusions? Second, what kind of sensational sound bites are going to come from this?

These are the questions that responsible researchers must ask themselves so there is not a false representation of what they did, what they found, and how the actual findings compare to their research intentions. Researchers have to be equally precise in both their statistical analysis AND in the discussion of the results.

I was tempted to run through several counterpoints that my 15 years of 340B policy and research experience yields, but was tempered by both the word count limitations on a blog post and the straightforwardness of my main objection. Simply put, the authors’ conclusions are not substantiated by the data collected. Conti and Bach say that they “found” that hospitals “served communities that were wealthier and had higher rates of insurance” and “generated profits.” They did not find this.

Read the rest of this entry »

Tax-Exempt Status For Nonprofit Hospitals Under The ACA: Where Are The Final Treasury/IRS Rules?


October 23rd, 2014

Months have now stretched into years, and there still remains no sign of final Treasury/IRS regulations interpreting the Affordable Care Act (ACA)’s provisions covering the expanded obligations of nonprofit hospitals that seek tax-exempt status under §501(c)(3) of the Internal Revenue Code.

The ACA amendments do not depend on formal agency policy to take effect. Nonetheless, Congress directed the Treasury Secretary to issue regulations and guidance necessary to carry out the reforms (26 U.S.C. §501(r)(7)). To this end, two important sets of proposed rules were issued: the first in June, 2012; and the second, in April 2013. While an informative IRS website lists various proposed rules and guidelines important to nonprofit hospitals, final rules seem to have performed a disappearing act.

Apparently recognizing the problems created by its delays, the agency has gone so far as to issue a special Notice letting nonprofit hospitals (and presumably the public) know that they can rely on its proposed rules. But this assurance overlooks the fact that the proposed rules themselves contained crucial areas in which final agency policy has not yet been adopted.

Read the rest of this entry »

Teaching Health Centers: An Attainable, Near-Term Pathway To Expand Graduate Medical Education


October 17th, 2014

Stakeholders in Graduate Medical Education (GME) and members of Congress eagerly anticipated the long delayed but recently released Institute of Medicine (IOM) GME report. While perceptively characterizing the defects in our GME system, recommendations of the report generated substantial controversy among participants at a recent GME forum hosted by Health Affairs. The IOM proposed limited and gradual changes in Medicare GME financing, but the lack of support for GME expansion was not well received by some.

At present there are multiple legislative GME proposals, but none has gained broad support among the various stakeholders. Congressional committees responsible for GME funding view this lack of consensus among GME stakeholders as a major obstacle.

We describe a near-term and attainable pathway to expand GME that could gain consensus among these stakeholders. This approach would sustain and expand Teaching Health Centers (THCs), a recent initiative that directly funds community-based GME sponsoring institutions to train residents in primary care specialties, dentistry and psychiatry. We further propose selectively expanding GME to meet primary care and other demonstrable specialty needs within communities, and building in evaluations to measure effectiveness of innovative training models.

Read the rest of this entry »

Drug Discount Analysis Misses The Mark


October 8th, 2014

Rena Conti and Peter Bach’s analysis of disproportionate share (DSH) hospitals in the 340B drug discount program — published in the October issue of Health Affairs — neglects an essential point: compared to non-340B DSH hospitals, 340B DSH hospitals provide over twice as much care to Medicaid and low-income Medicare patients, and almost twice as much uncompensated care. 340B DSH hospitals across the board provide high levels of uncompensated care. For these and other reasons enumerated below, the article does not support the criticism that 340B DSH hospitals are no longer serving vulnerable patients.

First, Conti and Bach misconstrue the 340B program’s intent. 340B is not – and never was – a direct assistance program for the poor. According to the Government Accountability Office, “The 340B program allows certain providers within the U.S. health care safety-net to stretch federal resources to reach more eligible patients and provide more comprehensive services, and we found that the covered entities we interviewed reported using it for these purposes.”

For example, 340B savings help The Henry Ford Hospital fund four oncology clinics and related services in Detroit and surrounding townships. The program is also enabling Henry Ford to hire pharmacists and nurses to follow up with their patients to ensure they are taking their medicines properly and that the treatment is effective.

Read the rest of this entry »

An Interview With George Halvorson: The Kaiser Permanente Renaissance, And Health Reform’s Unfinished Business


September 30th, 2014

For decades, health policymakers considered Kaiser Permanente the lode star of delivery system reform.  Yet by the end of 1999, the nation’s oldest and largest group model HMO had experienced almost three years of significant operating losses, the first in the plan’s history. It was struggling to implement a functional electronic health record, and had a reputation for inconsistent customer service.  But most seriously, it faced deep divisions between management and the leadership of its powerful Permanente Federation, which represents Kaiser’s more than 17,000 physicians, over both strategic direction and operations of the plan.

Against this backdrop, Kaiser surprised the health plan community by announcing in March 2002 the selection of a non-physician, George Halvorson, as its new CEO.  Halvorson had spent most of his career in the Twin Cities, most recently as CEO of HealthPartners, a successful mixed model health plan.  Halvorson’s reputation was as a product innovator; he not only developed a prototype of the consumer-directed health plan in the mid-1990’s, but also population health improvement objectives for its membership, both firsts in the industry.

During his twelve year tenure as CEO, Halvorson not only guided the plan to solid profitability, but added a million members in California, its largest market, despite a devastating recession and a national retreat of commercial HMO membership.  He invested over $6 billion in computerized patient care systems and population health management infrastructure, healed the breach with Kaiser’s physicians, and markedly increased its consumer satisfaction scores, earning 5 STAR ratings under Medicare Advantage.  He left the organization at the end of 2013 with more than $53 billion in revenues and more than $19 billion in reserves and investments.

This interview covers Halvorson’s time at Kaiser, his views of health reform, including the unfinished reform agenda, and his public health activism.  It was conducted by Jeff Goldsmith, a veteran health industry analyst, and Associate Professor of Public Health Sciences at the University of Virginia.  Jeff is a member of the editorial board of Health Affairs.

Read the rest of this entry »

How Engaging Patients Can Improve Care And Health Outcomes


September 26th, 2014

Patients and caregivers are gaining momentum as powerful new resources in efforts to improve the health care system. They are increasingly becoming active partners in their own care, as well as seeking to make the health care delivery system more responsive to their needs and easier to navigate. And they are increasingly engaging as collaborators in planning and conducting research, and disseminating its results, with the goal of producing evidence that can help patients and those who care for them make better-informed decisions about the clinical choices they face.

It is this last trend that led the Patient-Centered Outcomes Research Institute (PCORI) to support Health Affairs in developing a series of videos illustrating some of the ways that patients are bringing their unique experiences and community connections to efforts to improve care for themselves and others. This includes stories of how patients are becoming partners in research designed to address the outcomes important to them, taking account of their own concerns and circumstances.

Seen through this lens, being a research partner goes well beyond being the subject of a trial. Rather, it means helping to guide researchers in formulating the questions to be studied, making the right clinical comparisons, looking at appropriate populations, and focusing on the outcomes important to patients. This should greatly increase the chance that the research findings will produce relevant results that can have a real-world impact — something we plan to evaluate carefully over time.

Meaningful patient engagement is at the heart of PCORI’s approach to research, and several of the patients featured in the videos have in fact partnered with researchers in just this way in patient-centered outcomes research (PCOR) studies we fund. They recognize that PCOR, a form of comparative clinical effectiveness research that focuses on issues of concern to patients, is a vital building block for developing truly patient-centered care and health policy, more effective treatments, and better outcomes.

In the following sections, we highlight the projects mentioned in the videos to give you an idea of how patients and community members are partnering in research projects.

Read the rest of this entry »

Medicare Advantage: Stars System’s Disproportionate Impact On MA Plans Focusing On Low-Income Populations


September 22nd, 2014

The Centers for Medicare & Medicaid Services (CMS) evaluates Medicare Advantage (MA) health plan performance through a five Star Rating System. A close analysis of the Star System finds compelling evidence that organizations focusing on low-income individuals encounter systematic challenges due to the characteristics of the populations they serve.

These challenges result in lower ratings in the Star System, even for MA plans that are effectively serving low-income beneficiaries, threatening the viability of these plans and endangering the health of the most vulnerable. Starting in 2012, pursuant to provisions in the Affordable Care Act of 2010 (ACA), performance on the Star System also affects plan viability due to new payment incentives provided by the law for high performance.

We looked at trends in the Star Ratings from 2011-2014 and individual measure scores for each MA health plan contract to determine if plans focusing on low-income populations (contracts with 50 percent or more Dual Eligible Special Needs (D-SNP) enrollment or 50 percent or more of Part D Low Income Subsidy (LIS) eligible individuals) and the beneficiaries they serve are adversely affected by the Star Ratings System.

Dual eligible beneficiaries are individuals who are dually eligible for Medicare and Medicaid. Beneficiaries who qualify for the Part D Low-Income Subsidy are individuals with incomes below 150 percent of the Federal Poverty Level (FPL).

Read the rest of this entry »

Should We Be Done With Describing Health Disparities?


September 17th, 2014

A recent Health Affairs podcast featured a conversation with AcademyHealth president and CEO Lisa Simpson on health disparities along with Darrell Gaskin, the lead of one of the panel sessions at the 2014 National Health Policy Conference (NHPC), “Community Health and Disparity: Moving Beyond Description.” The conversation endorses interventions rather than descriptions as the future direction of health disparities research.

But should we be done with describing health disparities? In a paper we recently published online in the International Journal for Equity in Health, we show that the answer is: Not entirely.

In this paper, using large, publicly available data, 2008, 2009, and 2010 Behavioral Risk Factor Surveillance System (BRFSS) Selected Metropolitan/Micropolitan Area Risk Trends (SMART) and 2008, 2009, and 2010 United States Birth Records from the National Vital Statistics System, we reported education-, sex-, and race-related disparities in four health outcomes (poor/fair health, poor physical health days, poor mental health days, and low birthweight) in each of the selected 93 counties in the United States representing about 30 percent of the U.S. population.

Read the rest of this entry »

Same Care No Matter Where She Gives Birth: Addressing Variation In Obstetric Care Through Standardization


September 12th, 2014

In August, Health Affairs published a study highlighting an alarming fact in maternal health: The incidence of childbirth complications varies significantly from hospital to hospital across the United States. The study – led by Laurent Glance and colleagues at the University of Rochester – found that “women delivering vaginally at a low-performing hospital had twice the rate of any major complications than women delivering vaginally at a high-performing hospital.” The difference in these complication rates for cesareans was five-fold.

It is well known that variation in care contributes to higher rates of mortality and morbidity in all areas of health care, explaining the push toward checklists and other quality improvement tools and interdisciplinary collaboration. Identifying the primary reasons for variation in obstetric complication rates – why women giving birth in high-performing hospitals have lower complications rates – could be critical to understanding the reasons behind the increasing rates of maternal mortality and morbidity in the U.S. This study, along with other disturbing statistics, underscores the significant need for improvements in maternity care.

Read the rest of this entry »

Advancing Innovation To Eliminate Health Disparities


September 4th, 2014

The advent of population health management, community-based care coordination and mobile health technologies provide a promising opportunity to address longstanding and persistent health disparities. Separately each adds a new dimension to research and analysis, and to individual and community-level public health prevention and access to quality care. Together, providers, payers and researchers alike can acquire a richer understanding of contextual, environmental, and behavioral factors that contribute to disparate outcomes in health.

Existing innovations in data capture, epidemiologic profiling, clinical translation, and workforce development have yet to be taken to scale or appropriately deployed in a manner that would benefit vulnerable populations. Meaningful use technologies, for example, appear to be stuck in the proverbial pipeline with resistance in uptake and limited distribution of incentives. Meaning access and application in poor and disparate communities where they are more often subjects of research and not partners in innovation is far off.

What public health, and community-based and clinically focused interventions need is a fresh look at how health disparities are measured and the processes for application of solutions to needy populations.

Read the rest of this entry »

Exhibit Of The Month: Income-Related Disparities Associated With Negative Health Outcomes


August 29th, 2014

Editor’s note: This post is part of an ongoing “Exhibit of the Month” series. Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

Much is known about income-related disparities when it comes to preventative care and chronic conditions, but less so about the associations between poverty and negative health outcomes.

In “Geographic Clustering Of Diabetic Lower-Extremity Amputations In Low-Income Regions Of California,” published in the August issue of Health Affairs, authors Carl Stevens et al. identify diabetic amputation “hot spots” in low-income urban and rural areas of California (Exhibit 2).

Based on California data from 2009, they isolated 7,973 lower-extremity amputations in 6,828 adults with diabetes. They compare this to a corresponding map of poverty rates in the same region based on households who reported incomes below 200 percent of the poverty level (Exhibit 3).

Read the rest of this entry »

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

Read the rest of this entry »

Disparities In Access To Palliative Care


July 30th, 2014

Editor’s note: Otis Brawley also coauthored this post. This post is part of a periodic Health AffairsBlog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on an upcoming volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.

Racial and ethnic disparities in health care have been well documented among minority groups with respect to access to care, receipt of care, and quality of care. As a result of these disparities, minority populations are often diagnosed with late stage illness and have inferior outcomes likely leading to increased suffering.

Little is known, however, about disparities in access to and use of specialty palliative care. Palliative care is medical care aimed at relieving suffering and providing the best possible quality of life for people facing pain, symptoms, and stresses from serious illness. Palliative care is appropriate for patients at any age or illness stage and can be provided along with curative or life-prolonging therapies.

Read the rest of this entry »

Taking Stock Of The ACA: The Latest Data From The Health Reform Monitoring Survey


July 29th, 2014

Editor’s note: In addition to Sharon Long, this post is coauthored by Genevieve Kenney, Stephen Zuckerman, and Katherine Hempstead. 

Since early last year, the Urban Institute’s Health Reform Monitoring Survey (HRMS) has been collecting relevant, timely data that is providing insights on the implementation of the ACA and changes in health insurance coverage and related outcomes. (An article describing the survey was published in Health Affairs last December.)

Beginning in late 2013, the HRMS set the stage by exploring adults’ understanding of key ACA provisions, their level of health insurance literacy, and expectations about coverage changes in 2014 based on information collected just before the beginning of the first open enrollment period. More recently, the HRMS has shed light on the characteristics of the newly insured, identified who’s not shopping for insurance, and explained how some states’ decisions to expand Medicaid has reduced uninsurance rates.

The HRMS and other surveys have confirmed that the number of uninsured adults has declined significantly since the first open enrollment under the ACA started. On Tuesday July 29th 2014, Health Affairs Editor-in-Chief Alan Weil moderated a panel discussion on what the HRMS shows about the ACA’s performance thus far and what it implies for next year’s open enrollment period. (A recording is available for those who couldn’t join live.) At the event, we released three new policy briefs that, respectively, provide the latest detailed coverage estimates, describe the remaining uninsured, and explore how consumers are navigating the ACA’s Marketplaces.

Here’s a sample of what we’ve learned from this latest release of HRMS data and what was covered at today’s event:

Read the rest of this entry »

Washington Wakes Up To Socioeconomic Status


July 11th, 2014

John Mathewson, executive vice president of Health Care Services for Children with Special Needs (HSC) – a Medicaid managed care plan in D.C. for children on Supplemental Security Income (SSI) – recently spoke at the Association for Community Affiliated Plans (ACAP) CEO Summit before the July 4 Recess.

Mathewson described what he has dubbed The Kitten Paradox: When HSC examined environmental factors for children with asthma, it found that the presence of pets in the house was a common thread, not too far behind having a smoker around. Yet, it turns out the value a cat brings by protecting from mice or spawning a litter for sale outweighs any financial costs to the family associated with an ER visit, which are often free or carry a low copayment. Thus the paradox.

An awardee at the conference, Hennepin Health, catalogued the evidence showing that reliable housing can improve health outcomes, including improving mental health and lowering emergency room and inpatient hospital utilization.

The focus of these sessions was the social determinants of health, and a lot of these safety net health plan leaders’ heads were nodding throughout. The plans, which disproportionately serve Medicaid enrollees and thus ‘dual eligible’ seniors in Medicare, know something about the importance of social determinants that the health policy community – at least in Washington – is only now slowly waking up to.

Read the rest of this entry »

ACAView: New Findings On The Effect Of Coverage Expansion Since January 2014


July 9th, 2014

Editor’s note: In addition to Josh Gray, Iyue Sung also coauthored this post. 

Together, athenahealth and the Robert Wood Johnson Foundation (RWJF) have undertaken a new joint venture called ACAView, as part of the foundation’s Reform by the Numbers project, a source for timely and unique data on the impact of health reform.

The goal of ACAView is to provide current, non-partisan measurement and analysis on how coverage expansion under the Affordable Care Act (ACA) is affecting the day-to-day practice of medicine. athenahealth provides a single-instance, cloud-based software platform to a national provider base.

Any information that our clients enter using our software is immediately aggregated into centrally hosted databases, providing us with timely visibility into patient characteristics, clinical activities, and practice economics at medical groups around the country.

Read the rest of this entry »

New Offices Of Minority Health At FDA And CMS: Will They Help Eliminate Disparities In Health?


June 19th, 2014

Given the rocky roll-out of healthcare.gov, the end of the open enrollment period brought surprising good news: over eight million Americans signed up for coverage through the new Health Insurance Marketplaces. Three million previously uninsured young adults are now covered through their parents’ policies and six million more are enrolled in Medicaid and the Children’s Health Insurance Program.

Minorities are disproportionately more likely to be uninsured, and continued expansions in coverage will help significantly to close gaps in care. However, the impact of the Affordable Care Act (ACA) will not be limited to coverage. A number of provisions to address disparities were included in the ACA, relating to community health, workforce, and data collection. In addition, the ACA authorized new offices of minority health to lead and coordinate federal and national efforts to improve health and reduce disparities.

Several operating divisions at the U.S. Department of Health and Human Services (HHS), including the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality, had existing offices dedicated to improving the health of vulnerable populations. However, this was not the case for the Food and Drug Administration (FDA) or the Centers for Medicare & Medicaid Services (CMS).

Read the rest of this entry »

Thoughts On The VA Scandal And The Future


June 13th, 2014

For eight years, until May 2013, I directed the Department of Veterans Affairs (VA) medical research program from its Central Office and became familiar with the operations of the Veterans Health Administration (VHA). It was my only VA job and I felt honored to be part of the VA’s vital mission, as did most VA employees I met. Based on this experience, I have some ground level observations on the state of the VA and its future planning in light of the present scandal.

VA’s Scope and Assets

VA has three components: a large health system (VHA), a benefit center (Veterans Benefits Administration, or VBA), and the highly regarded National Cemetery Administration. All report to the VA Secretary but have different missions, issues, and management requisites. For example VHA was a pioneer in the Electronic Health Record (EHR), while VBA has had a more recent painful conversion to information technology (IT). VHA is run by the Undersecretary for Health, on whom VA Secretaries almost totally rely given their general lack of experience in health care.

VHA is divided into 21 networks and has 8.9 million enrollees (out of the 22 million U.S. veterans). It cares for 6.4 million veterans annually at over 1,700 sites of care, including 152 hospitals, about 820 clinics, 130 long-term care facilities, 300 Vet Centers for readjustment problems, and a suicide hotline, as well as homelessness and other programs. It has partly trained two-thirds of U.S physicians and made groundbreaking medical research contributions. These assets create strong constituencies for VA both within and outside the veterans’ community.

Read the rest of this entry »

Exhibit Of The Month: Racial Disparities In Clinical Studies


May 27th, 2014

Editor’s note: This post is part of an ongoing “Exhibit of the Month” series. Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

This month’s exhibit, published in the May issue of Health Affairs, illustrates losses to follow-up among black men in clinical studies due to incarceration. Their findings, based on certain National Heart, Lung and Blood Institute cohort studies, raise concerns regarding the generalizability of clinical research.

Read the rest of this entry »

Traditional Budgeting Fails To Account For The Changing Face Of America


May 23rd, 2014

The United States has been undergoing a major demographic shift over the past four decades, and by 2042, the various “minority” communities will in the aggregate make up the majority of our country.  That has real implications not only for things like immigration policy, but also – and critically – for population health considerations.  And it’s time that Congress started thinking about its health policy decisions in ways that recognize this coming demographic reality.

In 2012, there were more than 53 million Latinos living in the United States – up 50 percent from 2000, and up 600 percent from 1970.  This trajectory is even starker when we note that, in the United States as a whole, the population grew just 12 percent from 2000 to 2012.  Today, meanwhile, African Americans are about 13 percent of the population, and that population grew 15 percent from 2000 to 2010.

If current trends continue, there will be 133 million Latinos and nearly 66 million African Americans in the U.S. by 2050, meaning nearly one in two Americans in 2050 will be African American or Latino.

Why does this matter to health policy and the federal budget?  Because these ethnic groups have different health challenges and realities, and those, in turn, have very real economic consequences.

Read the rest of this entry »

Click here to email us a new post.