Research Roundup:COBRA subsidies; Children's insurance and dental coverage; Adopting health IT; Race and heart treatments

Jul 31 2010

Archives of Internal Medicine: Racial Differences In Admissions To High-Quality Hospitals For Coronary Heart Disease - "Racial disparities in the management of coronary heart disease (CHD) are widely documented, yet the reasons behind persistent gaps in quality of care are not fully understood," write the authors, who examined "Medicare patients with acute myocardial infarction and coronary artery bypass grafting (CABG) admitted during 2002 through 2005 to hospitals located in markets with top-ranked cardiac hospitals, as ascertained from the US News and World Report 'America's Best Hospitals' annual rankings."  They report: "black patients are equally or more likely to be admitted to high-quality cardiac hospitals compared with white patients with similar geographic access to these facilities, with the notable exception of patient undergoing CABG who reside in communities with marked social disadvantage."

"Given the proximity of high-quality hospitals to this segment of the black population, our study suggests an inequity in the use of such hospitals by underprivileged black patients undergoing CABG. Future research should focus on the complexity of geographical and social factors driving hospital choices for vulnerable populations in order to develop effective local interventions aimed at reducing racial disparities in health care delivery," the authors conclude (Popescu et al., 7/26).

Urban Institute: Federal Subsidy For Laid-Off Workers' Health Insurance: A First Year's Report Card For The New COBRA Premium Assistance - This brief examines the impact of COBRA subsidies, made possible through the American Recovery and Reinvestment Act (ARRA), on the number of people who sought coverage, and whether "the subsidy reduced 'adverse selection' of older, sicker people into COBRA coverage."

"The ARRA subsidies have increased participation in COBRA, but to different extents in different populations," the authors write, pointing to a Hewitt Associates study that found the "average take-up among involuntarily laid-off people doubled [from 19 percent] to 39 percent after ARRA. … The biggest jump by percentage points occurred in industrial manufacturing, which rose by 60 percentage points—from 7 to 67 percent. … The smallest increase was reported for financial services, where enrollment rose only 7 percentage points to 34 percent." The authors also add that the COBRA subsidy reduced adverse selection, though they note "much more and more detailed information is needed to fully assess the impact of subsidy selection." The brief also examines the implications for COBRA policy under the new health law (Bovbjerg, Dorn, Macri and Meyer, July 2010).

Kaiser Family Foundation: Health Coverage Of Children: The Role Of Medicaid And CHIP - "During the current recession, Medicaid and the Children's Health Insurance Program (CHIP) have served as an important safety-net for children in low or moderate income families," together insuring around one-third of all children, according to this fact sheet: "In 2008, despite a recession and a resulting decline in employer-sponsored coverage, the uninsured rate for children continued to drop and nearly 800,000 fewer children were uninsured than in 2007. That decline was caused by an increase in public coverage, with 1.7 million children gaining coverage through Medicaid or CHIP in 2008. In contrast, from 2004 to 2006, public coverage rates for children did not increase as private coverage rates fell." The fact sheet provides detail on children's coverage by income and race as well as uninsured rates by state (7/26).

Urban Institute: Dental Care In The Los Angeles Healthy Kids Program: Successes And Challenges - This brief examines the successes and challenges in dental care faced by the Los Angeles Healthy Kids Program - a public insurance program implemented in 2003 to "address unmet health care needs among children, and provide comprehensive, affordable health care coverage to uninsured children from families with incomes under 300 percent of the federal poverty level (FPL), who are not eligible for the Healthy Families or Medi-Cal programs."

Drawing upon the results of a five-year evaluation as well as analyses of "encounter data from SafeGuard Dental, the program's dental plan," the authors report: "Overall, our study finds that the L.A. Healthy Kids program has greatly improved coverage and access to dental care services for tens of thousands of poor, largely immigrant, Latino children." But some families experienced "delays in initiating dental care" or reported being "inappropriately charged copayments for covered dental care services not subject to cost sharing." The paper ends with a list of recommendations for how to improve the program (Hogan, Hill and Howell, July 2010).

Annals of Family Medicine: Evaluation Of The American Academy Of Family Physicians' Patient-Centered Medical Home National Demonstration Project - This supplement features a series of articles examining the outcomes, lessons and implications of the National Demonstration Project (NDP) of the patient-centered medical home (PCMH).

"The articles in this supplement demonstrate that it is possible for highly motivated, largely independent practices to implement most of the predominantly technological components of the PCMH," write the authors of an introduction to the supplement. "This implementation results in improved indicators of chronic disease care as assessed from medical records, but at the cost of reducing the quality of key attributes of primary care as rated by patients" (Stange, 2010).

Commonwealth Fund: Health Care Opinion Leaders' Views On Delivery System Innovation And Improvement - This report, based on the latest Commonwealth Fund/Modern Healthcare Health Care Opinion Leaders Survey conducted online between June 8 and July 7, examines 225 leaders' views on barriers to delivery system innovation and thoughts on how to strengthen accountability and coordination among health care providers: "a majority of respondents feel that integrated delivery systems (64%) and accountable care organizations (54%) will be either effective or very effective or extremely effective reform models."

"Sixty-five percent of survey respondents believe that providing special payment arrangements to accountable care systems and giving providers financial incentives to practice in ACOs will be very or extremely effective strategies to foster accountability, coordination, and integration in care delivery. About half of opinion leaders feel that giving patients incentives to join accountable care systems (51%) and providing infrastructure support to spur development of ACOs (50%) will be effective strategies; only one-third of leaders believe requiring patients (34%) or providers (33%) to join or practice in accountable care systems will be effective strategies for fostering more accountability in care delivery" (Stremikis, Davis and Audet, 7/26).

Archives of Internal Medicine: National Quality Forum Performance Measures For HIV/AIDS Care - Using electronic data for HIV patients who received care at the Department of Veteran Affairs, this analysis of more than 21,000 patients who were treated in 2008 revealed that the treatment of more than 80 percent of patients included six of the 10 National Quality Forum performance recommended measures. In addition, the study found that "African Americans and hard drug users were less likely to access care and less likely to receive HIV-specific care but more likely to receive indicated general medical care.

Although "the national VA rates for many of the NQF measures for HIV/AIDS care are generally high," the numbers vary by facility, "which indicates room for improvement," the study authors write. "The ability to measure performance should aid quality managers, health care providers, and administrators in identifying best practices from high-performing facilities and in assisting low-performing facilities to improve care" (Backus et al., 7/26).

Annals of Family Medicine: Gradual Electronic Health Record Implementation: New Insights On Physician and Patient Adaptation - Researchers "observed [170] clinical encounters and conducted patient interviews" over a 22-month period at one family medicine outpatient clinic in Rhode Island. They report: "Strong patient trust in the physician-patient relationship was maintained and work flow improved with EHR implementation. ... Gradual EHR implementation may help support the development of beneficial physician and staff adaptations, while maintaining positive patient-physician relationships and fostering the sharing of medical information," they conclude (Shield et al., July/August 2010).