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…


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

Center for Medicare and Medicaid Innovation: 11 States Awarded State Innovation Model Implementation Grants; 17 States, DC and 3 Territories Receive Planning Grants

The Center for Medicare and Medicaid Innovation has announced Round Two awards for the State Innovation Model, authorized by section 3201 of the Affordable Care Act, with 4-year implementation (test) awards to 11 states: Colorado, Connecticut, Delaware, Idaho, Iowa, Michigan, New York, Rhode Island, Ohio, Tennessee, and Washington.  These grants range from $99.9 million to New York to $20 million to Rhode Island.  Six states – Oregon, Vermont, Massachusetts, Arkansas, Minnesota, and Maine – are continuing their implementation of State Innovation Model Round One awards.  The State Innovation Model supports improved multi-payer payment and health care delivery models that will result in quality improvement at reduced health care costs.

17 other states, the District of Columbia, and the territories of Puerto Rico, American Samoa and the Commonwealth of the Northern Mariana Islands received one year planning (design) grants.  The 17 states are Arizona, California, Hawaii, Kentucky, Illinois, Maryland, Montana, Nevada, New Hampshire, New Jersey, New Mexico, Oklahoma, Pennsylvania, Utah, Virginia, West Virginia, and Wisconsin.  These awards range from $3 million to California and Pennsylvania to $750,000 to American Samoa and the Commonwealth of the Northern Mariana Islands.

Both the Round Two implementation and planning grants begin on January 1, 2015.

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

Health Research & Educational Trust: A Framework for Stratifying Race, Ethnicity and Language Data

This guide from the Health Research & Educational Trust outlines a framework for hospitals and health systems to stratify patient race, ethnicity, and language data to identify and eliminate health care disparities. The framework includes the following five steps:

  • Assemble a working group that is focused on health care disparities data
  • Validate the race, ethnicity, and language data
  • Identify the highest priority metrics for stratification
  • Determine if stratification is possible on the selected metrics
  • Stratify the data

Link to Original Source

Posted in Demographic Data, Demographic Data: Language Need, Demographic Data: Race and Ethnicity, Health Care Disparities | Leave a comment

Centers for Medicare and Medicaid Services: Proposed Changes to Medicare Shared Savings Program

The Centers for Medicare and Medicaid Services (CMS) has published a proposed regulation that would make significant changes to the Medicare Shared Savings Program Accountable Care Organizations (ACO).  This is the only ACO program specifically authorized by Congress in the Affordable Care Act (section 3022), although CMS has supported additional ACO models such as the Pioneer ACOs through the Center for Medicare and Medicaid Innovation, and Medicaid ACOs through state plan amendments, section 1115 waivers, and State Innovation Model grants.  There are over 330 Medicare Shared Savings Program ACOs operating in 47 states, the District of Columbia, and Puerto Rico, covering about 4.9 Medicare beneficiaries.   An announcement about a next round of Medicare Shared Savings Program ACOs (to begin January 1, 2015) is also expected.

Among the proposed changes are:

  • Allowing Medicare Shared Savings Program ACOs to continue with the “Track 1″ shared savings, but no risk of losses, for another three years (for a total of five years) rather than being required to use “Track 2″ shared savings AND shared risk for losses
  • Including nurse practitioners, physician assistants, and clinical nurse specialists as primary care providers for beneficiary assignment, and removing certain specialists as providers for beneficiary assignment
  • Changing the “opt-out” process for ACO beneficiaries who do not want their data shared with the ACO to only require posted signs at points of care (rather than individual written notices/letters), and requiring beneficiaries to call 1-800-Medicare to opt out
  • Using regional rather than national Medicare expenditure data to set benchmarks for shared savings (and shared losses) and re-setting the benchmarks based on the regional market and ACO performance
  • Offering the option of a “Track 3″ with potential for higher shared savings, using prospective beneficiary assignment (rather than the current retrospective reconciliation)
  • Modifying the “Track 2″ shared savings, shared losses formula to make it more variable

The proposed changes also include changes to the governance and leadership requirements for Medicare Shared Savings Program ACOs (e.g., no longer requiring the ACO medical director to be an ACO provider).  Finally, in recognition of the mixed success of the Pioneer ACOs, the proposed changes include a streamlined process for transitioning  Pioneer ACOs into the Medicare Shared Savings Program.

Comments are due February 6, 2015.

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

Peterson Center on Healthcare Launched to Transform U.S. Healthcare

Today the Peter G. Peterson Foundation announced the launch of the Peterson Center on Healthcare, a new organization dedicated to transforming U.S. healthcare into a high-performance system that delivers high-quality care at a lower cost. With an initial commitment of $200 million from the Peterson Foundation, the Center will work to find and validate innovative healthcare solutions, and accelerate their adoption on a national scale, collaborating with stakeholders across the healthcare system and engaging in grant-making, partnerships and research.  The Center has an impressive “who’s who”, bipartisan Advisory Board.

The Peterson Center on Healthcare will use three strategies:

  • Finding and validating innovative solutions for healthcare providers, employers and insurers, and state-level systems
  • Accelerating adoption and scaling of those innovative solutions
  • Fostering the conditions for change and improvement through data transparency and innovation, driving innovation to improve quality while lowering costs, moving to value-based payments, engaging consumers, and advancing state and federal policies.

The Peterson Center on Healthcare announced three first projects:

A partnerships with Kaiser Family Foundation to track healthcare system quality and cost, called the Peterson-Kaiser Health System Tracker

A project by the National Quality Forum to convene public and private healthcare leaders to enhance the availability of data and analytics to support systems improvement in healthcare

Analysis from the Stanford University’s Clinical Excellence Research Center on identifying and learning from providers of “most valuable care” who have achieved high quality healthcare at lower than average cost.

Link to Original Source


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

On Executives Orders…and Immigration History and Policies

The Executive Order signed today by President Barack Obama will dramatically change the lives of five million undocumented immigrants who have lived here in the United States for many years, worked hard, paid taxes, raised their families, and contributed to their communities and to our nation. President Obama will continue to be attacked by his political critics for acting “unilaterally” while Congress remains deadlocked and unable to enact any meaningful legislation on immigration policy reform (or almost any other subject). It is telling that the primary response of the critics is to threaten to “shut the federal government down” (again) by refusing to pass appropriations legislation for the current fiscal year (one of core functions of Congress in our system of a three-branched government). The critics don’t seem interested in advancing any policy alternatives, or in engaging in real debate, about the immigration policies at issue.

In fact, President Obama’s Executive Order on immigration policy is consistent with some of the best examples of presidential leadership, especially when Congress is unwilling to act to lead the country forward. In our nation’s history, there have been other milestone Executive Orders issued, both before I was born and during my lifetime, that are of particular importance to me and the work that I have been privileged to be a part of:

  • President Franklin Roosevelt issued Executive Order 8802 to end racial discrimination by federal defense contractors
  • President Harry Truman issued Executive Order 9981 to end racial discrimination in the armed forces
  • President Lyndon Johnson issued Executive Order 11246 to end racial discrimination by federal contractors (before the 1964 Civil Rights Act was enacted by Congress)
  • President Bill Clinton issued Executive Order 13166 ensuring equal access for limited English proficient Americans to federally funded programs and services.
  • Earlier this year, President Obama issued Executive Orders 13658 and 13672 to raise the minimum wage paid, and to end discrimination based on sexual orientation and gender identity, by federal contractors.

Of course, the other Executive Order that stands out for Asian Americans is Executive Order 9066 from President Roosevelt that authorized the relocation and internment of 120,000 primarily U.S. citizen Japanese Americans during World War II. Today, we look at that action, subsequently found to be based on contrived evidence of the alleged threat to our national security, as one of the most shameful moments in our history.

But I will always remember the tremendous pride that I felt over fifteen years ago when I was ushered into the Oval Office, along with a few dozen elected officials and leaders from the Asian American, Native Hawaiian, and Pacific Islander communities, to witness President Clinton sign Executive Order 13125 – based on an idea that I had, and an initial draft of an Executive Order that I had written a year and a half earlier – establishing the White House Initiative on Asian Americans and Pacific Islanders.   I was honored to be invited to the White House again in 2009 to witness President Obama sign Executive Order 13515 re-establishing that White House Initiative.

Today’s Executive Order also brings back memories about work that I did nearly thirty years ago leading up to, and after the enactment of, the 1986 Immigration Reform and Control Act, which authorized the legalization of 1.6 million undocumented immigrants. As past of that work, first as a law student and then as a lawyer, I often made presentations about what I call the mythology and rhetoric of a narrative of the United States as a “nation of immigrants”, which conveniently overlooks the Chinese Exclusion Act of the 1882, the exclusion of other Asian immigrants (and their detention on Angel Island through the 1940), the refusal to admit Jewish refugees on the ship St. Louis during World War II, the exploitation of Mexican workers through the bracero program of the 1940s-1960s, and the denial of tens of thousands of refugee applications from Salvadorans and Guatemalans fleeing U.S.-supported violence in their countries in the 1980s. Our immigration laws and policies have always been restrictive, based on outright racial bias, business interests, and foreign policies rather than openness, fairness, humanitarianism, or equal opportunity.

The 1986 law was one of those policy changes that corrected some of that long history of exclusion and unfairness, creating a pathway to legalization for millions of immigrants. Legal services organizations, immigration attorney associations, faith-based institutions, and other community-based organizations all worked extremely hard over the next several years to conduct outreach and education about the new law, and to assist millions with their applications for legalization. Private foundations, state and local governments, and community institutions such as the United Way all partnered together to provide funding, support coordination among those community efforts, and to optimize the beneficial impacts of the new law.

In 1986, as a new attorney just a year and half out of law school, I worked with many others locally and nationally to establish new organizational relationships and coalitions to help implement the law. I organized comments on implementing regulations, trained volunteer attorneys to assist clients with their applications for legalization, and made dozens of presentations about the new law.

Beginning tomorrow, we will need similar local and national efforts to fund and support the implementation of President Obama’s executive order. The good news is that many community organizations – and now national and local advocacy groups founded and led by undocumented immigrants themselves – have been organizing and preparing for this policy change for over the past decade. And in an age of the internet, smartphones, and social media, it is a lot easier and faster to spread the word.

While the political and media debate about the wisdom – and legality – of President Obama’s action today will continue, his Executive Order will be another milestone in the legacy of his presidency, and in the history of presidential Executive Orders that moved our country forward.

Posted in The iBau Blog, White House Initiative on Asian Americans and Pacific Islanders | Leave a comment

Melissa Stafford Jones Named New HHS Region IX Regional Director

U.S. Health and Human Services Secretary Sylvia M. Burwell today announced the appointment of Melissa Stafford Jones as the Region IX Regional Director.  As a Regional Director, Stafford Jones will serve as a key representative of the Department of Health and Human Services in working with federal, state, territorial, local, and tribal officials on health and social service issues, including implementation of the Affordable Care Act. The Region IX office is based in San Francisco, and works with officials in Arizona, California, Hawaii, Nevada, Guam, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Republic of Marshall Islands and the Republic of Palau.

For more than a decade, Melissa Stafford Jones has been a senior leader at the California Association of Public Hospitals and Health Systems, serving most recently as the Chief Executive Officer.  In this role, she has been a vocal advocate for ensuring access to care for low-income and uninsured patients throughout the state of California.

In her 20-year career in health care, she has worked with a wide range of policymakers and stakeholders at the local, state and national levels on an extensive platform of health policy matters. She helped implement national health reform and Medicaid coverage expansion in California.  She also served as a leader in developing strategies to maintain a strong health care safety net, while at the same time, utilizing new strategies like the blending of physical and behavioral health services, and promoting cultural competence and language access for patients.

Stafford Jones is a graduate of University of California at Berkeley, School of Public Health and Saint Mary’s College of California and lives in Walnut Creek, California.

Posted in The iBau Blog | Leave a comment

Families USA: Network Adequacy and Health Equity

This policy brief from Families USA describes the issue of network adequacy and its importance for achieving health equity for communities of color, individuals who speak languages other than English, and other populations experiencing health disparities.  As more previously uninsured individuals and families gain access to commercial health insurance under the Affordable Care Act, it is vital that the health care providers in the networks offered by these health insurance plans are adequate to meet the needs of all the insured population.  The policy brief describes some best practices in defining network adequacy, including definitions of essential community providers, in state-based health insurance marketplaces being implemented under the Affordable Care Act.

Link to Original Source

Posted in Health Care Reform, Health Care Reform: Advancing Equity | Leave a comment

Health Access: California’s Uneven Safety Net – A Survey of County Health Care

This 2013 report from Health Access describes county-funded “indigent” health care programs for low-income residents in California. While there are comprehensive county-based programs in counties such as San Francisco, Alameda, San Mateo, Santa Clara, and Los Angeles, there are minimal programs in many of the other 58 California counties.  The report also describes county-specific eligibility requirements, including whether programs are available for undocumented and other immigrants.

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Posted in Health Care Reform, Immigrant and Refugee Health | Leave a comment

American Community Survey: Language Use in the U.S., 2011

This data brief from the U.S. Census Bureau reports data from the 2011 American Community Survey about language use in the United States.  It provides useful background information for health care systems and providers to learn about the potential language assistance needs in their local service areas.  Nationally, 41.8% of the over 60.5 million Americans aged 5 years and older, or over 25.3 million individuals, spoke English less than “very well” and are likely to need language assistance services when accessing and utilizing health care. The data brief also provides these data by state and major metropolitan areas.

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Since this data brief was published, updated data from the 2012 and 2013 American Community Survey are now available.

Posted in Demographic Data: Language Need, Language Access, Language Access: Making the Case | Leave a comment

Advocacy to Make Increased Medicaid Primary Care Payments Permanent

National primary care physician organizations, including the American College of Physicians, American Academy of Family Physicians, and American Academy of Pediatrics, have taken policy positions supporting making permanent the increased Medicaid primary care payments for calendar years 2013 and 2014 under section 1202 of the Health Care and Education Reconciliation Act.

The American College of Physicians published a detailed policy analysis of the Medicaid program in the context of the implementation of the Affordable Care Act that includes its position supporting the permanent Medicaid primary care payment increase:

Link to Original Source

In June 2014, these three national primary care organizations urged Congress to enact at least a two-year extension of the increased payments.

Link to Original Source

In July 2014, Senators Sherrod Brown (D-OH), Patty Murray (D-WA), Jay Rockefeller (D-WV) and Mary Landrieu (D-LA) introduced S.2694, to extend the increased Medicaid primary care rates for an additional two calendar years, and to add obstetricians and gynecologists, nurse practitioners, physician assistants, and certified nurse midwives as eligible for the comparable Medicare primary care rates.

Link to Original Source

Given the newly-elected Republican majorities in both the U.S. Senate and the House of Representatives that have prioritized the repeal of the ACA as one their legislative priorities, these advocacy efforts have steep political opposition to overcome.

Meanwhile, according to the Kaiser Family Foundation, at least 15 states have decided to continue these increased Medicaid payments to primary care providers at least through 2015, with another 12 states still deciding.

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