Report on Public Health and Health Care

The Institute of Medicine (IOM) has published a report summarizing its February workshop that explored the relationship between public health and health care.

According to the IOM, the workshop

iom_logo… was designed to discuss and describe the elements of successful collaboration between health care and public health organizations and professionals; reflect on the five principles of primary care–public health integration (which can be applied more broadly to the health care–public health relationship): shared goals, community engagement, aligned leadership, sustainability, and data and analysis; and explore the “elephants in the room” when public health and health care interact: what are the key challenges and obstacles and what are some potential solutions, including strengths both sides bring to the table. The workshop presentations reflected on collaboration in four contexts: payment reform, the Million Hearts initiative, hospital – public health collaboration, and asthma control.

Because of the nature of the communities they serve and the work they do, private safety-net hospitals are often important parts of public health efforts in cities across the country.

Find the IOM report Collaboration between Health Care and Public Health: Workshop Summary here.

30-Day Readmission Standard Flawed, Study Suggests

A new study raises the possibility that Medicare’s policy of penalizing hospitals that readmit patients within 30 days of their discharge may be flawed.

According to a new report in the Annals of Internal Medicine, risk factors for readmission often change within those 30 days.

In addition, patients with chronic medical problems are more likely to need readmission. Even the time of day of discharge appears to affect patients’ likelihood of readmission, with those discharged between 8 a.m. and 1:00 p.m. less likely to be readmitted.

The study also found that social determinants and insurance status also increase the likelihood of readmission within 30 days of discharge.

annals of internal medicineTogether, these and other findings appear to raise questions about the fairness of Medicare’s hospital readmissions reduction program.

These findings also mirror a growing body of research that suggests the program is inherently unfair to safety-net hospitals that serve large numbers of low-income patients who have had limited and sporadic access to medical care during their lives. NAUH has long pointed to the unfairness of this program and supported changes to improve it, most recently in a March letter to the House sponsors of H.R. 1343, the Establishing Beneficiary Equity in the Hospital Readmission Program Act, a bill that seeks to address those inequities.

To learn more, see this Fierce Healthcare report. Find the study “Differences Between Early and Late Readmissions Among Patients: A Cohort Study” here, on the web site of the Annals of Internal Medicine.

Looking at Payment and Delivery System Reform

Last fall the Robert Wood Johnson Foundation brought together grant recipients and national experts to talk about health care payment and delivery system reform design and implementation issues.

rwjfNow, the foundation has released a brief paper that addresses what the experts consider to be the three greatest challenges in the pursuit of such reform:

  • aligning alternative payments with clinician compensation
  • considering social determinants of health in payment reform models
  • repurposing hospital resources

The paper also takes a look at whether health care payments should be subject to risk adjustment to reflect the social and economic barriers to better health and care that some patients face. The National Association of Urban Hospitals (NAUH) has long advocated such risk adjustment in Medicare payments and has endorsed legislation to compel Medicare to introduce such a policy change, including the Establishing Beneficiary Equity in the House Readmissions Program Act of 2015, which was introduced in both the House and the Senate last month.

These issues and more are addressed in greater detail in the new paper “Three Emerging Challenges for Sustained Payment and Delivery System Reform,” which can be found here.

Numbers Link Medicaid Expansion, Diabetes Diagnoses

One of the primary arguments made by the National Association of Urban Hospitals in favor of government reimbursement policies that support the work of private safety-net hospitals is that the patients they serve have had sporadic contact with the health care system over the years and often present with medical problems that go well beyond the immediate reason that brings them to hospitals.

Now comes new information that supports that argument.

The medical testing company Quest Diagnostics has found that the number of Medicaid patients its testing has found to have diabetes has risen more than 24 percent during two recent six-month review periods in states that have expanded their Medicaid programs while the number of such patients found to have diabetes in states that did not expand their Medicaid programs saw only a 0.4 percent increase in diabetes diagnoses.

Because of where they are located, private safety-net hospitals serve higher proportions of Medicaid patients than the typical community hospital and are therefore more likely to be caring for these more challenging patients newly diagnosed with diabetes.

For more information about the Quest findings and their implications, see this New York Times article. In addition, the latest edition of the journal Diabetes Care presents a study on the subject. See that article here.

Congress to Consider Adding Risk Adjustment to Medicare Readmissions Program

A new bill introduced in Congress this week would require Medicare to consider the social determinants of health of the patients individual hospitals serve as part of its hospital readmissions reduction program.

The Establishing Beneficiary Equity in the Hospital Readmissions Program Act of 2015 was introduced as S. 688 in the Senate, sponsored by Senators Rob Portman (R-OH) and Joe Manchin (D-WV), and in the House by Representatives Jim Renacci (R-OH) and Eliot Engel (D-NY) as H.R. 1343.

Medical EquipmentRep. Renacci introduced a similar measure last year.  NAUH endorsed that bill.  This year’s version has bipartisan sponsorship in both the House and Senate.

Since the launch of Medicare’s readmissions reduction program several years ago, NAUH has maintained that it treats private safety-net hospitals unfairly because it fails to reflect the large numbers of especially challenging patients such hospitals serve – challenging because of the many socio-economic barriers to care they face.  In recent years a number of studies have confirmed that bias and this latest proposal seeks to correct this shortcoming in the Medicare program.

To learn more about this proposal, see this news release announcing the bill.  Find the bill itself here.

Low-Income Patients Struggle With Diabetes Management

Low-income diabetics are more likely than others to struggle to manage their condition – even if they have health insurance.

According to a new study published in JAMA Internal Medicine, “Increasing access to care may be insufficient to improve the health of patients with diabetes mellitus and unmet basic needs.”  The study defines those unmet needs as food insecurity, cost-related medication underuse, housing instability, and energy insecurity.

jama internal medicineThe study, “Material Needs Insecurities, Control of Diabetes Mellitus, and Use of Health Care Resources,” found that difficulty affording food led to more outpatient physician visits; trouble paying for medicine and underuse of medicine for that reason led to more emergency room visits and hospitalizations; and all of the material insecurities contributed to increased health care costs.

The study was based on observation of 400 patients served by community health centers in Massachusetts.  It found that 19 percent of those patients had trouble affording food, 28 percent had difficulty paying for medicine, 11 percent struggled to pay for someplace to live, and 14 percent had a hard time paying their utility bills.  Overall, nearly half had trouble managing their diabetes.

The study’s findings reinforce NAUH’s long-held belief that low-income patients are fundamentally more challenging to treat than others and often lack the community and social supports needed to address their medical needs effectively.

Learn more about the study and its implications in this U.S. News & World Report article or find the study itself here, on the web site of the  JAMA Internal Medicine.

Unemployment Plays Major Role in Hospital Readmissions

A new study has found that employment status is the leading socioeconomic indicator of hospital readmissions for patients who have suffered heart attacks, heart failure, and pneumonia.

iStock_000001497717XSmallUsing 2011 and 2012 data from the Centers for Medicare & Medicaid Services, researchers examined readmissions for these conditions based on nine factors that constitute what is known as the Community Need Index:  elderly poverty, single parent poverty, child poverty, lack of health insurance, minority, no high school, renting, unemployment, and limited English.  Their analysis found that only employment status and lack of high school education were statistically significant predictors of hospital readmissions for the three conditions studied, with employment status more than three times as powerful an indicator as lack of high school education.

High unemployment is typically a major problem in the communities served by private  safety-net hospitals.

Learn more about the study in this Fierce Healthcare report and see the study itself here.

 

Residents of Disadvantaged Neighborhoods More Likely to Require Readmission

Medicare beneficiaries living in the most disadvantaged neighborhoods are more likely than others to require readmission to the hospital for problems associated with congestive heart failure, pneumonia, or myocardial infarction.

annals of internal medicineThis is one of the findings in a new Annals of Internal Medicine study titled “Neighborhood Socioeconomic Disadvantage and 30-Day Rehospitalization:  A Retrospective Cohort Study.”

The study, based on data from 2004 through 2009, compared Medicare readmission rates in different geographic areas using what is called a validated area deprivation index that measures relative social determinants of health to identify the most disadvantaged areas.  Researchers concluded that

The 30-day rehospitalization rate did not vary significantly across the least disadvantaged 85% of neighborhoods, which had an average rehospitalization rate of 21%. However, within the most disadvantaged 15% of neighborhoods, rehospitalization rates increased from 22% to 27% with worsening ADI.

These findings confirm the argument that the National Association of Urban Hospitals has been making ever since Medicare’s hospital readmissions reduction program was introduced:  that the low-income Medicare patients many private safety-net hospitals serve are fundamentally more difficult to treat than the typical hospital patient and that the readmissions reduction program needs to be risk-adjusted to account for this difference.

The Annals of Internal Medicine study is just the latest academic research that confirms NAUH’s contention about Medicare’s readmissions reduction program.

Find the study here, on the web site of the Annals of Internal Medicine.

Homelessness and Safety-Net Hospitals

Homeless people with serious medical problems are more likely than others to be readmitted to hospitals – and especially, to safety-net hospitals – during their convalescence from illnesses and injuries.

This is one of the conclusions in the recently published Journal of Community Health Nursing article “Assessing the Needs for a Medical Respite:  Perceptions of Service Providers and Homeless Persons.”

According the study, homeless people lack safe places to convalesce.  Shelters do not suffice, the study found, because they are not open around the clock and lack staff qualified to support recovery.  The homeless also report that their drugs are often stolen in shelters and they are vulnerable to infections while staying in them.

iStock_000001497717XSmallAs a result, many of these patients end up being readmitted to the safety-net hospitals that originally treated them – often, for extended periods of time.  Among others, this poses a real challenge for the country’s private safety-net hospitals because they serve so many more homeless patients than the typical hospital.

In more than 70 cities, respite care facilities have been established to serve the homeless recovering from serious injuries and illnesses.

Learn more about the challenges facing homeless patients and the role safety-net hospitals play in addressing those challenges in this Dallas Morning News story and find the Journal of Community Health Nursing article here.

New Study: Geography Doesn’t Explain Variations in Medicare Spending

Social determinants of health play a much greater role than geography in explaining variations in Medicare spending.

According to a new report from the Brookings Institution,

Underlying socioeconomic and demographic characteristics have important implications for the geographic patterns in Medicare spending.  The findings contradict prior research claiming that most of the variation in Medicare spending can be attributed to geographic differences in medical “practice styles.”

iStock_000005787159XSmallAs a result, according to the study, “…geographic variation in health care spending does not provide a useful measure of inefficiency and waste in the system” because, among other reasons, “…cross-state variation in Medicare spending is tightly associated with the characteristics of state populations, and once these characteristics are controlled for, the variation in spending is fairly small.”

This conclusion contradicts previous findings suggesting that variations in Medicare expenditures were based largely on geography, which in turn gave rise to suggestions that Medicare payments to providers should be adjusted to reflect those variations by reducing payments in high-expenditure areas and increasing them in low-expenditure areas.  The National Association of Urban Hospitals (NAUH) has long questioned the notion that variations in Medicare spending can be attributed to geography alone and has opposed past proposals to adjust Medicare payments based on geography.

Learn more about this new perspective on differences in Medicare spending in “Why the Geographic Variation in Health Care Spending Can’t Tell Us Much About the Efficiency or Quality of Our Health Care System,” a new report from the Brookings Institution that can be found here.