Why you should use this website…

After working for over fourteen years in community-based advocacy organizations, and then for seven years in health policy philanthropy, I have been privileged to be a resource for many people on many issues. There is a “database” of knowledge in my head which has been collected through the great working relationships I have been fortunate to develop, as well as the opportunities I have had to access, read, digest, disseminate, fund, and write articles and publications.

And through over 350 presentations (and counting!) at conferences, workshops, seminars, and trainings over the past 30 years, I have tried to share the resources, analyses, and contacts that are in my head with others, often accompanied by multi-page lists of references and citations.  During the past four years that I have been working as a independent consultant, I have continued to identify and provide those resources and references for my organizational clients.

This website uses technology to share what is in my head, in those presentations, and in those reference lists as virtual, real-time, open-source resources for those of you who might find them useful.  I invite your commentary and analyses on these resources, much like a continuously updated annotated bibliography.

I also hope that this website becomes a platform for the best in social networking – where those of us with common interests, questions, and critiques can connect, probe, push, and work together to advance these issues which I care so much about.

Please give me your comments, feedback, criticisms, and suggestions – and join me – in my technology-enabled journey forward towards greater patient-centeredness and equity…

Ignatius

Posted in The iBau Blog | Leave a comment

Resources to Advance Patient-Centeredness and Health Equity

I have compiled key publications and resources on some current topics in health care policy.  Below are descriptions of the key topic areas, which also can be accessed using the menu on the right side of this page.

Health Care Reform: Opportunities to Advance Patient-Centeredness and Equity

With the historic enactment of national health care reform in March 2010, it can be a little overwhelming to understand all the details and implications of this huge structural shift in national health care policy.

As I continue to refine my own knowledge and understanding of the national health care reform law, I will share my analyses and presentations here.  I will be highlighting what I call the “patient-centeredness” and “equity” elements of the legislation, two of the components of health care quality identified by the Institute of Medicine.

Text of Patient Protection and Affordable Care Act, as amended by the Health Care and Education Reconciliation Act

Side-by Side Analysis of Equity Provisions in Final Senate and House Bills

California Pan-Ethnic Health Network Bulletin, Advancing Patient-Centeredness and Equity in Health Care Reform, July 2010

Plenary Presentation at California Pan-Ethnic Health Network “Building Quality and Equitable Health Care Systems”, June 2010

The federal government health care reform implementation website also has useful information and is available in Español (Spanish).

I also have compiled some of the publications and resources that I have found most useful in understanding the Patient Protection and Affordable Care Act.

Kaiser Family Foundation Summary of PPACA

Kaiser Family Foundation PPACA Implementation Timeline

Joint Center for Political and Economic Studies Advancing Health Equity for Racially and Ethnically Diverse Populations

Summit Health Institute for Research and Education Health Equity Activist Guide to the PPACA

Finally, I am compiling publications and resources on some of the key topics and issues emerging from the implementation of health care reform:

Medical Homes

Accountable Care Organizations

Comparative Effectiveness Research

Medical Homes: A Promising Model for Advancing Patient-Centeredness and Equity

One of the emerging models of health care delivery system re-design is the concept of a “medical home”.   In 2007, the American Academy of Family Practice, American Academy of Pediatrics, American College of Physicians and American Osteopathic Association issued a Joint Principles defining patient-centered medical homes.

While the specific terminology and elements of a medical home (also being called a “health care home”, “primary care home” or “advanced primary care practice”) vary, the core idea is that everyone should have a partnership with a primary care provider who will provide access to comprehensive, coordinated, high quality health care.

Medical homes will be given a huge catalyst with the imminent widespread adoption of health information technology by physician practices, community health centers and hospitals.

I have compiled some key analyses and background resources on the concept of medical homes.

Robert Wood Johnson Foundation – Health Affairs Policy Brief on Medical Homes

Deloitte Health Care Solutions Issue Briefs on Medical Homes and “Medical Homes 2.0

Center for Studying Health System Change Issue Brief on Medical Homes

Mathematica Issue Brief on Medical Homes

National Academy for State Health Policy Issue Brief on Medical Homes

The California Endowment Resource Guide on Health Homes

National Partnership for Women and Families Consumer Principles for Medical Homes

Some key articles are:

Berenson RA, et al.  “A house is not a home: Keeping patients at the center of practice redesign.” Health Affairs (2008); 27(5):1219-1230

Pham HH.  “Good neighbors: How will the patient-centered medical home relate to the rest of the healthcare delivery system?”  J Gen Intern Med (2010); 25(6):630-634

Merrell K and Berenson RA.  “Structuring payment for medical homes.”  Health Affairs(2010); 29(5):852-858

Several organizations are developing standards for recognizing or qualifying medical homes, including the National Committee for Quality AssuranceURAC and The Joint Commission.

There have been many medical home demonstration projects, many coordinated by the Patient-Centered Primary Care Collaborative.  The Centers for Medicare and Medicaid Services is beginning a national multi-payer advance primary care demonstration project.

The next National Medical Home Summit will be March 14-16 in Philadelphia, PA.

Accountable Care Organizations: Experimenting with Payment Reform

One of the most interesting concepts which is being promoted in the national health care reform legislation are “accountable care organizations” (ACO) – new or existing health care organizations which would assume responsibility (“accountability”) for improving the health outcomes of a defined number of patients (at least 5,000) in a specific geographic area.  The ACO  would be required to engage a sufficient percentage of the local providers (hospitals, physicians, community health centers, etc.) so that it could establish appropriate goals for quality outcomes and then take the cost savings from that quality improvement (for example, reduced number of avoidable hospitalizations) and distribute those savings among all the providers.

What is somewhat surprising about the degree of support and interest in the concept is that this is still largely an idea based on cost analyses and savings projections from Medicare claims data, with little practical evidence that it actually works to sufficiently change the current cost and payment incentives in our health care system.  Moreover, while not excluding the ability of a hospital/health system, independent practice association or health plan to be a local ACO, the model contemplates a new type of administrative organization solely focused on these issues of quality improvement and shared cost savings.  Finally, there are many actuarial, measurement and legal issues to overcome to make this concept viable.

The “thought leaders” who have developed the concept of an accountable care organization are Mark McClellan, former Administrator of the Centers for Medicare and Medicaid Services and now at the Engleberg Center for Health Care Reform at the Brookings Institution and Elliot Fisher of Dartmouth Medical School.  They have created a learning network with useful tools for developing an ACO.

Some of the best analyses of accountable care organizations have been published by:

Robert Wood Johnson Foundation – Health Affairs Policy Brief on Accountable Care Organizations

Urban Institute Policy Brief on Accountable Care Organizations

Deloitte Center for Health Care Solutions Policy Brief on Accountable Care Organizations

National Academies of Practice Policy Paper on Accountable Care Organizations

Key articles are:

Fisher ES, et al.  “Fostering accountable health care: Moving forward in Medicare.”Health Affairs (2009); 28(2):w219-w231

McClellan M, et al.  “A national strategy to put accountable care into practice.”Health Affairs (2010); 29(5):982-990

National Accountable Care Organization Congress is being held on October 25-27, 2010 in Century City, California.

Comparative Effectiveness Research: Improving Quality and Containing Costs

One the more controversial concepts in contemporary health care policy is comparative effectiveness research (CER).  This research attempts to directly compare the effectiveness of different treatments and interventions for various diagnoses and conditions.  For example, when a woman is diagnosed with breast cancer, what is her best choice for treatment – surgery, chemotherapy, radiation, or a combination of all three?  In what sequence and what dosage?  The attention to comparative effectiveness research was significantly raised when $1.1 billion was made available to support CER in the American Recovery and Reinvestment Act.

The concern is that this research will be used to deny coverage or payment for certain treatments or interventions, or otherwise “ration” health care services.  Accordingly, the Patient Protection and Affordable Care Act no longer used the term “comparative effectiveness research” and instead established the Patient-Centered Outcomes Research Institute.

I have compiled some key background documents on the $1.1 billion being invested in CER as well as some policy analyses of what implications comparative effectiveness research might have for health care quality improvement and cost containment.

Institute of Medicine National Priorities for Comparative Effectiveness Research

National Institutes of Health Comparative Effective Research

Agency for Healthcare Quality Comparative Effectiveness Research

Office of the Secretary Comparative Effectiveness Research

Robert Wood Johnson Foundation – Health Affairs Policy Brief on Comparative Effectiveness Research

Kaiser Family Foundation Issue Brief on Comparative Effectiveness Research

Institute for Health Care Reform Policy Analysis on Comparative Effectiveness Research

Mathematica Issue Brief on Comparative Effectiveness Research

The October 2010 edition of Health Affairs is focused on comparative effectiveness research.  Among the key articles:

Patel K. “Health reform’s tortuous route to the Patient-Centered Outcomes Research Institute.” Health Affairs (2010); 29(10): 1777-1782

Garber AM and Sox HC.  “The role of costs in comparative effectiveness research.  Health Affairs (2010); 29(10): 1805-1811

Health Information Technology: Advancing Patient-Centeredness and Equity through Technology

The other major health care policy legislation enacted within the past two years is the Health Information Technology for Economic and Clinical Health (HITECH) Act, which was part of the economic stimulus legislation, the American Recovery and Reinvestment Act.  The HITECH Act provides up to $30 billion to hospitals, physicians, community health centers and other “eligible providers”.  The federal funds will be available through incentive payments paid through Medicare and Medicaid.  Hospitals and physicians must demonstrate “meaningful use of certified electronic health records” to qualify for the incentive payments.  The Office of National Coordinator for Health Information Technology is overseeing most of the implementation of the HITECH Act, in collaboration with the Centers for Medicare and Medicaid Services, which is overseeing the Medicare and Medicaid incentive payments.

I have compiled some key resources on the implementation of the HITECH Act, with a focus on how it might impact safety net health care providers, and patients and health care consumers, especially from underserved communities.

The best overview of the HITECH Act was published by the California HealthCare Foundation.  Manatt Health Solutions recently published an insightful “one year after enactment” review of the implementation of the HITECH Act.  Other useful resources include:

Robert Wood Johnson Foundation – Health Affairs Policy Brief on Meaningful Use

National Partnership for Women and Children Consumer Benefits from Meaningful Use

I have been most interested in how the implementation and utilization of health information (and communications) technologies can advance patient-centeredness and equity.

Here is my presentation on the HITECH Act for the National HIT Collaborative for the Underserved and a bulletin I authored, published by the California Pan-Ethnic Health Network on these issues.

And here are some useful resources for understanding how patients and consumers, particularly from communities of color and other underserved populations, could benefit from health information and communications technologies:

Pew Internet Project on Digital Divide

California HealthCare Foundation 2010 Consumer Survey

California HealthCare Foundation: How Smartphones are Changing Health Care

California HealthCare Foundation: Creating EHR Networks in the Safety Net

One of the concepts I have been promoting is the process of identifying the specific issues or needs for underserved populations – for example, the need for tailored, adaptable patient education materials in multiple languages and formats – and then developing and implementing “universal” solutions that benefit everyone – for example, the ability to archive and access multiple versions of patient education materials from an electronic health record system.  This would mean educational materials about asthma care would be available electronically from an electronic health record system in English, Spanish, Chinese and Vietnamese, at a literacy level usable by patients and families with lower health literacy in each of those languages, and could be printed in a large fonts for persons who would benefit from increased readability.

There are many useful articles that have been published about the implementation of the HITECH Act:

Brailer DJ.  “Guiding the health information technology agenda.”  Health Affairs (2010); 29(4): 586-595

Bates DW and Bitton A. “The future of health information technology in the patient-centered medical homes.”  Health Affairs (2010); 29(4): 614–621

Tang PC and Lansky D.  “The missing link: bridging the patient-provider health information gap.” Health Affairs. (2005);24(5):1290-1295.

Torda P, Han ES and Scholle SH.  Easing the adoption and use of electronic health records in small practices.” Health Affairs (2010); 29(4): 668–675

Miller RH , et al. “The value of electronic health records in solo or small group practices.”
Health Affairs, (2005); 24(5): 1127-1137

Lee J , et al.  “The adoption gap: Health information technology in small physician practices.”  Health Affairs, (2005); 24(5): 1364-1366

Miller RH and West CE.  “The value of electronic health records in community health centers: Policy implications.”  Health Affairs,(2007); 26(1): 206-214

Shields AE, et al.  “Adoption of health information technology in community health centers: Results of a national survey.”  Health Affairs (2007); 26(5): 1373-1383

Millery M and Kukafka R.  “Health information technology and quality of health care: Strategies for reducing disparities in underresourced settings.” Med Care Res Rev.(2010) Jul 30. [Epub ahead of print]

Baig AA, et al. “The use of quality improvement and health information technology approaches to improve diabetes outcomes in African American and Hispanic patients.  Med Care Res Rev. (2010) Jul 30. [Epub ahead of print]

Ngo-Metzger Q, et al.  “Improving communication between patients and providers using health information technology and other quality improvement strategies: Focus on Asian Americans.” Med Care Res Rev. (2010) Jul 30. [Epub ahead of print]

I will continue to add more content on sub-topics for this huge change in health care delivery in the U.S., as well as catalog and comment on additional resources as they become available.

Demographic Data: The Baseline for Advancing Equity

Collecting data from patients about their income, education, race, ethnicity, language, sexual orientation, gender identity and expression, health literacy and other demographic information will enable health care providers and systems to better understand individual patient needs as well as identify and address disparities at a population level.

Institute of Medicine Report: Standardization of Race, Ethnicity and Language Data

Hospitals, health plans and physician practices are all beginning to collect more data on patient demographics.

Health Research and Education Trust: Toolkit for Collecting Race, Ethnicity and Primary Language Data

America’s Health Insurance Plans: Toolkit for Race, Ethnicity and Primary Language Data Collection

The meaningful use requirements for Medicare and Medicaid incentive payments under the Health Information will require hospitals and physicians to collect race, ethnicity and language data on at least 50 percent of their unique patients.  These requirements will further stimulate data collection activities over the next few years.

Meanwhile, it is important to consider other demographic data which could identify disparities for other underserved populations.  For example, there is recent discussion about how best to collect data about sexual orientation and gender identity/expression to improve the quality of health care for lesbian, gay, bisexual and transgender patients and their families.

National Coalition for LGBT Health Issue Brief on Data Collection

University of California San Francisco Center of Excellence for Transgender HIV Prevention Recommendations for Inclusive Data Collection from Transgender Individuals

Language Access: Ensuring Meaningful Access to Health Care

There is a growing body of evidence that language barriers for individuals with limited English proficiency has a direct relationship to the quality of health care. Providing language assistance services can improve the quality of care and reduce health care disparities among individuals with limited English proficiency.  Language assistance services include both verbal interpretation services and written translation services.

National Council on Interpreting in Health Care Searchable Annotated Bibliography on Language Access

With funding from the Robert Wood Johnson Foundation, a special November 2007 supplement of the Journal of General Internal Medicine is focused on language access issues, with open access to all the articles.

There are many useful resources that can help support the many reasons for improving language access, including legal and regulatory requirements, patient safety, risk management, quality improvement and disparities reduction.

Here is my presentation on how to make the multiple “cases” for language access.

There are important background resources which support the legal and regulatory requirements for language access that apply to all health care providers that receive any type or amount of federal funding (almost all health care providers):

Title VI of the 1964 Civil Rights Act Requires Language Access

U.S. Department of Health and Human Services Title VI Guidance on Language Access

U.S. Department of Health and Human Services Office of Minority Health National Standards for Culturally and Linguistically Appropriate Services

There is growing evidence for other reasons for ensuring language access:

Joint Commission Article: Language Proficiency and Adverse Events

National Health Law Program: High Cost of Language Barriers in Medical Malpractice

Hospitals, health plans, community health centers and physician office practices have all demonstrated the feasibility and importance of ensuring language access:

Joint Commission Report: Hospitals, Language and Culture

Joint Commission Report: One Size Does Not Fit All

Joint Commission Report: Roadmap for Effective Communication, Cultural Competency and Patient- and Family-Centered Care

George Washington University: How Hospitals Use Bilingual Clinicians and Staff

Northwestern University: Facilitators and Barriers to Providing Language Services in California Public Hospitals

Robert Wood Johnson Foundation Speaking Together Program

California Health Care Safety Net Institute Model Hospital Policies and Procedures on Language Access

National Committee for Quality Assurance Innovative Practices in Multicultural Health Care 2009

National Committee for Quality Assurance Innovative Practices in Multicultural Health Care 2008

National Committee for Quality Assurance Innovative Practices in Multicultural Health Care 2007

National Committee for Quality Assurance Innovative Practices in Multicultural Health Care 2006

National Association of Community Health Centers: Serving Patients with Limited English Proficiency

Association of Clinicians for the Underserved: Language Access – Understanding the Barriers and Challenges in Primary Care Settings

National Health Law Program: Language Access in Small Provider Settings

The National Council on Interpreting in Health Care has developed a Code of Ethics and Standards of Practice for health care interpreters.

And a national program for the certification of health care interpreters has been created by the Certification Commission for Healthcare Interpreters, which is conducting its first test cycle in October and November 2010.

Finally, here are some publications which explain how federal matching funds from Medicaid and the Children’s Health Insurance Program can be used by states to reimburse health care providers for language assistance services.

National Health Law Program: How States Can Get Federal Funding for Language Assistance Services

National Health Law Program: Medicaid and Children’s Health Insurance Program Reimbursement for Language Assistance Services

Center for Budget and Policy Priorities Medicare Payment for Language Services

Cultural Competency: Customizing Health Care for Diverse Patients

The Institute of Medicine identified patient-centeredness as one of the elements of quality health care.  The definition of patient-centeredness includes responsiveness to the needs and preferences of the patient.  There is a conceptual overlap between patient-centeredness and cultural competence:

The Commonwealth Fund Cultural Competency Report: Cultural Competency and Patient-Centered Care

Joint Commission Report: Roadmap for Effective Communication, Cultural Competency and Patient- and Family-Centered Care

There are many useful frameworks and resources for understanding and applying cultural competency in health care:

U.S. Department of Health and Human Services Office of Minority Health National Standards for Culturally and Linguistically Appropriate Services

National Quality Forum Framework for Cultural Competency

Health Resources and Services Administration Organizational Cultural Competence Assessment

Management Sciences for Health Provider’s Guide to Quality and Culture

Georgetown University National Center for Cultural Competence

Many health care organizations are integrating concepts of cultural competency into their quality improvement and disparities reduction activities:

The California Endowment Report: Building Culturally Competent Health Systems

Encouraging Cultural and Linguistic Competent Practices in Mainstream Health Organizations

Health professions education and training programs also are integrating cultural competency into their curricula:

Association of American Medical Colleges: Cultural Competency Education

The May 2010 Supplement 2 to the Journal of General Internal Medicine is focused on cultural competency and health disparities issues in medical education – all the articles in the issue are available through open access (scroll down to bottom of right side of page)

American Association of Colleges of Nursing: Cultural Competency in Baccalaureate and in Master’s and Doctoral Nursing Education

California Dental Pipeline Program Toolkit for Treating Culturally Diverse Patients

California Assembly Bill 1195 Requires Cultural and Linguistic Competency Content in Continuing Medical Education

Institute for Medical Quality CME Resources on Cultural and Linguistic Competency

Health Care Disparities: A Continuing National Challenge

There is now overwhelming, irrefutable evidence of health care disparities in the U.S.:

Institute of Medicine Report: Unequal Treatment – Confronting Racial and Ethnic Disparities in Health Care

National Healthcare Disparities Report 2009

Fortunately, many health care organizations have recognized the persistence of health care disparities and have begun to develop and implement interventions to reduce those disparities:

U.S. Department of Health and Human Services Office of Minority Health Draft National Plan of Action

National Quality Forum Disparities-Sensitive Ambulatory Health Care Quality Measures

National Health Plan Collaborative: Toolkit on Reducing Disparities

Center for Healthcare Strategies: Toolkit for Reducing Racial and Ethnic Health Care Disparities for Medicaid Managed Care Plans

National Committee for Quality Assurance Innovative Practices in Multicultural Health Care 2009

National Committee for Quality Assurance Innovative Practices in Multicultural Health Care 2008

National Committee for Quality Assurance Innovative Practices in Multicultural Health Care 2007

National Committee for Quality Assurance Innovative Practices in Multicultural Health Care 2006

National Public Health and Hospital Institute: Assuring Healthcare Equity

American Medical Association Activities on Health Disparities

Center for Studying Health System Change: Physician Efforts to Reduce Disparities

Mathematica Policy Brief: Partnerships between Employers and Health Plans to Reduce Health Care Disparities

National Business Group on Health: Why Companies are Making Health Disparities Their Business

Health Workforce Diversity: The Quality and Economic Imperatives

Given the historic discrimination against African Americans, American Indians and other racial and ethnic minorities and their exclusion from the health professions in this country, it remains a national challenge to diversify the racial and ethnic background of students entering the health professions. While almost all of the business world recognizes the value and benefits of workforce diversity, there is still strong resistance within admissions committees and faculties of health professions educational institutions to changing traditional admissions criteria (grades and standardized test scores) to account for the qualities of the “whole person” that would make a student a successful health professional.

As our nation’s health care systems undergo continued reform, there is also growing maldistribution of health professionals, both geographically as well as type of practice and specialization.   There are chronic and increasing shortages of health professionals for rural and urban underserved areas, especially in primary care.   These shortages will only be exacerbated by the increased demand for health care services as the previously millions of uninsured and underinsured Americans obtain health care coverage under national health care reform and begin to seek their own regular providers of health care.

Finally, as models of health care delivery move toward more patient-centered and team-based approaches such as medical homes, physicians and other clinicians will need to be more than knowledgeable, technically proficient providers of procedures, medications and medical devices.  The abilities to manage and supervise teams, to conduct motivational interviewing, to engage in care management and support behavior change, and to effectively communicate with and coordinate care with other providers, patients, families and caregivers will become more and more important skills.  Having more diverse providers reflective of the patient populations served who can build rapport and trust with patients will be essential.

Here are some key background resources on the imperative for health workforce diversity:

Institute of Medicine Report: In the Nation’s Compelling Interest

Sullivan Commission Report: Missing Persons – Minorities in the Health Professions

American Medical Association Apology to Black Physicians

Association of  American Medical Colleges Diversity Initiatives

American Association of Colleges of Nursing Diversity in Nursing Education Resource Center

Connecting the Dots Initiative in California

University of California San Francisco: Strategies for Increasing the Diversity of the Health Professions

Lesbian, Gay, Bisexual and Transgender Health Issues

Lesbian, gay, bisexual and transgender individuals and communities have largely been overlooked by health care systems and providers.  Unfortunately, there is evidence that many lesbian, gay, bisexual and transgender patients and health care consumers continue to experience discrimination and exclusion from health care services, and also experience disparities in health care and outcomes.

Healthy People 2010 Companion Document on Lesbian, Gay, Bisexual and Transgender Health

Presidential Memorandum on Respecting the Rights of Hospital Patients

Human Rights Campaign Foundation Health Equality Index

National Coalition for LGBT Health Issue Brief on Health Disparities

Center for American Progress Issue Brief on LGBT Health Disparities

Similar to many underserved populations and communities, one of the central issues for improving the health care for lesbian, gay, bisexual and transgender individuals is demographic data collection – being able to voluntarily and safely identify as lesbian, gay, bisexual and transgender to one’s health care provider, or on a health survey.

National Coalition for LGBT Health Issue Brief on Data Collection

University of California San Francisco Center of Excellence for Transgender HIV Prevention Recommendations for Inclusive Data Collection from Transgender Individuals

National Coalition for LGBT Health Issue Brief on Inclusion in Federal Health Surveys

In addition, there are important issues of providing clinically appropriate care for lesbian, gay, bisexual and transgender patients and health care consumers, cultural competency training and workforce development.

AHRQ Innovations Exchange on Culturally Competent Care for Lesbian, Gay, Bisexual and Transgender Patients

Gay and Lesbian Medical Association Guidelines for the Care of Lesbian, Gay, Bisexual and Transgender Patients

National Coalition for LGBT Health Guiding Principles for Inclusion in Health Care

Joint Commission Report: Roadmap for Effective Communication, Cultural Competency and Patient- and Family-Centered Care

National Coalition for LGBT Health Issue Brief on Health Care Workforce

National Coalition for LGBT Health Issue Brief on Cultural Competency

Improving health care for lesbian, gay, bisexual and transgender patients and their families is another important step towards patient-centered and equitable health care for all.

Patient-Centeredness: The Promise of Quality and a Pathway to Equity

One of the six components of quality health care identified by the Institute of Medicine is patient-centeredness.  While there has been significant attention on the components of safety, timeliness, effectiveness, efficiency, there has been less attention on the components of equity and patient-centeredness.

I have begun to use patient-centeredness as a key concept to drive change and improvement in our health care systems, as well as a pathway to health equity.  To me, patient-centeredness means providing the best care to all patients at all times, based on their individual, contextualized needs and preferences.  It means customizing and tailoring health care and services for diverse individuals while expecting and achieving the same (highest) quality outcomes for everyone.  If we can really transform our current health care systems into more patient-centered ones where patients really are more engaged as partners in their own health care and their own health, we are likely to see quality improvement, reduction of health care disparities, more engaged clinicians and health care providers, and patients and health care consumers with greatly improved experiences of health care.

Here are some key resources on patient-centeredness:

Institute of Medicine Workshop on Equality and Patient-Centeredness

Joint Commission Report: Roadmap for Effective Communication, Cultural Competency and Patient- and Family-Centered Care

Institute for Family-Centered Care: Partnering with Patients and Families to Create a Patient- and Family Centered Health Care System

Economic and Social Research Institute: Patient-Centered Care for Underserved Populations

Some key articles on the concept of patient-centeredness are:

Epstein RM, Fiscella K , Lesser CS Stange KC.  “Why the nation needs a policy push on patient-centered health care.”  Health Affairs (2010); 29(8):1489-1495

Bechtel C and Ness DL. “If you build it, will they come? Designing truly patient-centered health care.” Health Affairs (2010); 29(5):914-920

Berwick DM. “What ‘patient-centered’ should mean: Confessions of an extremist.” Health Affairs (2009); 28(4):w555-w565

Davis KA, et al.  “A 2020 vision of patient-centered primary care,” J Gen Int Med (2005); 20 (10): 953-957

Posted in Cultural Competency, Cultural Competency: Assessments, Cultural Competency: Curricula, Cultural Competency: Evaluation, Cultural Competency: Frameworks, Cultural Competency: Training, Demographic Data, Demographic Data: Gender Identity/Expression, Demographic Data: Language Need, Demographic Data: Race and Ethnicity, Demographic Data: Sexual Orientation, Health Care Disparities, Health Care Disparities: Effective Interventions, Health Care Disparities: Stakeholders Engaged, Health Care Disparities: The Evidence of Disparities, Health Care Reform, Health Care Reform: Accountable Care Organizations, Health Care Reform: Advancing Equity, Health Care Reform: Comparative Effectiveness Research, Health Care Reform: General Analysis, Health Care Reform: Medical Homes, Health Care Reform: Payment Reform, Health Care Reform: Quality Improvement, Health Care Reform: Workforce Development, Health Information Technology, Health Information Technology: Meaningful Use, Health Information Technology: Mobile Health, Health Information Technology: Personal Health Records, Health Literacy, Health Workforce Diversity, Health Workforce Diversity: Building the Demand Side, Health Workforce Diversity: Pipelines and pathways, Health Workforce Diversity: Who is Underrepresented, Language Access, Language Access: Best Practices, Language Access: Certification, Language Access: Government Funding, Language Access: Making the Case, Language Access: Standards, Lesbian, Gay, Bisexual and Transgender Health, Patient-Centeredness, The iBau Blog | Leave a comment

U.S. Preventive Services Task Force Draft Recommendation for Hepatitis B Screening

The U.S. Preventive Services Task Force has issued a draft recommendation to upgrade screening for Hepatitis B virus (HBV) infection in non-pregnant adolescents and adults at high risk for infection from a “D” recommendation to a “B” recommendation. Persons considered at high risk for HBV infection include persons from high-prevalence countries, persons who are HIV-positive, injection drug users, household contacts of persons with HBV infection, and men who have sex with men. The significance of the upgrade to a “B” recommendation is that all “A” and “B” recommendations for screening are to be offered by health plans without co-payments under the Patient Protection and Affordable Care Act (ACA). The recommendation is based on a detailed review of clinical evidence.

Link to Original Source

The U.S. Preventive Services Task Force has prepared a fact sheet explaining the draft recommendation:

Link to Original Source

Public comments on the draft recommendation are due on March 10, 2014 and may be submitted online.

Posted in Asian American, Native Hawaiian and Pacific Islander Health, Immigrant and Refugee Health | Leave a comment

Congress Outlines Bipartisan Agreement for Repeal of Medicare Sustainable Growth Rate Payment Formula

The bipartisan leadership of the House Ways and Means Committee, House Energy and Commerce Committee, and Senate Finance Committee have announced an agreement to finally repeal and replace the problematic Medicare Sustained Growth Rate (SGR) payment formula for physicians under Medicare. For the past 11 years, Congress has deferred the application of the SGR formula (first created in 1997), which would now result in a 27% rate decrease for physicians under Medicare. The agreement provides physicians an 0.5% rate increase for each of the next five years, and then conditions future rate increases on meeting requirements of “alternate payment models” or being a patient-centered medical home. The agreement does not specify any “offsets”, or how the new payments will be paid for, since they will raise Medicare spending, at least in the short-term. The agreement also fails to address the issue of what happens to the Medicare program “extenders”, other Medicare programs such that pay for certain therapy and ambulance services, provide additional funding to rural hospitals, and fund programs that provide Medicare beneficiary education about and assistance with their Medicare benefits. These extenders were funded as part of each year’s deferrals of the application of the SGR formula.

Commentators have noted that the release of the agreement was timed for today’s Senate confirmation of Senator Max Baucus, chairperson of the Senate Finance Committee, as U.S. Ambassador to China. Senator Baucus had expressed his desire to secure the agreement to finally repeal and replace the SGR before he left the Senate.

Legislation containing the elements of what is included in the agreement announced today had been passed the Senate Finance Committee (S.1871) and had passed the House Energy and Commerce Committee (H.R.2810). It is not yet clear how today’s agreement will now be incorporated into those bills towards votes by both the full Senate and House of Representatives.

Link to Original Source

Posted in Health Care Reform, Health Care Reform: Payment Reform, Health Care Reform: Quality Improvement | Leave a comment

Centers for Medicare & Medicaid Services: First Year Savings from Medicare and Pioneer Accountable Care Organizations

The Centers for Medicare & Medicaid Services (CMS) has announced “interim” first year savings data from both the Medicare Shared Savings Program Accountable Care Organizations (ACOs) and the Pioneer ACOs. In its press release, CMS reports that among the 114 Medicare Shared Savings Program ACOs, 54 reduced Medicare expenses by $128 million. 29 of those 54 Medicare ACOs were eligible for shared savings totaling more than $126 million. Updating data reported earlier, CMS also reports that 9 of the 23 remaining Pioneer ACOs (9 Pioneer ACOs left the program after its first year) together reduced Medicare expenses by $147 million. While these initial year one results do show significant reductions in Medicare expenses, the fact that less than half of each type of ACOs achieved the total savings is not encouraging. The level of total savings also is far less than projected, highlighting the challenge of generating significant savings so quickly in a 12-month timeframe. CMS states that “final” first year savings totals will be reported later in 2014.

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Congressional Budget Office: Budget and Economic Forecast for 2014-2024

These are the sections of the 182-page report (Appendices B and C) issued by the Congressional Budget Office (CBO) with its budget and economic forecast for the next ten years, federal fiscal years 2014-2024. The finding by the CBO in Appendix C that the ongoing implementation of the Patient Protection and Affordable Care Act (ACA) would have a negative impact on the labor market has created a political firestorm. This the actual wording of the finding:

“CBO estimates that the ACA will reduce the total number of hours worked, on net, by about 1.5 percent to 2.0 percent during the period from 2017 to 2024, almost entirely because workers will choose to supply less labor — given the new taxes and other incentives they will face and the financial benefits some will receive. Because the largest declines in labor supply will probably occur among lower-wage workers, the reduction in aggregate compensation (wages, salaries, and fringe benefits) and the impact on the overall economy will be proportionally smaller than the reduction in hours worked. Specifically, CBO estimates that the ACA will cause a reduction of roughly 1 percent in aggregate labor compensation over the 2017–2024 period, compared with what it would have been otherwise….

The reduction in CBO’s projections of hours worked represents a decline in the number of full-time-equivalent workers of about 2.0 million in 2017, rising to about 2.5 million in 2024. Although CBO projects that total employment (and compensation) will increase over the coming decade, that increase will be smaller than it would have been in the absence of the ACA. The decline in full-time-equivalent employment stemming from the ACA will consist of some people not being employed at all and other people working fewer hours; however, CBO has not tried to quantify those two components of the overall effect. The estimated reduction stems almost entirely from a net decline in the amount of labor that workers choose to supply, rather than from a net drop in businesses’ demand for labor, so it will appear almost entirely as a reduction in labor force participation and in hours worked relative to what would have occurred otherwise rather than as an increase in unemployment (that is, more workers seeking but not finding jobs) or underemployment (such as part-time workers who would prefer to work more hours per week).”

The CBO itself has substantial uncertainty about its finding:

“CBO’s estimate of the ACA’s impact on labor markets is subject to substantial uncertainty, which arises in part because many of the ACA’s provisions have never been implemented on such a broad scale and in part because available estimates of many key responses vary considerably. CBO seeks to provide estimates that lie in the middle of the distribution of potential outcomes, but the actual effects could differ notably from those estimates.”

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Centers for Medicare & Medicaid Services: Strong Enrollment of Eligible Hospitals and Providers in HITECH Act EHR Incentive Programs

The Centers for Medicare & Medicaid Services (CMS) has released updated data (as of November 2013) about the number of eligible hospitals and providers who have registered for Health Information Technology for Economic and Clinical Health (HITECH) Act incentive payments for the meaningful use of electronic health records (EHRs). 93% of eligible hospitals and 82% of eligible physicians and other providers have registered for CMS’ HITECH Act incentive payments. 339 eligible hospitals and nearly 96,000 eligible providers have yet to register. More significantly for the advancement of actual adoption and use of EHRs, 86% of the registered eligible hospitals (over 4,300 hospitals), 71% of Medicaid registered eligible providers (more than 58,000 providers), and 62% of Medicare registered eligible providers (more than 151,000 providers) have received HITECH Act incentive payments.

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Congressional Budget Office: Analysis of Impact of Affordable Care Act

The Congressional Budget Office (CBO) has released its latest analysis of the impact of the Patient Protection and Affordable Care Act (ACA), as part of other reports updating the economic and budget deficit forecasts for 2014. Highlights of the analysis include CBO’s estimate that, in 2014, 13 million previously uninsured Americans would obtain health insurance coverage, at a net ACA implementation cost of $41 billion. In 2015, an additional 20 million previously uninsured Americans would obtain health insurance coverage, at a net implementation cost of $88 billion. The CBO also lowered its total 10-year net cost of ACA implementation by $9 billion.

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RWJF-Health Affairs Policy Brief: Young Adults and the Affordable Care Act

This policy brief from the Robert Wood Johnson Foundation and Health Affairs examines the critical issue of enrolling uninsured young adults in health insurance coverage. According to 2008 Census data, 37 percent of individuals ages 19-25 are uninsured, and 25 percent of individuals ages 26-35 are uninsured. The enrollment of these so-called “young invincibles” also is vital to the success of the Patient Protection and Affordable Care Act (ACA) because they are generally healthier (and are less likely to use health care services) and will therefore balance the risk pool and costs of insuring older and sicker uninsured individuals.

Young people are at a critical stage in their lives, when long-term health risks, such as obesity, sexually transmitted disease, and tobacco use, often present themselves, and when early medical intervention can make a real difference. Uninsured young adults without insurance are two to four times as likely as their peers to forgo treatment for medical problems. Lacking proper health insurance can also lead to long-term financial problems if substantial medical debt is incurred. Now, in addition to having new ways to access affordable insurance, young adults will find that those plans offer better coverage. For example, many preventive care visits, which young adults are likely to need more than treatment for illnesses, are covered entirely.

Under the ACA, individuals can remain on their parent’s family coverage until age 26. Low-income young adults are eligible for Medicaid (in the 25 states and District of Columbia that have chosen to expand Medicaid). Young adults with low and moderate incomes have the highest rates of uninsurance. A Commonwealth Fund tracking survey found that 59 percent of young adults with incomes under 133 percent of poverty either were uninsured or had been uninsured at some point in 2013. In the 25 states without the Medicaid expansion, young adults with incomes under the poverty level ($11,490 for an individual in 2013) will not be eligible for either Medicaid or federal premium tax subsidies through health insurance marketplaces and are at the greatest risk of remaining uninsured.

Finally, the individual mandate to purchase insurance through health insurance marketplaces is intended to drive uninsured young adults (and other uninsured individuals) to purchase health insurance when their employers or families do not provide them coverage. Those with incomes of 133-400 percent of the federal poverty level, including many young adults entering the workforce for the first time, will be eligible for premium tax credits to lower the cost for coverage through the exchanges. The Young Invincibles, a nonprofit, foundation-supported advocacy group, estimates some 9 million individuals ages 18-34 could be eligible for premium tax credits.

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Centers for Medicare & Medicaid Services: 123 New Medicare Shared Savings Program Accountable Care Organizations Announced for 2014

In a late and quiet announcement, the Centers for Medicare & Medicaid Services (CMS) has announced 123 new Medicare Shared Savings Program Accountable Care Organizations (ACOs), to begin operations next week, on January 1, 2014. According to CMS, these new ACOs operating in 40 states and the District of Columbia will bring an additional 1.5 million Medicare beneficiaries into Medicare ACOs, resulting in over 5.3 million Medicare beneficiaries in over 360 ACOs.

These ACOs are authorized under section 3022 of the Patient Protection and Affordable Care Act.

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December 23, 2013: The Uninsured in America

As Monday’s December 23, 2013 deadline approaches for enrollment in health insurance coverage that would begin in January 1, 2014 under the Patient Protection and Affordable Care Act (ACA), here are two resources to remind us of the need for health insurance insurance coverage.

The New York Times has published an online interactive map of the percentage and number of uninsured Americans, based on the latest data from the Census Bureau’s American Community Survey:

Los Angeles

And the Kaiser Family Foundation has published state-by-state estimates of the nearly 17.2 million Americans are eligible for federal subsidies in 2014 to assist with the payment of their health insurance premiums and co-payments through the ACA:

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These estimates include over 2 million individuals in Texas, 1.9 million individuals in California, and over 1.5 million individuals in Florida.

Given that the total number of individuals who have enrolled in the all federal and state health insurance marketplaces just reached one million in early December, there remains much more work to be done to enroll the remaining millions of eligible, uninsured Americans into affordable health insurance coverage.

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Centers for Medicare & Medicaid Services: Request for Information on Accountable Care Organization Models

The Centers for Medicare & Medicaid Services (CMS) has issued a request for information for comments and ideas about accountable care organization (ACO) models, including whether CMS should fund another round of Pioneer ACOs, and what new or alternate ACO models CMS should consider funding. Given the mixed results of the first year of the Pioneer ACO program, it is interesting that CMS is now using a request for information/public input process to receive these ideas. The request for information includes 7 specific questions from CMS about the Pioneer ACO model and 25 specific questions about the “evolution” and design of ACO models that “encourage greater care integration and financial accountability”. CMS has authority under section 3021 of the Patient Protection and Affordable Care Act (ACA) to fund these types of innovations through its Center for Medicare & Medicaid Innovation. Responses to the request for information are due March 1, 2014 and can be submitted online.

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