Blog Home

Archive for the 'Nonmedical Determinants' Category




Poverty’s Association With Poor Health Outcomes and Health Disparities


October 30th, 2014

A recent ecological study by Carl Stevens, David Schriger, Brian Raffetto, Anna Davis, David Zingmond, and Dylan H. Roby, published in the August issue of Health Affairs, showed significant associations between neighborhood poverty and diabetes-related lower extremity amputations (LEA) in the state of California, which adds to the growing evidence that where you live (not just how you live) may directly impact your health.

The authors linked data from multiple sources (i.e. California Health Information Survey, Census Bureau’s American Community Survey, health facility discharge data) and used geographic information system (GIS) analyses and regression analyses to identify amputation “hot spots” and uncovered a 10-fold variation in LEA rates between low-income and high-income neighborhoods.

Read the rest of this entry »

Health Affairs Briefing: Collaborating For Community Health


October 29th, 2014

Policymakers are paying increasing attention to the relationship between the characteristics of communities and the health of the people living in them. The November 2014 issue of Health Affairs, “Collaborating For Community Health,” examines new possibilities created by alignment of the fields of health and community development.

These possibilities come from both sides, including recent changes in the community development field that have set the stage for the new focus on improving health, as well as new approaches to health care financing that create incentives for improving health outcomes.

You are invited to join us on Wednesday, November 5, at a forum featuring authors from the new issue at the National Press Club in Washington, DC.

WHEN:
Wednesday, November 5, 2014
9:00 a.m. – 12:00 p.m.

WHERE:
National Press Club
529 14th Street NW
Washington, DC, 13th Floor

REGISTER NOW!

Follow live Tweets from the briefing @Health_Affairs, and join in the conversation with #HA_CommunityHealth.

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 »

Brownsville: A Culture of Health, Not Health Challenges


October 14th, 2014

Editor’s Note: This post is part of an ongoing series written for Health Affairs Blog by local leaders from communities honored with the annual Robert Wood Johnson Foundation Culture of Health Prize. In 2014, six winning communities were selected by RWJF from more than 250 applicants and celebrated for placing a priority on health and creating powerful partnerships to drive change.

Brownsville is a culturally diverse, south Texas border town, a stone’s throw from Mexico. The 180,000 residents, mostly Spanish-speaking, live in one of the poorest metropolitan areas in the United States and have massive public health needs. In Brownsville, 48 percent of the children live in poverty, and 80 percent of our population is obese or overweight. Thirty percent have diabetes and half of them don’t know it. About 67 percent have no health insurance.

But in Brownsville, you will also find a robust, bike-friendly city, community gardens, and the world’s largest Zumba® class. That’s because in the last 10 years Brownsville has developed innovative partnerships, extensive outreach efforts, and a shared commitment to achieve wellness.

Read the rest of this entry »

An Evolving Approach To Collaborations Among Health And Other Sectors


September 25th, 2014

Much evidence exists on the potential for prevention and health promotion to decrease the burden of chronic diseases. The Institute of Medicine (IOM), for example, has issued many reports with recommendations to use population-based and individual prevention programs and policy and legal interventions to improve diets, increase physical activity, and stop tobacco use.

These reports also note that achieving progress in health promotion will require the engagement of other non-health sectors. This isn’t breaking news—terms like “multisectoral” or “health in all policies” prevail in public health dialogue. Yet the question remains – if it is so well accepted that the health sector alone cannot improve health, why don’t multisectoral programs and policies happen more often and more successfully?

Read the rest of this entry »

IOM Report Calls For Transformation Of Care For The Seriously Ill


September 24th, 2014

The new Institute of Medicine (IOM) report on care near the end of life in the United States was released last week. I had the privilege of serving on the Committee for the last two years, involved both in the writing of the report itself and in coming to consensus on its recommendations.

The name of the report and the charge to the Committee from the IOM was focused on “end of life.” However, the title, “Dying in America,” is something of a misnomer. The report itself focuses extensively on people with serious and chronic illness with indeterminate prognoses, why the current health care system fails so consistently to meet their needs, and what must change to improve the situation.

Hospice is the gold standard of care quality for those that are predictably dying and clearly at the end of life, and we are fortunate as a nation to have such a strong (mostly home) hospice infrastructure, but that’s not where most of the problems lie. The problems lie in the lack of options for people who are either not hospice-eligible (prognosis uncertain or continuing to want and benefit from disease treatment) or are referred to hospice much too late in their disease course to influence their experience and their families’.

The new report builds on the 1998 IOM report “Approaching Death” and goes well beyond the usual nostrums of calling for reimbursement for advance care planning and decrying all the “waste” in health care spending during the last year of life.

Read the rest of this entry »

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.

Read the rest of this entry »

Taos Pueblo: A Sovereign Nation Sees Positive Public Health Results


September 15th, 2014

Editor’s note: This post is part of an ongoing series written for Health Affairs Blog by local leaders from communities honored with the annual Robert Wood Johnson Foundation Culture of Health Prize. In 2014, six winning communities were selected by RWJF from more than 250 applicants and celebrated for placing a priority on health and creating powerful partnerships to drive change. Interested communities are encouraged to apply for the 2015 RWJF Culture of Health Prize. Applications are due September 17, 2014.

The Taos Pueblo in New Mexico is a National Historic Landmark and one of a handful of places around the world designated a World Heritage Site by the United Nations. Native Americans have continuously lived in this ancient tribal community, with its remarkable multi-story adobe buildings, for more than 1,000 years. Today, the Taos Pueblo tribe has about 1,350 people living on some more than 100,000 acres, just outside the artist community of Taos.

The pueblo has its share of poverty and unemployment, along with troubling rates of diabetes, obesity, and alcoholism. Data from the Indian Health Service clinic at the pueblo show that about 47 percent of pueblo youth under age 20 are overweight or obese. And 21 percent of the adults have diabetes. Many pueblo residents live below the poverty level, which is not surprising as their economy is based on tourism, crafts, and a small casino.

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 »

Collaboration, Consistency, and Community Spirit: How Durham Advances Health


August 28th, 2014

Editor’s note: This post is part of an ongoing series written for Health Affairs Blog by local leaders from communities honored with the annual Robert Wood Johnson Foundation Culture of Health Prize. In 2014, six winning communities were selected by RWJF from more than 250 applicants and celebrated for placing a priority on health and creating powerful partnerships to drive change. Interested communities are encouraged to apply for the 2015 RWJF Culture of Health Prize. Applications are due September 17, 2014.

Durham, North Carolina is so richly endowed with health care resources that it is known as “the City of Medicine;” it is home to 95 percent of the companies that comprise the Research Triangle. Yet, while many of the county’s 288,133 residents are thriving, others are not nearly as healthy.

A 2004 community health assessment revealed that in Durham’s very diverse population — currently, 38.7 percent black, 42.1 percent white, and 13.5 percent Hispanic — there were high rates of cardiovascular disease and other chronic conditions, HIV and other sexually transmitted diseases, and infant mortality.

A 2007 evaluation also showed that 29 percent of the county’s adults were obese. The rate was 42 percent among African Americans. In the same report, 49 percent of adults said their health prevented them from participating in even moderate physical activities. Among children entering kindergarten in 2009, 18 percent were overweight or obese.

Read the rest of this entry »

Health Policy Brief: The Relative Contribution Of Multiple Determinants To Health Outcomes


August 22nd, 2014

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) examines factors that can contribute to health status. In the United States, less than 9 percent of health expenditures go to disease prevention, and there is little support for social services, such as programs for older adults, housing, and employment programs.

This brief focuses on “multiple determinant” studies that seek to quantify the relative influence of some of these factors on health. It is part of a larger project, supported by the Robert Wood Johnson Foundation, which aims to create a structure for conducting analyses that demonstrate the value of investments in nonclinical primary prevention and their impact on health care costs.

Read the rest of this entry »

Spokane County: A Community Comes Together To Improve Health And Education For Every Child


August 18th, 2014

Editor’s Note: This post is part of an ongoing series written for Health Affairs Blog by local leaders from communities honored with the annual Robert Wood Johnson Foundation Culture of Health Prize. In 2014, six winning communities were selected by RWJF from more than 250 applicants and celebrated for placing a priority on health and creating powerful partnerships to drive change. Interested communities are encouraged to apply for the 2015 RWJF Culture of Health Prize. Applications are due September 17, 2014.

Spokane County is a metro area of more than 470,000 people, yet it’s still driven by the spirit of a small town. That sense of community is an essential part of the county’s ongoing work to improve the health of all residents by focusing on education.

In 2006, Spokane Public Schools’ high school graduation rate was less than 60 percent overall, while Spokane County’s rate was 72.9 percent. Spokane County educators were increasingly concerned about the future health and well-being of the county’s children, especially the 18 percent living in poverty.

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 »

Five Engagements That Will Define The Future Of Health


July 31st, 2014

I recently had the pleasure of opening and moderating the first day of the 2014 Colorado Health Symposium, which had as its theme “Transforming Health: The Power of Engagement.”  I found thinking about engagement, well, engaging, and in this post I summarize the keynote presentation I gave at the conference.

Engagement has many meanings, including some negative ones (such as “a hostile encounter between military forces”).  I focused on engagement as “emotional involvement or commitment” and described five engagements that will define the future of health.

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 »

Investing In The Social Safety Net: Health Care’s Next Frontier


July 7th, 2014

Editor’s note: In addition to Jennifer DeCubellis, Leon Evans also coauthored this post. 

The United States spends 250 percent more than any other developed country on health care services, yet we are ranked below 16 other countries in overall life expectancy. A less frequently discussed statistic, however, is the degree to which the U.S. under-invests in social services: for every dollar spent on health care, only 50 cents is invested in social services. In comparison, other developed countries spend roughly $2 on social services for every dollar spent on health care. The U.S. is 10th among developed countries in its combined investment in health care and social services.

This imbalance has ramifications for the nation’s Medicaid program, where just five percent of beneficiaries with complex health and social problems drive more than 50 percent of all program costs. Many individuals in this high-cost group have chronic complex medical, behavioral health, and/or supportive service needs, and in the absence of coordinated intervention, they tend to be frequent visitors to emergency rooms and have high rates of avoidable hospital admissions.

Read the rest of this entry »

Happy Birthday HCPF


July 1st, 2014

Today marks the 20th birthday of the Colorado Department of Health Care Policy and Financing.  The story of its creation provides an important reminder of how our thinking about health care has evolved over the past few decades – and how it continues to evolve today.

Back in the bad old days, Medicaid was just another social service.  Housed within a broader social services agency, Colorado Medicaid – as was the case in most states – grew up with a typical welfare mentality.  Program enrollees were beneficiaries.  If they did not enroll, we assumed it meant they did not need or want our services.  Eligibility was a cumbersome, rule-bound process with inscrutable results and unintelligible notices to applicants of what was missing from their file.

Read the rest of this entry »

The 2014 Culture of Health Prizes


June 25th, 2014

Today the Robert Wood Johnson Foundation awarded its 2014 Culture of Health Prize to six communities. These communities —  Brownsville, TexasBuncombe County, North CarolinaDurham County, North CarolinaSpokane County, WashingtonTaos Pueblo, New Mexico; and Williamson, West Virginia — were selected for the work they have done to place a high priority on health and bring partners together to drive local change.

Read the rest of this entry »

Health Affairs June Issue: Where Can We Find Savings In Health Care?


June 2nd, 2014

The June issue of Health Affairs, released today, features various approaches to cost-savings in the U.S. health care system. A variety of articles analyze the effects of potential policy solutions on the Medicare and Medicaid programs and their impact on the health of beneficiaries and tax payer wallets.

Federal approaches to reduce obesity and Type 2 diabetes rates by improving nutrition could work—but the how matters. Sanjay Basu of the Stanford University School of Medicine and coauthors modeled the effects of two policy approaches to reforming the Supplemental Nutrition Assistance Program (SNAP), which serves one in seven Americans. They found that ending a subsidy for sugar-sweetened beverage purchases with SNAP dollars would result in a decrease in obesity of 281,000 adults and 141,000 children, through a 15.4 percent reduction in calories by the lowering of purchases of this source. They also found that a $0.30 credit back on every dollar spent on qualifying fruits and vegetables could more than double the number of SNAP participants who meet federal guidelines for fruit and vegetable consumption.

With more than forty-six million people receiving SNAP food stamp benefits, the authors suggest that policy makers closely examine the implications of such proposals at the population level to determine which will benefit people’s health the most and prove most cost-effective.

If you’re between ages 15–39 when you are diagnosed with cancer, the implications later in life extend well beyond your health. Gery P. Guy Jr. of the Centers for Disease Control and Prevention and coauthors examined Medical Expenditure Panel Survey data and determined that survivors of adolescent and young adult cancers had annual per person medical expenditures of $7,417, compared to $4,247 for adults without a cancer history. They also found an annual per capita lost productivity of $4,564 per cancer survivor — because of employment disability, missed workdays, and an increased number of additional days spent in bed as a result of poor health — compared to $2,314 for adults without a cancer history.

The authors suggest that the disparities are associated with ongoing medical care needs and employment challenges connected to cancer survivorship, and that having health insurance alone is not enough to close the gap. They stress the importance of access to lifelong follow-up care and education to help lessen the economic burden of this important population of cancer survivors.

Read the rest of this entry »

Click here to email us a new post.