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SUMMARIES OF
Commonwealth REPORTS
May 2004 - Nov 2004
ENORMOUS DIFFICULTIES FOR DISABLED MEDICARE BENEFICIARIES
While most of the 40 million Americans covered under Medicare are age 65 and older, nearly 6 million qualify because of severe and permanent disabilities. Unlike older Americans, who typically enroll and become eligible for coverage within months of turning age 65, disabled beneficiaries must wait two years before their coverage takes effect. Many who are in the waiting period face enormous problems. They put off needed care, reported feeling depressed and anxious about the future, and believing they were not in control of their own lives. Medicare plays a vital role in providing decent, appropriate, and affordable health care coverage to more than 40 million beneficiaries. The vast majority of Americans with Medicare are age 65 and older, who typically enroll and become eligible for coverage within three or four months of turning age 65. However, the same is not true for the nearly six million people under age 65 who qualify for Medicare because of a severe and permanent disability. There are growing indications that many individuals in the waiting period face enormous difficulties obtaining needed health care, and that as many as one-third may be uninsured.
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DEEP DIVIDE IN US LABOR FORCE WITH HEALTH CARE ACCESS
Employer-based health insurance provides the majority of US workers with access to health care and protection against devastating financial losses. Millions of workers, however, do not receive health benefits from their employers, and few sources of affordable coverage exist outside the employer-based system. A deep divide in the US labor force and an urgent need for expanding access to comprehensive and affordable coverage to working Americans and their families were found. According to the authors, higher-wage workers are more likely than their lower-paid counterparts to have health insurance and health-related benefits, such as paid sick leave, and to use preventive care services. Low-wage workers, meanwhile, are much more likely to forgo needed health care because of cost and to report problems paying medical bills. Eighty-eight percent of employees earning more than $15 per hour have employer-sponsored coverage, compared with only 41% of those earning less than $10 per hour. Higher-wage workers also are more likely to have health-related benefits, like paid sick leave, and to use preventive care services, like blood pressure tests, mammograms, and dental exams.
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PERCEPTIONS OF DISRESPECT FORM BARRIER TO MINORITY HEALTH CARE
Perceptions of disrespect and of being treated unfairly within patient provider relationships affect whether patients heed doctors' advice or return for treatment. These consequences are the unwelcome results of perceived racial discrimination and can be avoided if doctors strive to be respectful and culturally sensitive to the needs of their patients, regardless of ethnic or racial background. In "R-E-S-P-E-C-T: Patient Reports of Disrespect in the Health Care Setting and Its Impact on Care" Blanchard and Lurie found that minorities are significantly more likely than whites to report being treated with disrespect or being looked down upon in patient-provider relationships. Drawing on prior research that documented racial and ethnic disparities in health care across numerous diseases and care settings, the authors hypothesized that minority and non-native English speaking patients report negative health care experiences more often than do whites. They further hypothesized that patients who report such negative experiences are less likely to seek care initially or return for follow-up care.
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SIGNIFICANT DISPARITIES IN CARE FOR AMERICAN INDIANS AND NATIVE ALASKANS
American Indians and Alaska Natives (AIANs) continue to suffer significant disparities in their health status, despite the efforts of the Indian health system to improve the quality of care in AIAN communities. This system is severely underfunded, resulting in concerns over the quality of health care delivered to this population. This paper is a review of the current status of the quality of health care for AIANs. A substantial urban AIAN population is both understudied and which may be underserved by the traditional AIAN health care infrastructure. The author also reports on changes to this infrastructure, with management shifting from the Indian Health Service (IHS) to tribes and the use of more managed care. The author reviews initiatives on the treatment and control of specific medical conditions. The author offers 10 conclusions or recommendations with respect to disparities between medical care for AIANs and the general population.
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DISPARITIES IN CARE FOR NYC POOR AFTER 200 YEARS OF EFFORTS
New York City's Health Department has, throughout its history, paid special attention to improving the health of the City's most vulnerable residents. From the late 1800s, when the Department developed sanitation programs to improve living conditions in tenement neighborhoods, to the early 1900s, when public health physicians were dispatched door-to-door in poor areas of the City, to the 1990s, when new programs were developed to fight tuberculosis and HIV/AIDS, the Health Department has recognized that social and economic factors are inextricably linked to health. While great gains have occurred in improving overall health and reducing health disparities, the persistence of racial, ethnic, economic, or other social inequalities in health is unacceptable. Eliminating health inequalities must involve investment on four fronts: improving access to and the quality of preventive health care, promoting healthy life choices, creating social and physical environments supportive of healthy living, and reducing the burden of poverty and other social disadvantage. Reaching these goals requires a broad and detailed understanding of which groups are most vulnerable, the patterns of illnesses and risk factors among these groups, and how disparities change over time. We hope this report is useful to all our partners in this effort.
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EASY ROAD TO FULL PRESCRIPTION COVERAGE IN MEDICARE
Prices for a group of key prescription medicines are 34 to 59 percent lower in Canada, France, and the United Kingdom than in the US. If Medicare could match these prices through negotiation, drug formularies, or some other mechanism, the "doughnut hole" in drug coverage could be eliminated.Could senior citizens and the disabled have full prescription drug coverage as well as fewer out-of-pocket costs, without causing any increase in total Medicare spending? According to researchers they could if prescription drug prices in the United States were typical of the prices found in other industrialized countries. Prices for a group of key prescription medicines were shown to be 34 to 59 percent lower in Canada, France, and the United Kingdom than in the US.
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WHY IS CARE FOR MINORITY CHILDREN INFERIOR TO THAT OF MOST US CHILDREN?
The medical care that minority children receive often is inferior to the health care services enjoyed by other children. Current research on racial and ethnic disparities documents widespread failings in both access to care and the quality of care for millions of minority children. But methods to reduce these disparities do exist, particularly when implemented by the federal government. In "Policies to Reduce Racial and Ethnic Disparities in Child Health and Health Care" (Health Affairs, Sept./ Oct. 2004), Beal describes an arsenal of weapons available for reducing racial disparities in health care: broadening health care coverage, adopting common quality improvement efforts, improving the training of health care providers, and boosting the ranks of minority clinicians.
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LOW INCOME AMERICANS CUT OUT BY 'CONSUMER DIRECTED' CARE
Consumer-directed health plans are being promoted as a way to curb rising health care spending. Based on the premise that health care services are overutilized, these plans give consumers financial incentives to reduce the use of "nonessential" care. At the same time, they shift the financial burden of health care to patients through higher cost-sharing. Consumer-directed plans' high deductibles and out-of-pocket costs can prevent patients from receiving necessary and effective care, potentially costing the health care system more in the long run. Davis says these new plans raise serious concerns, particularly for low-income individuals and those with serious or chronic illnesses. Instead of focusing on consumer financial incentives, better management of patients with high-cost conditions has more potential to both improve quality and lower costs, she argues. Health care leaders and policymakers, Davis says, must promote and reward high-performing health systems, hospitals, and physicians.
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ETHNIC DISPARITIES IN PEDIATRIC CARE AND IN QUALITY CARDIAC CARE
In recent years, researchers have identified a wide array of racial and ethnic disparities in health and access to quality health care in the United States. A continuing challenge is determining the root causes of these inequities and designing policies and programs that can help correct them. Two new studies undertaken with Commonwealth Fund support shed light on the factors leading to disparities in two health areas: children's health and coronary care. "Child Health Disparities: Framing a Research Agenda" (Ambulatory Pediatrics, July/Aug. 2004), presents a research framework for identifying racial disparities in children's health and health care, determining the root causes of these inequities, and developing effective interventions by researching disparities at the individual, health system, community, and societal levels. Because children have different patterns of disease and wellness than adults, the study of child health disparities needs to take into account these unique characteristics, the authors say. Researchers should concentrate on preventive care, issues of culture and language, and the social determinants of health care, including housing, nutrition, environmental exposures, and stress factors prevalent in low-income communities.
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"Explaining Disparities in Access to High Quality Cardiac Surgeons" (Annals of Thoracic Surgery, July 2004), considers whether previously observed racial differences in access to high-quality cardiac surgeons are due to socioeconomic differences, racial differences in referrals to high-quality hospitals, or racial differences in referrals to "low-volume" surgeons. In examining a group of nearly 28,000 patients in New York State who underwent coronary artery bypass graft surgery in 1996 97, the authors found that African Americans were treated by surgeons with risk-adjusted mortality rates 13.8% higher than surgeons who treated whites. The surgeons who operated on Asian/Pacific Islanders had mortality rates 17% higher. Choice of hospital was the primary factor explaining the disparities, suggesting that physician referral patterns may be important determinants of where minorities receive treatment.
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PROBLEMS WITH RACE-DISCORDANT PAIRINGS OF PATIENT AND PROVIDER
Ethnic minorities are poorly represented among physicians and other health professionals. In what is called "race-discordant" relationships, patients from ethnic groups frequently are treated by professionals from a different ethnic background. The research reviewed here documents ongoing racial and ethnic disparities in health care and links patient-physician race and ethnic concordance with higher patient satisfaction and better health care processes. Based on this research, the authors issue the following recommendations: 1) health policy should be revised to encourage workforce diversity by funding programs that support the recruitment of minority students and medical faculty; 2) health systems should optimize their providers’ ability to establish rapport with minority patients to improve clinical practice and health care delivery; 3) cultural competency training should be incorporated into the education of health professionals; and 4) future research should provide additional insight into the mechanisms by which concordance of patient and physician race, ethnicity, and language influences processes and outcomes of
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LIMITATIONS TO APPROACH TO UHC IN MAINE'S DIRIGO SYSTEM
The Dirigo Health Reform Act was developed by the Maine Governor's Office of Health Policy and Finance with significant input from health care policy experts and the Health Action Team (see Appendix A), a group of key stakeholders appointed by Governor John Baldacci. The Reform Act, Public Law 469, was enacted with bipartisan support and a two-thirds majority in each chamber of the Maine Legislature. Governor Baldacci signed the bill into law on June 18, 2003. The purpose of the Reform Act is to make quality, affordable health care available to every Maine citizen within five years and to initiate new processes for containing costs and improving health care quality. A major premise behind the law is that successful health care reform must address cost, quality, and access simultaneously and with equal vigor. The law is built on the assumption that health reform cannot be done in a piecemeal fashion. If attention is paid only to access, costs will increase. If lowering the cost of care is the primary concern, access will be limited. And if quality is the sole focus, people will remain uninsured and costs will remain high.
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CRISIS DEEPENS AS HOPITALS TRY TO RECOVER GREATER RATES FROM THE UNINSURED
Recent reports of hospitals billing uninsured patients at higher rates than insured patients and using aggressive collection practices are symptoms of two underlying trends in the US health care system growing instability in insurance coverage and rapid growth in the cost of care. Such hospital practices will only exacerbate the problems experienced by uninsured and underinsured families in accessing and paying for needed medical care. "The pressures that gave rise to the conflict [between hospitals and uninsured patients] will continue to grow apace," says Collins to Congressional Committee. Broad policy solutions for expanding access to affordable insurance coverage and reducing health care inflation, Collins maintains, are required to address the root cause of the affordability crisis in U.S. health care. Health insurance has become both less available and more expensive to workers and their families, and health care itself continues to become more expensive. Indeed, health care cost growth is expected to outpace the growth rate in the economy by a wide margin for the foreseeable future. In 2003, two of five adults ages 19 to 64 more than 70 million people had problems paying their medical bills in the last 12 months or were paying off medical debt accrued over the last three years.
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STATES ARE KEY PLAYERS IN REDUCING RACIAL ETHNIC DISPARITIES TO HEALTH CARE
States are key players in the effort to reduce or eliminate racial and ethnic disparities in health and health care. In "A State Policy Agenda to Eliminate Racial and Ethnic Health Disparities" a wide range of initiatives launched or planned by states and localities are detailed, along with practical strategies for improving insurance coverage, access to care, and medical outcomes for minority Americans. Among the many promising practices covered in the report are: using state purchasing power to promote quality improvement efforts by health plans and providers; targeting specific health conditions that disproportionately affect minorities, such as asthma and diabetes; and targeting insurance coverage expansions to low-income families. The authors recommend the creation of a national coordinating council to promote state-based activities to conduct and support research on best practices, develop strategies to advise states, and educate state officials and other stakeholders about the latest developments in the field.
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UNINSURED FORGO CARE, FORCED INTO DEBT, HAVE LIVES DISRUPTED
A substantial body of research indicates that the uninsured are more likely than the insured to delay or forgo care because of cost, but even the insured may find cost a significant barrier to care. Recent research has documented that, in order to obtain medical care, many individuals are forced into debt, often with serious consequences for themselves and their families. In one survey, 60% of uninsured respondents who received ambulatory care primarily at safety-net facilities said they needed help paying for their medical care, and nearly half (46%) said they owed money to the facility where they received care. The proportion with outstanding bills rose to about 67% for those who received care in emergency rooms. In another survey, more than a quarter of families in which one or more members were uninsured reported having to change their way of life significantly to pay medical bills, a figure that rose to nearly 40% when all family members were uninsured. A 2001 survey found that 10 percent of Medicare beneficiaries reported not being able to pay medical bills, and 12 percent said they had to change their way of life to pay bills.
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GRADUATING HIGH SCHOOL AND COLLEGE STUDENTS DISPROPORTIONATELY UNINSURED
Around the United States high school and college students are graduating and beginning new chapters in their lives. Unfortunately, many of them will do so without health insurance. It was found that 13 million young adults between the ages of 19 to 29 lacked health insurance in 2002, representing a disproportionately large and growing share of the uninsured. Nearly two of five college graduates and one-half of high school graduates who do not go on to college will endure a period without health insurance, according to the study. Young adults (ages 19 to 29) are one of the largest and fastest-growing segments of the population without health insurance. Young adults often lose coverage under their parents' policies at age 19, or when they graduate from high school or college. Nearly two of five college graduates and one-half of high school graduates who do not go on to college will endure a time without health insurance in the first year after graduation. Three policy changes could extend coverage to uninsured young adults and prevent others from losing coverage: extending eligibility for dependents under private coverage through age 23; extending eligibility for Medicaid/CHIP public coverage to age 23; and ensuring that colleges and universities require full-time and part-time students to have insurance, and that they offer coverage to both. Young adults are a relatively low-cost population to insure, and keeping them in insurance pools may lower the average costs of group coverage.
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MAJOR REVISIONS NEEDED TO NATION'S PREVENTIVE PEDIATRIC CARE
The nation's system of preventive pediatric care requires major revisions if chronic health problems and unmet behavioral and developmental needs among American children are to be addressed "Rethinking Well-Child Care" (Pediatrics, July 2004). Pointing to the prevalence of obesity, attention-deficit disorder/hyperactivity, behavior disorders, depression, adolescent risk behaviors, and the stresses faced by parents, Schor warns, "The term 'well-child care' is applicable to fewer children." As acute pediatric medical care becomes, more and more, the work of hospitals, emergency physicians, and pediatric sub-specialists, well-child care calls for new approaches to pediatric office practice, to the scheduling of office visits, and to health care partnering. Well-child care accounts for 22% of an average pediatrician's patient contacts and an unknown, but no doubt substantial, part of child health care expenditures.
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HOSPITALS SPOTTY IN COLLECTING DATA ON RACE/ETHNICITY
To address racial and ethnic disparities in quality of and access to health care, it's critical to have basic data about patients' race, ethnicity, and primary language. But methods for collecting such data vary widely across the health care sector, making comparison and analysis difficult. Although the majority of hospitals are now collecting race and ethnicity data, many say there are drawbacks, including problems with accuracy and confidentiality. The authors recommend formalizing and standardizing the data collection process relying on patients to provide information, and giving them a uniform rationale for doing so. According to the Institute of Medicine, standardized data collection is critical to understanding and eliminating racial and ethnic disparities in health care. A critical barrier to eliminating disparities and improving the quality of patient care is the frequent lack of even the most basic data on race, ethnicity, and primary language of patients within health care organizations. The methods for collecting these data are disparate and, for the most part, incompatible across organizations and institutions in the health care sector. Among hospitals that collect data on race/ethnicity, 70% did not see any drawbacks to collecting the data.
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