Health policy research roundup: Long-term care, diabetes disparities, health IT

Jan 8 2010

Annals of Internal Medicine: Cultural Competency Training and Performance Reports to Improve Diabetes Care for Black Patients - In this study, researchers measure the effects cultural competency training and performance training for physicians has on the clinical outcomes for black patients with diabetes.

By comparing the patient outcomes among blacks whose physicians received training to those who had not, the authors conclude that though "cultural competency training combined with individual clinician-level performance feedback on racial disparities … increased awareness of disparities," such changes were "not accompanied by improvement in diabetes outcomes for black patients. ... Future studies should focus on methods to build on this increased clinician awareness, possibly through programs that engage patients and the community in more effective management of diabetes and incorporate the skills of other allied health professionals, including nurses, pharmacists, and nutritionists," they conclude (Sequist et al., 1/5).

Kaiser Family Foundation: Summaries of Coverage Provisions In House and Senate Reform Legislation - These two briefs tease out the health coverage provisions embedded in the House's Affordable Health Care for America Act and the Senate's Patient Protection and Affordable Care Act, including information on the individual mandate, expansion of public programs, health insurance exchanges, employer requirements and coverage and cost estimates (1/6).

The January issue of Health Affairs is out (with a long-term care theme), here are some highlights: 

Health Affairs: Long-Term Care: Who Gets It, Who Provides It, Who Pays, And How Much? - "With projections indicating a doubling in the need for long-term care over the next forty years, spending on publicly paid services—already an ever-increasing share of ever-rising national health care expenditures—is of grave concern to policymakers at the federal and state levels," write the authors of this paper. They examine "the size and characteristics of the U.S. population needing help with daily activities, the nature of unpaid and paid providers of long-term care, sources of payment, and spending for those services, both individually and on a national level," and conclude: "A redistribution in long-term care spending from institutional to noninstitutional settings, and from agency to independent providers, appears to offer the potential for a sizable reduction in spending or for an expansion of services to a broader population for the same expenditure" (Kaye, Harrington and LaPlante, Jan. 2010).

Health Affairs: Medicare And Medicaid In Long-Term Care - "Although Medicare and Medicaid pay for 67 percent of nursing home and home care in the United States, these programs are generally not coordinated or integrated," write the authors of this paper that characterizes the fragmentation and competing incentives in state Medicaid long-term care programs and Medicare post-acute services. "Medicare focuses on limiting hospital and postacute use and costs, resulting in shifts in care to the Medicaid long-term care program," which "in turn, has little incentive to reduce Medicare hospital and emergency room use. Policy changes are needed to align the incentives for the two programs" (Ng, Harrington and Kitchener, Jan. 2010).

Health Affairs: The Revolving Door Of Rehospitalization From Skilled Nursing Facilities - The authors of this paper quantify the frequency and cost of rehospitalizations, based on Medicare inpatient claims data made over the period 2000-2006 and found that "In 2006 there were 1.79 million skilled nursing facility episodes, of which 419,669 (23.5 percent) resulted in a rehospitalization within thirty days. Total Medicare reimbursements associated with these rehospitalizations exceeded $4.34 billion, and the average Medicare payment per rehospitalization was $10,352." The authors also examine several issues related to offering incentives to help reduce rehospitalizations (Mor, Intrator, Feng and Grabowski, Jan. 2010).

Health Affairs: Physician Orders Contribute To High-Tech Imaging Slowdown - Although the use "of advanced diagnostic imaging (magnetic resonance imaging, computed tomography, and nuclear medicine) in Medicare outpatients rose 72.7 percent between 2000 and 2005 …," the authors of this paper report there was "a notable slowdown in growth of discretionary outpatient advanced diagnostic imaging in the Medicare population, beginning in 2006 and continuing in 2007." They attribute the slowdown to "the advent of radiology business management companies" and recommendations by major medical societies such as the American College of Radiology and the American College of Cardiology. The authors conclude: "Given that payments have been reduced, growth has nearly stopped, and access for beneficiaries does not appear to have been restricted, the Medicare program might be on its way to mitigating the 'high-tech imaging problem' that is well known among policymakers. … Despite this encouraging development, utilization continues to be high, and further attention will have to be paid to how much of it is appropriate" (Levin, Rao and Parker, Jan. 2010).

Journal of General Internal Medicine/Commonwealth Fund: Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices - To better understand how small- and medium practices deploy EMRs to support care coordination, the authors of this study interviewed physicians and staff members at small (fewer than 10 physicians) and medium-sized (11 to 50 physicians) practices with commercial ambulatory care electronic medical record systems in place for at minimum of two years. Although the practices reported that EMRs help to facilitate within-office coordination, they were less able to support coordination between clinics and other settings, "in part due to their design and a lack of standardization of key data elements required for information exchange," according to the authors of the study. They conclude: "There is a gap between policy-makers' expectation of, and clinical practitioners' experience with, current electronic medical records' ability to support coordination of care. … By reforming payment policy to include care coordination, policymakers could encourage the evolution of EMR technology to include capabilities that support coordination" (O'Malley et al., 12/22).

Kaiser Family Foundation: Uninsured Young Adults: Who They Are and How They Might Fare Under Health Reform - This issue brief (.pdf) examines how young adults (ages 19 to 29), who have the highest uninsured rate of any group in the U.S., obtain health coverage. "National health reform legislation being debated in Washington aims to decrease the number of uninsured by expanding access to both private insurance and Medicaid. These policies have the potential to reach most uninsured young adults, the majority of whom have low-incomes that would qualify them for either Medicaid coverage or subsidies for private insurance purchased through a health insurance Exchange," the authors write. "Given that most uninsured young adults have very low incomes, adequate premium and cost-sharing subsidies will be crucial to ensuring that this population signs up for health coverage and can obtain the health care services they need" (Schwartz and Schwartz, 12/22).

Kaiser Family Foundation: The COBRA Subsidy and Health Insurance for the Unemployed - This issue brief (.pdf) examines COBRA, the law that allows workers who lose their jobs and their employer-sponsored health coverage to buy that coverage on their own. The brief details the subsidies extended to workers through the American Recovery and Reinvestment Act of 2009 (ARRA) to cover much of their COBRA costs, explains how the provisions interact with other programs designed to help people obtain and maintain health coverage, and examines the implications of the program. "Although ARRA is a valuable first step towards protecting coverage for those who become unemployed during this recession, providing security for all of those who need health insurance will require more comprehensive health reform," the author concludes (Schwartz, 12/23).

A related factsheet (.pdf) provides information on the recent extension of the COBRA subsidy program (12/23).

Commonwealth Fund: Texas Health Harris Methodist-Cleburne: A System Approach to Surgical Improvement - This case study examines the strategies and factors that contribute to high performance on surgical care improvement measures at Texas Health Harris Methodist-Cleburne, ranked in the top 2 percent of 2,300 hospitals in composite assessments of five surgical care measurements. Drawing from information obtained through interviews with hospital personnel, data available to the public and self-reported by the institution, the author of the study describes how Texas Health's use of concurrent reviews and report cards has contributed to its success (Lashbrook, 12/24).