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

Breaking News: Karen DeSalvo Named Acting Assistant Secretary for Health

Director of the Office of National Coordinator for Health Information Technology Karen DeSalvo, MD, was named today as Acting Assistant Secretary of Health.  Dr. DeSalvo served as Commissioner of Health in New Orleans, and helped to lead the public health response to Hurricane Katrina.

Source: The Hill

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Centers for Medicare and Medicaid Services Announces ACO Investment Model

The Centers for Medicare and Medicaid Services has announced the availability of an additional $140 million in federal funding for Medicare Shared Savings Program Accountable Care Organizations (ACOs) to assist with start-up costs and to provide advance payments of potential shared savings rather than waiting for an end-of-year calculation of payments. The ACO Investment Model was developed in response to stakeholder concerns and available research suggesting that some providers lack adequate access to the capital needed to invest in infrastructure necessary to successfully implement population care management. Participation in this ACO Innovation Model will be limited to two groups of ACOs:

New Shared Savings Program ACOs joining in 2016: The ACO Investment Model seeks to encourage uptake of coordinated, accountable care in rural geographies and areas where there has been little ACO activity, by offering pre-payment of shared savings in both upfront and ongoing per beneficiary per month payments. These ACOs can be eligible for three types of payments:
+ An upfront, fixed payment: Each ACO receives a fixed payment.
+ An upfront, variable payment: Each ACO receives a payment based on the number of its preliminarily prospectively-assigned beneficiaries.
+ A monthly payment of varying amount depending on the size of the ACO: Each ACO receives a monthly payment based on the number of its preliminarily prospectively-assigned beneficiaries.

ACOs that joined Shared Savings Program starting in 2012, 2013 and 2014: The ACO Investment Model also will help ACOs succeed in the shared savings program and encourage progression to higher levels of financial risk, ultimately improving care for beneficiaries and generating Medicare savings.
These ACOs can be eligible to receive two types of payments:

+ An upfront, variable payment: Each ACO receives a payment based on the number of its preliminarily prospectively-assigned beneficiaries.
+ A monthly payment of varying amount depending on the size of the ACO: Each ACO receives a monthly payment based on the number of its preliminarily prospectively-assigned beneficiaries.

Applications for the ACO Investment Model can be submitted between October 15 and December 1 by ACOs that started in the Medicare Shared Savings Program in 2012 or 2013. The application period for ACOs that started in 2014 or will start in 2016 will open in the summer of 2015.

Posted in Health Care Reform, Health Care Reform: Accountable Care Organizations | Leave a comment

Center for Medicare and Medicaid Services: 7.2 Million Additional Americans Enrolled in Medicaid and CHIP Under ACA

In a report released by the Centers for Medicare and Medicaid Services, Medicaid enrollment numbers grew to over 66 million in June 2014 with more than 7.2 million additional people enrolled in Medicaid and the Children’s Health Insurance Program compared to an average monthly enrollment prior to the start of open enrollment in October 2013. And because enrollment in these programs can happen year-round, that number is still growing.

While enrollment in states that expanded Medicaid under the Affordable Care Act has risen by 18.5 percent since before open enrollment in the health insurance marketplaces began in October 2013, states that have not expanded reported only a 4 percent increase in enrollment during this same period. If the remaining 24 states accept federal funding to expand their Medicaid programs, 5.7 million more low-income Americans could have access to affordable, quality care. Expanding Medicaid is covered by 100 percent federal funds in the first three years, and federal funding never falls below 90 percent after that.

Link to Original Source

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Conflicting Court Opinions on Availability of Federal Tax Subsidies in Federally-Facilitated Health Insurance Marketplace

This past month saw directly conflicting U.S. Court of Appeals decisions issued on the issue of whether federal tax credits are available to subsidize premiums for low-income individuals obtaining health insurance coverage through the federally-facilited health insurance marketplace under the Patient Protection and Affordable Care Act (ACA).

In an opinion issued in the case King v. Burwell, on July 22, 2014, the 4th Circuit Court of Appeals issued a decision upholding availability of the federal tax credits in the federally-facilitated health insurance marketplace. 34 states are using a federally-facilitated marketplace. The states of Alabama, Georgia, Kansas, Oklahoma, Nebraska, South Carolina and West Virginia filed an amicus brief in support of the Virginia taxpayers challenging the interpretation of the Internal Revenue Service (IRS) that such subsidies were available, therefore subjecting them to the individual responsibility requirement to purchase health insurance through the federally-facilitated marketplace. The availability of the federal tax subsidies makes the insurance “affordable” for these taxpayers, and they cannot claim an exemption from the individual mandate because of affordability. The Commonwealth of Virginia supported the IRS interpretation.

While the court found the language of the relevant sections of the ACA ambiguous, it deferred to the interpretation of the IRS that federal tax credits are available through the federally-facilitated marketplaces. In a concurring opinion, one judge in the three-judge panel found the relevant sections of the ACA unambiguous in support of the IRS’s interpretation.

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On the exactly same day, on July 22, the District of Columbia Circuit Court of Appeals issued a directly contradictory decision in the case Halbig v. Burwell, involving a similar challenge by a resident of West Virginia:

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In a 2-1 decision, the District of Columbia Circuit Court interpreted the relevant sections of the ACA literally, to rule that the federal tax subsidies are only available through health insurance exchanges “established” by the states, and not through the federally-facilitated exchange. The same states filed a similar amicus brief challenging the availability of the federal tax subsidies. The dissenting opinion follows a similar rationale used by the 4th Circuit panel in King v. Burwell.

The federal government will seek a rehearing of Halbig decision by the full Circuit Court (an “en banc” review), but the issue may be headed to the United States Supreme Court for ultimate resolution.

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Covered California Announces Health Plan Premiums for 2015

Covered California, California’s state-based health insurance marketplace established under the Patient Protection and Affordable Care Act, has announced tentative premiums and federal tax credit subsidies for individual health insurance coverage from the ten health plans that will be offering health insurance to Californians through the marketplace in 2015. (One local health plan currently participating in the marketplace, the Contra Costa Health Plan, has decided not to offer insurance through Covered California in 2015). While some rates increased and others decreased, compared to this current year’s rates, the average rates statewide increased 4.2%. The changes in rates were different in the 19 geographic regions defined by Covered California, with a highest average increase of 6.6% in Region 4 (San Francisco), compared to an average decrease of 1.9% in Region 10 (San Joaquin, Stanislaus, Merced, Mariposa, and Tulare counties).

The rates are subject to final review and approval by Covered California, California’s Department of Managed Health Care, and California’s Department of Insurance. The open enrollment period for health insurance coverage that would be effective beginning January 1, 2015 will begin on November 15, 2014. Meanwhile, consumers can use the Covered California website to “shop and compare” with the new rates.

Family rates, rates for newly available dental coverage, and rates for small businesses will be announced later.

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U.S. Department of Health and Human Services: Final Rule on Patient Access to Lab Results

This final regulation published by the U.S. Department of Health and Human Services in February 2014 clarifies that patients have the right to directly receive their own laboratory results, overcoming rationales that used the 1996 Health Insurance Portability and Accountability Act (HIPAA) and the Clinical Laboratory Improvement Amendments of 1988 (CLIA) to justify the withholding of such results from patients. Patients and patient’s personal representatives have the right to directly receive the laboratory results, as well as direct that the laboratory results be transmitted to persons or entities designated by the patient (or patient’s personal representative). This clarification will facilitate direct patient access to personal health information as well as facilitate increased health information exchange among health care providers. The regulation was jointly developed and published by the Office of Civil Rights, Centers for Medicare and Medicaid Services, and Centers for Disease Control and Prevention, and became effective on April 7, 2014.

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Robert Wood Johnson Foundation: Quality Field Notes – Resource Guide on Equity

This resource guide on health care equity from the Robert Wood Johnson Foundation includes references for tools to support race, ethnicity, and language data collection, tools to reduce disparities, and national and state reports on health care disparities.

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Robert Wood Johnson Foundation: Quality Field Notes – Issue Brief on Equity

This issue brief on equity from the Robert Wood Johnson Foundation describes efforts by its Aligning Forces for Quality program sites to reduce disparities in the quality of care for racial and ethnic minorities. Many of the activities described focus on the collection of race, ethnicity, and language data in order to identify disparities. The issue brief then describes activities to engage diverse patients and communities in developing and implementing collaborative strategies to reduce those identified disparities.

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There also are a video, fact sheet, and case studies to accompany the issue brief:

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Health Research & Education Trust: The Second Curve of Population Health

This issue brief from the Health Research & Education Trust of the American Hospital Association and the Association for Community Health Improvement highlights the role that hospitals and health systems can have in advancing the third component of the triple aim, improvement in population health. While hospitals have historically viewed their patients as individuals coming to them for discrete procedures and unconnected episodes of care, health care delivery system reform will require hospitals to see their patients as part of a population, a community that they are partly responsible for health improvement outcomes.

This guide builds upon prior American Hospital Association reports that outline a road map for hospitals and care systems to use as they transition to the second curve of population health. Though the extent to which hospitals and care systems engage in population health may vary, a significant shift toward population health initiatives is anticipated in the next three to five years. The tactics described in this guide provide a framework for initiatives that hospitals and care systems could pursue to develop an institutional infrastructure that supports population health.

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American Hospital Association: Your Hospital’s Path to the Second Curve – Integration and Transformation

This issue brief from the American Hospital Association (AHA) describes the need for hospitals to transform from volume-based payments to value-based revenue and business models. Environmental pressures are driving hospitals and care systems toward greater clinical integration, more financial risk and increased accountability. To provide high-quality, efficient and integrated care, hospitals and care systems must explore and pursue transformational paths that align with the organization’s mission and vision and cater to patients and communities. Hospital leaders need to develop strategies that move their organizations from the first curve, or volume-based environment, to the second curve, in which they will be building value-based systems and business models.

This report outlines must-do strategies, organizational capabilities to master and 10 strategic questions that every organization should answer to begin a transformational journey. The report’s “guiding questions” will help hospitals and care systems reflect and gain new perspectives on the benefits and value of integration. A comprehensive assessment, also found in the report, may lead health care organizations toward a customized path or series of paths to successfully transform for the future. Five paths for hospitals and care systems to consider are:

+ Redefine to a different care delivery system (i.e., either more ambulatory or oriented toward long-term care)
+ Partner with a care delivery system or health plan for greater horizontal or vertical reach, efficiency and resources for at-risk contacting (i.e., through a strategic alliance, merger or acquisition)
+ Integrate by developing a health insurance function and/or services across the continuum of care (e.g. behavioral health, home health, post-acute care, long-term care, ambulatory care)
+ Experiment with new payment and care delivery models (e.g., bundled payment, accountable care organization, medical home)
+ Specialize to become a high-performing and essential provider (e.g., children’s hospital, rehabilitation center)

There is no single “right” transformational journey and not all hospitals need to become an integrated entity. However, the time is now for hospitals and care system to accelerate organizational transformation, which requires making strategic, yet swift, progress toward achieving the Triple Aim of health care—improving care quality and patient experience, improving population health and reducing per capita costs.

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