Solving Disparities Through Payment And Delivery System Reform: A Program To Achieve Health Equity

Racing the Machine: Data Analytic Technologies and Institutional Inscription of Racialized Health Injustice

Recent scientific and policy initiatives frame clinical settings as sites for intervening upon inequality. Electronic health records and data analytic technologies offer opportunity to record standard data on education, employment, social support, and race-ethnicity, and numerous audiences expect biomedicine to redress social determinants based on newly available data. However, little is known on how health practitioners and institutional actors view data standardization in relation to inequity. This article examines a public safety-net health system's expansion of race, ethnicity, and language data collection, drawing on 10 months of ethnographic fieldwork and 32 qualitative interviews with providers, clinic staff, data scientists, and administrators. Findings suggest that electronic data capture institutes a decontextualized racialization within biomedicine as health practitioners and data workers rely on biological, cultural, and social justifications for collecting racial data. This demonstrates a critical paradox of stratified biomedicalization: The same data-centered interventions expected to redress injustice may ultimately reinscribe it.

Measuring Equity in Readmission as a Distinct Assessment of Hospital Performance

Importance

Equity is an essential domain of health care quality. The Centers for Medicare & Medicaid Services (CMS) developed 2 Disparity Methods that together assess equity in clinical outcomes.

Objectives

To define a measure of equitable readmissions; identify hospitals with equitable readmissions by insurance (dual eligible vs non-dual eligible) or patient race (Black vs White); and compare hospitals with and without equitable readmissions by hospital characteristics and performance on accountability measures (quality, cost, and value).

Design, Setting, and Participants

Cross-sectional study of US hospitals eligible for the CMS Hospital-Wide Readmission measure using Medicare data from July 2018 through June 2019.

Main Outcomes and Measures

We created a definition of equitable readmissions using CMS Disparity Methods, which evaluate hospitals on 2 methods: outcomes for populations at risk for disparities (across-hospital method); and disparities in care within hospitals' patient populations (within-a-single-hospital method).

Exposures

Hospital patient demographics; hospital characteristics; and 3 measures of hospital performance-quality, cost, and value (quality relative to cost).

Results

Of 4638 hospitals, 74% served a sufficient number of dual-eligible patients, and 42% served a sufficient number of Black patients to apply CMS Disparity Methods by insurance and race. Of eligible hospitals, 17% had equitable readmission rates by insurance and 30% by race. Hospitals with equitable readmissions by insurance or race cared for a lower percentage of Black patients (insurance, 1.9% [IQR, 0.2%-8.8%] vs 3.3% [IQR, 0.7%-10.8%], P < .01; race, 7.6% [IQR, 3.2%-16.6%] vs 9.3% [IQR, 4.0%-19.0%], P = .01), and differed from nonequitable hospitals in multiple domains (teaching status, geography, size; P < .01). In examining equity by insurance, hospitals with low costs were more likely to have equitable readmissions (odds ratio, 1.57 [95% CI, 1.38-1.77), and there was no relationship between quality and value, and equity. In examining equity by race, hospitals with high overall quality were more likely to have equitable readmissions (odds ratio, 1.14 [95% CI, 1.03-1.26]), and there was no relationship between cost and value, and equity.

Conclusion and Relevance

A minority of hospitals achieved equitable readmissions. Notably, hospitals with equitable readmissions were characteristically different from those without. For example, hospitals with equitable readmissions served fewer Black patients, reinforcing the role of structural racism in hospital-level inequities. Implementation of an equitable readmission measure must consider unequal distribution of at-risk patients among hospitals.

Contributions of Key Components of a Medical Home on Child Health Outcomes

OBJECTIVES

The medical home model is a widely accepted model of team-based primary care. We examined five components of the medical home model in order to better understand their unique contributions to child health outcomes.

METHODS

We analyzed data from the 2016-2017 National Survey of Children's Health (NSCH) to assess five key medical home components - usual source of care, personal doctor/nurse, family-centered care, referral access, and coordinated care - and their associations with child outcomes. Health outcomes included emergency department (ED) visits, unmet health care needs, preventive medical visits, preventive dental visits, health status, and oral health status. We used multivariate regression controlling for child characteristics including age, sex, primary household language, race/ethnicity, income, parental education, health insurance coverage, and special healthcare needs.

RESULTS

Children who were not white, living in non-English households, with less family income or education, or who were uninsured had lower rates of access to a medical home and its components. A medical home was associated with beneficial child outcomes for all six of the outcomes and the family-centered care component was associated with better results in five outcomes. ED visits were less likely for children who received care coordination (aOR 0.81, CI 0.70-0.94).

CONCLUSIONS FOR PRACTICE

Our study highlights the role of key components of the medical home and the importance of access to family-centered health care that provides needed coordination for children. Health care reforms should consider disparities in access to a medical home and specific components and the contributions of each component to provide quality primary care for all children.

Hospital value-based payment programs and disparity in the United States: A review of current evidence and future perspectives

Beginning in the early 2010s, an array of Value-Based Purchasing (VBP) programs has been developed in the United States (U.S.) to contain costs and improve health care quality. Despite documented successes in these efforts in some instances, there have been growing concerns about the programs' unintended consequences for health care disparities due to their built-in biases against health care organizations that serve a disproportionate share of disadvantaged patient populations. We explore the effects of three Medicare hospital VBP programs on health and health care disparities in the U.S. by reviewing their designs, implementation history, and evidence on health care disparities. The available empirical evidence thus far suggests varied impacts of hospital VBP programs on health care disparities. Most of the reviewed studies in this paper demonstrate that hospital VBP programs have the tendency to exacerbate health care disparities, while a few others found evidence of little or no worsening impacts on disparities. We discuss several policy options and recommendations which include various reform approaches and specific programs ranging from those addressing upstream structural barriers to health care access, to health care delivery strategies that target service utilization and health outcomes of vulnerable populations under the VBP programs. Future studies are needed to produce more explicit, conclusive, and consistent evidence on the impacts of hospital VBP programs on disparities.

Addressing Health Disparities in Public Health Through the Application of Data Science Software in the Last 5 Years

The application of data science resources can enhance our ability to reduce health disparities affecting communities across the country. In this paper, we use the Preferred Reporting Items for Structured Review and Meta-Analyses methodology to conduct a thematic analysis of selected studies and identify micro and macro themes within the literature. The authors of this analysis reviewed articles that included data science software applications and their role in focusing efforts to address health disparities affecting the health of citizens in specific communities across the country. Abstracts were reviewed for research relevance after duplicates were removed, and documents were eliminated from consideration during the screening based on the exclusion criteria. At the conclusion of the structured literature review, the results emphasized the strong utility of geographically directed assessment. This highlights the need for the integration of geo- and statistical methodologies in the use of data science software for healthcare applications, which can be a useful means to identify locations where health disparities are present and can focus efforts to resolve these health disparities. Nurses, physicians, and health educators can be dispatched to the geographical areas where health disparities are most prevalent.

Real-World Considerations for Implementing Pediatric Quality Measures: Insights From Key Stakeholders

OBJECTIVE

Since its inception, the Pediatric Quality Measures Program has focused on the development and implementation of new and innovative pediatric quality measures (PQM) for both public and private use. Building the evidence base related to measure usability and feasibility is central to increasing measure uptake and, thereby, to increased performance monitoring and quality improvement (QI) for children in Medicaid or the Children's Health Insurance Program. This paper describes key stakeholder insights focused on measure implementation and increasing the uptake of PQM.

METHODS

The PQMP Learning Collaborative conducted semistructured interviews with 9 key informants (KIs) representing states, health plans, and other potential end users of the measures. The interviews focused on gaining KIs' perspectives on 6 research questions focused on assessing the feasibility and usability of PQM and strengthening the connection between measurement and improvement.

RESULTS

Our synthesis identified insights that highlight facilitators and barriers from the KIs' experience and the strategies they employ when using measures to drive improvement "on-the-ground." Importantly, while the KIs agreed on how essential the research questions are to measure implementation and uptake, they uniformly acknowledged the complexity of the issues raised and pinpointed multiple unresolved issues.

DISCUSSION

The views expressed by these stakeholders point to several key issues - including incorporation of socio-economic status into quality measures and performance comparisons, use of benchmark data, and criteria for QI versus accountability - for developing a real-world research agenda to guide the future direction of quality measurement and implementation to improve children's health care.

New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care

Unacceptable healthcare disparities in endocrine disease have persisted for decades, and 2021 presents a difficult evolving environment. The COVID-19 pandemic has highlighted the gross structural inequities that drive health disparities, and antiracism demonstrations remind us that the struggle for human rights continues. Increased public awareness and discussion of disparities present an urgent opportunity to advance health equity. However, it is more complicated to change the behavior of individuals and reform systems because societies are polarized into different factions that increasingly believe, accept, and live different realities. To reduce health disparities, clinicians must (1) truly commit to advancing health equity and intentionally act to reduce health disparities; (2) create a culture of equity by looking inwards for personal bias and outwards for the systemic biases built into their everyday work processes; (3) implement practical individual, organizational, and community interventions that address the root causes of the disparities; and (4) consider their roles in addressing social determinants of health and influencing healthcare payment policy to advance health equity. To care for diverse populations in 2021, clinicians must have self-insight and true understanding of heterogeneous patients, knowledge of evidence-based interventions, ability to adapt messaging and approaches, and facility with systems change and advocacy. Advancing health equity requires both science and art; evidence-based roadmaps and stories that guide the journey to better outcomes, judgment that informs how to change the behavior of patients, providers, communities, organizations, and policymakers, and passion and a moral mission to serve humanity.

Health Care Disparities and the Future of Pancreatic Cancer Care

There have been tremendous advances in the diagnosis and treatment of pancreatic cancer in the past decade, yet we are failing to achieve equitable outcomes for all patient populations. Disparities exist in the incidence, diagnosis, treatment, and outcomes of patients with pancreatic cancer. Inequities are based on racial and ethnic group, sex, socioeconomic status, and geography. To address disparities, future steps must focus on research methods, including collection and methodology, and policy measures, including access, patient tools, hospital incentives, and workforce diversity. Through these comprehensive efforts, we can begin to rectify inequitable care for treatment of patients with pancreatic cancer.

Capturing patients, missing inequities: Data standardization on sexual orientation and gender identity across unequal clinical contexts

In effort to address fundamental causes and reduce health disparities, public programs increasingly mandate sites of care to capture patient data on social and behavioral domains within Electronic Health Records (EHRs). Data reporting drawing from EHRs plays an essential role in public management of social problems, and data on social factors are commonly cited as foundational for eliminating health inequities. Yet one major shortcoming of these data-centered initiatives is their limited attention to social context, including the institutional conditions of biomedical stratification and variation of care provision across clinical settings. In this article, we leverage comparative fieldwork to examine provider and system responses to mandated data collection on patient sexual orientation and gender identity (SOGI), highlighting unequal clinical contexts as they appear across a large county safety-net institution and an LGBTQ-oriented health organization. Although point of care data collection is commonly justified for governance in the aggregate (e.g., disparity monitoring), we find standardized data on social domains presents a double-edged sword in clinical settings: formal categories promote visibility where certain issues remain hidden, yet constrain clinical utility in sites with greater knowledge and experience with related topics. We further illustrate how data standardization captures patient identities yet fundamentally misses these unequal contexts, resulting in limited attenuation of inequity despite broad expectations of clinical change. By revealing the often-invisible contexts of care that elude standard measurement, our findings underline the strengths of qualitative social science in accounting for the complex dynamics of enduring social problems. We call for deeper engagement with the unequal contexts of biomedical stratification, especially in light of increasing pressure to quantify the social amidst the rising tide of data-driven care.

Development, implementation, and use of an "equity lens" integrated into an institutional quality scorecard

Few healthcare provider organizations systematically track their healthcare equity, and fewer enable direct interaction with such data by their employees. From May to August 2019, we enhanced the data architecture and reporting functionality of our existing institutional quality scorecard to allow direct comparisons of quality measure performance by gender, age, race, ethnicity, language, zip code, and payor. The Equity Lens was made available to over 4000 staff in September 2019 for 82 institutional quality measures. During the first 11 months, 235 unique individuals used the tool; users were most commonly from the quality and equity departments. Two early use cases evaluated hypertension control and readmissions by race, identifying potential inequities. This is the first description of an interactive equity lens integrated into an institutional quality scorecard made available to healthcare system employees. Early evidence suggests the tool is used and can inform quality improvement initiatives.

Impacts of innovation in dental care delivery and payment in Medicaid managed care for children and adolescents

Background

We evaluated a 14-county quality improvement program of care delivery and payment of a dental care organization for child and adolescent managed care Medicaid beneficiaries after 2 years of implementation.

Methods

Counties were randomly assigned to either the intervention (PREDICT) or control group. Using Medicaid administrative data, difference-in-difference regression models were used to estimate PREDICT intervention effects (formally, “average marginal effects”) on dental care utilization and costs to Medicaid, controlling for patient and county characteristics.

Results

Average marginal effects of PREDICT on expected use and expected cost of services per patient (child or adolescent) per quarter were small and insignificant for most service categories. There were statistically significant effects of PREDICT (p < .05), though still small, for certain types of service:

Expected number of diagnostic services per patient-quarter increased by .009 units;

Expected number of sealants per patient-quarter increased by .003 units, and expected cost by $0.06;

Total expected cost per patient-quarter for all services increased by $0.64.

These consistent positive effects of PREDICT on diagnostic and certain preventive services (i.e., sealants) were not accompanied by increases in more costly service types (i.e., restorations) or extractions.

Conclusion

The major hypothesis that primary dental care (selected preventive services and diagnostic services in general) would increase significantly over time in PREDICT counties relative to controls was supported. There were small but statistically significant, increases in differential use of diagnostic services and sealants. Total cost per beneficiary rose modestly, but restorative and dental costs did not. The findings suggest favorable developments within PREDICT counties in enhanced preventive and diagnostic procedures, while holding the line on expensive restorative and extraction procedures.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06549-3.

Health Equity Beyond Data: Health Care Worker Perceptions of Race, Ethnicity, and Language Data Collection in Electronic Health Records

BACKGROUND

Recent research and policy initiatives propose addressing the social determinants of health within clinical settings. One such strategy is the expansion of routine data collection on patient Race, Ethnicity, and Language (REAL) within electronic health records (EHRs). Although previous research has examined the general views of providers and patients on REAL data, few studies consider health care workers' perceptions of this data collection directly at the point of care, including how workers understand REAL data in relation to health equity.

OBJECTIVE

This qualitative study examines a large integrated delivery system's implementation of REAL data collection, focusing on health care workers' understanding of REAL and its impact on data's integration within EHRs.

RESULTS

Providers, staff, and administrators expressed apprehension over REAL data collection due to the following: (1) disagreement over data's significance, including the expected purpose of collecting REAL items; (2) perceived barriers to data retrieval, such as the lack of standardization across providers and national tensions over race and immigration; and (3) uncertainty regarding data's use (clinical decision making vs. system research) and dissemination (with whom the data may be shared; eg, public agencies, other providers, and insurers).

CONCLUSION

Emerging racial disparities associated with COVID-19 highlight the high stakes of REAL data collection. However, numerous barriers to health equity remain. Health care workers need greater institutional support for REAL data and related EHR initiatives. Despite data collection's central importance to policy objectives of disparity reduction, data mandates alone may be insufficient for achieving health equity.

State Medicaid Authorities' Policy Communications With Providers on Individualized Pediatric Dental Care

OBJECTIVES

Medicaid's Early and Periodic Screening, Diagnostic and Treatment (EPSDT) pediatric benefit is designed to meet children's medically necessary needs for care. A 2018 Centers for Medicare & Medicaid Services (CMS) Bulletin advised Medicaid programs to ensure that their dental payment policies and periodicity schedules include language that highlights that medically necessary care should be provided even if that care exceeds typical service frequency or intensity. We assessed the extent to which Medicaid agencies' administrative documents reflect EPSDT's flexibility requirement.

METHODS

From August 2018 through July 2019, we retrieved dental provider manuals, periodicity schedules, and fee schedules in all 50 states and the District of Columbia; analyzed these administrative documents for consistency with the CMS advisory; and determined whether instructions were provided on how to bill for services that exceed customary frequencies or intensities.

RESULTS

Dental-specific periodicity schedules were not evident in 11 states. Eighteen states did not include flexibility language, for example, as advocated by the American Academy of Pediatric Dentistry. Flexibility language was not evident in 24 dental provider manuals or in 47 fee schedules. Only 8 states provided billing instructions within fee schedules for more frequent or intensive services.

CONCLUSION

Updating Medicaid agency administrative documents-including dental provider manuals and periodicity and fee schedules-holds promise to promote individualized dental care as ensured by EPSDT.

Differences in Outpatient Dermatology Encounter Work Relative Value Units and Net Payments by Patient Race, Sex, and Age

Importance

Clinical productivity measures may be factors in financial incentives for providing care to specific patient populations and thus may perpetuate inequitable health care.

Objective

To identify the association of patient race, age, and sex with work relative value units (wRVUs) generated by outpatient dermatology encounters.

Design, Setting, and Participants

This cross-sectional study obtained demographic and billing data for outpatient dermatology encounters (ie, an encounter performed within a department of dermatology) from September 1, 2016, to March 31, 2020, at the Emory Clinic, an academic dermatologic practice in Atlanta, Georgia. Participants included adults aged 18 years or older with available age, race, and sex data in the electronic health record system.

Main Outcomes and Measures

The primary outcome was wRVUs generated per encounter.

Results

A total of 66 463 encounters among 30 036 unique patients were included. Patients had a mean (SD) age of 55.9 (18.5) years and were predominantly White (46 575 [70.1%]) and female (39 598 [59.6%]) individuals. In the general dermatologic practice, the mean (SD) wRVUs per encounter was 1.40 (0.71). In adjusted analysis, Black, Asian, and other races (eg, American Indian or Native American, Native Hawaiian or Other Pacific Islander, and multiple races); female sex; and younger age were associated with fewer wRVUs per outpatient dermatology encounter. Compared with general dermatologic visits with White patients, visits with Black patients generated 0.27 (95% CI, 0.25-0.28) fewer wRVUs per encounter, visits with Asian patients generated 0.22 (95% CI, 0.20-0.25) fewer wRVUs per encounter, and visits with patients of other race generated 0.19 (95% CI, 0.14-0.24) fewer wRVUs per encounter. Female sex was also associated with 0.11 (95% CI, 0.10-0.12) fewer wRVUs per encounter, and wRVUs per encounter increased by 0.006 (95% CI, 0.006-0.006) with each 1-year increase in age. In the general dermatologic practice excluding Mohs surgeons, destruction of premalignant lesions and biopsies were mediators for the observed differences in race (56.2% [95% CI, 53.1%-59.3%] for Black race, 53.2% [95% CI, 45.6%-63.8%] for Asian race, and 53.6% [95% CI, 40.4%-77.4%] for other races), age (65.6%; 95% CI, 60.5%-71.4%), and sex (82.3%; 95% CI, 72.7%-93.1%). In a data set including encounters with Mohs surgeons, the race, age, and sex differences in wRVUs per encounter were greater than in the general dermatologic data set. Mohs surgery for basal cell and squamous cell carcinomas was a mediator for the observed differences in race (46.0% [95% CI, 42.6%-49.4%] for Black race, 41.9% [95% CI, 35.5%-49.2%] for Asian race, and 34.6% [95% CI, 13.8%-51.5%] for other races), age (49.2%; 95% CI, 44.9%-53.7%), and sex (47.9%; 95% CI, 42.0%-54.6%).

Conclusions and Relevance

This cross-sectional study found that dermatology encounters with racial minority groups, women, and younger patients generated fewer wRVUs than encounters with older White male patients. This finding suggests that physician compensation based on wRVUs may encourage the provision of services that exacerbate disparities in access to dermatologic care.

Factors Influencing Utilization of Preventive Health Services in Primary Health Care in the Republic of Serbia

The use of preventive health services is a long-term health investment due to its potential to help individuals to take care of their health. This study aimed to explore the availability and performance of health services in primary health care (PHC) in the domain of general practice (GP), pediatrics, and gynecology, as well as to analyze the influence of sociodemographic and health determinants on the utilization of preventive health services. This descriptive study used data from the National Health Insurance Fund and the Statistical Office of the Republic of Serbia for 2015 and included 149 independent PHC units. The relationship between the utilization of preventive services and sociodemographic and health characteristics of the population was analyzed by bivariate and multivariate linear regression models. The higher health expenditure per capita and noncommunicable diseases mortality rate were, the more preventive health services were provided by a chosen GP. Children with a higher completion rate of primary school (p = 0.024), higher health expenditure (p = 0.017), and higher life expectancy at birth (p = 0.041) had more preventive health services. The fertility rate was positively associated with the number of preventive health services per 1000 women (p = 0.033). Our findings should serve as a starting point for where efforts should be made to achieve better health outcomes.

Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care

Background

An academic safety-net hospital leveraged the federally funded state Delivery System Reform Incentive Payment programme to implement a hospital-wide initiative to reduce healthcare-associated infections (HAIs) and improve sepsis care.

Methods

The study period was from 2013 to 2017. The setting is a 770-bed urban hospital with six intensive care units and a large emergency department. Key interventions implemented were (1) awareness campaign and clinician engagement, (2) implementation of HAI and sepsis bundles, (3) education of clinical personnel using standardised curriculum on bundles, (4) training of key managers, leaders and personnel in quality improvement methods, and (5) electronic medical record-based clinical decision support. Throughout the 5-year period, staff received frequent, clear, visible and consistent messages from leadership regarding the importance of their participation in this initiative, performing hand hygiene and preventing potential regulatory failures. Several process measures including bundle compliance, hand hygiene and culture of safety were monitored. The primary outcomes were rates of central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) and sepsis mortality.

Results

From 2013 to 2017, the hospital-wide rates of HAI reduced: CLABSI from 1.6 to 0.8 per 1000 catheter-days (Poisson regression estimate: −0.19; 95% CI −0.29 to −0.09; p=0.0002), CAUTI from 4.7 to 1.3 per 1000 catheter-days (−0.34; −0.43 to −0.26; p<0.0001) and SSI after 18 types of procedures from 3.4% to 1.3% (−0.29; −0.34 to −0.24; p<0.0001). Mortality of patients presenting to emergency department with sepsis reduced from 9.4% to 2.9% (−0.42; −0.49 to −0.36; p<0.0001). Adherence to bundles of care and hand hygiene and the hospital culture of patient safety improved. Results were sustained through 2019.

Conclusion

A hospital-wide initiative incentivised by the Delivery System Reform Incentive Payment programme succeeded in reducing HAI and sepsis mortality over 5 years in a sustainable manner.

Cherry Blossoms, COVID-19, and the Opportunity for a Healthy Life

To date, short-term funding and policy fixes for the coronavirus disease 2019 (COVID-19) pandemic have focused on saving the current health care system; policies have not maximized the population's health, prioritized the safety net, nor addressed the fundamental problems that have hindered our nation's response for our most vulnerable neighbors. We need to plan more lasting equity-specific reforms now. I explain 3 lessons that should inform reforms to the health care delivery and payment systems to reduce health disparities and maximize the public's health: (1) Proven roadmaps and processes for reducing health care disparities already exist, as do themes of successful interventions. Implement them; (2) Payment reform needs to create a business case for health care organizations to address social determinants of health and implement care interventions to reduce health disparities; (3) We as a nation need to have hard conversations about whether we truly value the opportunity for everyone to have a healthy life.

Practical Lessons for Teaching About Race and Racism: Successfully Leading Free, Frank, and Fearless Discussions

Successfully teaching about race and racism requires a careful balance of emotional safety and honest truth-telling. Creating such environments where all learners can thrive and grow together is a challenge, but a consistently doable one. This article describes 12 lessons learned within 4 main themes: ground rules; language and communication; concepts of social constructs, intersectionality, and bidirectional biases; and structural racism, solutions, and advocacy. The authors' recommendations for how to successfully teach health professions students about race and racism come from their collective experience of over 60 years of instruction, research, and practice. Proficiency in discussing race and addressing racism will become increasingly relevant as health care institutions strive to address the social needs of patients (e.g., food insecurity, housing instability) that contribute to poor health and are largely driven by structural inequities. Having interprofessional team-based care, with teams better able to understand and counteract their own biases, will be critical to addressing the social and structural determinants of health for marginalized patients. Recognizing that implicit biases about race impact both patients and health professions students from underrepresented racial/ethnic backgrounds is a critical step toward building robust curricula about race and health equity that will improve the learning environment for trainees and reduce health disparities.

Analysis of Public-Private Partnership in Providing Primary Health Care Policy: An Experience From Iran

Background: This study aims to analyze the public-private partnership (PPP) policy in primary health care (PHC), focusing on the experience of the East Azerbaijan Province (EAP) of Iran. Methods: This research is a qualitative study. Data were gathered using interviews with stakeholders and document analysis and analyzed through content analysis. Results: Participants considered political and economic support as the most important underlying factors. Improving system efficiency was the main goal of this policy. Most stakeholders were supporters of the plan, and there was no major opponent. Implementing the health evolution plan (HEP) was an opportunity to design this policy. Participants considered the lack of provision of infrastructure as the main weakness, changing the role of the public sector as the main strength, and promoting social justice as the main achievement of policy. The results of the quantitative data review showed that following the implementation of this policy, health indicators have been improved. Conclusions: Based on the results of this study, the PPP model in EAP is a new and successful experience in PHC in Iran. Supporting and developing this policy may improve the quality and quantity of providing care.

Neighborhood Disadvantage and Hospital Quality Ratings in the Medicare Hospital Compare Program

BACKGROUND

The Centers for Medicare and Medicaid Services provide nationwide hospital ratings that may influence reimbursement. These ratings do not account for the social risk of communities and may inadvertently penalize hospitals that service disadvantaged neighborhoods.

OBJECTIVE

This study examines the relationship between neighborhood social risk factors (SRFs) and hospital ratings in Medicare's Hospital Compare Program.

RESEARCH DESIGN

2017 Medicare Hospital Compare ratings were linked with block group data from the 2015 American Community Survey to assess hospital ratings as a function of neighborhood SRFs.

SUBJECTS

A total of 3608 Medicare-certified hospitals in 50 US states.

MEASURES

Hospital summary scores and 7 quality group scores (100 percentile scale), including effectiveness of care, efficiency of care, hospital readmission, mortality, patient experience, safety of care, and timeliness of care.

RESULTS

Lower hospital summary scores were associated with caring for neighborhoods with higher social risk, including a reduction in hospital score for every 10% of residents who reported dual-eligibility for Medicare/Medicaid [-3.3%; 95% confidence interval (CI), -4.7 to -2.0], no high-school diploma (-0.8%; 95% CI, -1.5 to -0.1), unemployment (-1.2%; 95% CI, -1.9 to -0.4), black race (-1.2%; 95% CI, -1.7 to -0.8), and high travel times to work (-2.5%; 95% CI, -3.3 to -1.6). Associations between neighborhood SRFs and hospital ratings were largest in the timeliness of care, patient experience, and hospital readmission groups; and smallest in the safety, efficiency, and effectiveness of care groups.

CONCLUSIONS

Hospitals serving communities with higher social risk may have lower ratings because of neighborhood factors. Failing to account for neighborhood social risk in hospital rating systems may reinforce hidden disincentives to care for medically underserved areas in the United States.

The "Waze" of Inequity Reduction Frameworks for Organizations: a Scoping Review

BACKGROUND

Different conceptual frameworks guide how an organization can change its policies and practices to make care and outcomes more equitable for patients, and how the organization itself can become more equitable. Nonetheless, healthcare organizations often struggle with implementing these frameworks.

OBJECTIVE

To assess what guidance frameworks for health equity provide for organizations implementing interventions to make care and outcomes more equitable.

STUDY DESIGN

Fourteen inequity frameworks from scoping literature review 2000-2017 that provided models for improving disparities in quality of care or outcomes were assessed. We analyzed how frameworks addressed key implementation factors: (1) outer and inner organizational contexts; (2) process of translating and implementing equity interventions throughout organizations; (3) organizational and patient outcomes; and (4) sustainability of change over time.

PARTICIPANTS

We conducted member check interviews with framework authors to verify our assessments.

KEY RESULTS

Frameworks stressed assessing the organization's outer context, such as population served, for tailoring change strategies. Inner context, such as existing organizational culture or readiness for change, was often not addressed. Most frameworks did not provide guidance on translation of equity across multiple organizational departments and levels. Recommended evaluation metrics focused mainly on patient outcomes, leaving organizational measures unassessed. Sustainability was not addressed by most frameworks.

CONCLUSIONS

Existing equity intervention frameworks often lack specific guidance for implementing organizational change. Future frameworks should assess inner organizational context to guide translation of programs across different organizational departments and levels and provide specific guidelines on institutionalization and sustainability of interventions.

Promoting Health Equity And Eliminating Disparities Through Performance Measurement And Payment

Current approaches to health care quality have failed to reduce health care disparities. Despite dramatic increases in the use of quality measurement and associated payment policies, there has been no notable implementation of measurement strategies to reduce health disparities. The National Quality Forum developed a road map to demonstrate how measurement and associated policies can contribute to eliminating disparities and promote health equity. Specifically, the road map presents a four-part strategy whose components are identifying and prioritizing areas to reduce health disparities, implementing evidence-based interventions to reduce disparities, investing in the development and use of health equity performance measures, and incentivizing the reduction of health disparities and achievement of health equity. To demonstrate how the road map can be applied, we present an example of how measurement and value-based payment can be used to reduce racial disparities in hypertension among African Americans.

Advancing Health Services Research to Eliminate Health Care Disparities

Findings from health services research highlight continuing health care disparities in the United States, especially in the areas of access to health care and quality of care. Although attention to health care disparities has increased, considerable knowledge gaps still exist. A better understanding of how cultural, behavioral, and health system factors converge and contribute to unequal access and differential care is needed. Research-informed approaches for reducing health care disparities that are feasible and capable of sustained implementation are needed to inform policymakers. More important, for health equity to be achieved, it is essential to create a health care system that provides access, removes barriers to care, and provides equally effective treatment to all persons living in the United States.

Lessons for achieving health equity comparing Aotearoa/New Zealand and the United States

Aotearoa/New Zealand (Aotearoa/NZ) and the United States (U.S.) suffer inequities in health outcomes by race/ethnicity and socioeconomic status. This paper compares both countries' approaches to health equity to inform policy efforts. We developed a conceptual model that highlights how government and private policies influence health equity by impacting the healthcare system (access to care, structure and quality of care, payment of care), and integration of healthcare system with social services. These policies are shaped by each country's culture, history, and values. Aotearoa/NZ and U.S. share strong aspirational goals for health equity in their national health strategy documents. Unfortunately, implemented policies are frequently not explicit in how they address health inequities, and often do not align with evidence-based approaches known to improve equity. To authentically commit to achieving health equity, nations should: 1) Explicitly design quality of care and payment policies to achieve equity, holding the healthcare system accountable through public monitoring and evaluation, and supporting with adequate resources; 2) Address all determinants of health for individuals and communities with coordinated approaches, integrated funding streams, and shared accountability metrics across health and social sectors; 3) Share power authentically with racial/ethnic minorities and promote indigenous peoples' self-determination; 4) Have free, frank, and fearless discussions about impacts of structural racism, colonialism, and white privilege, ensuring that policies and programs explicitly address root causes.

Pay-for-performance incentive program in a large dental group practice

BACKGROUND

Dentists increasingly are employed in large group practices that use financial incentive systems to influence provider performance. The authors describe the design and initial implementation of a pay-for-performance (P4P) incentive program for a large capitated Oregon group dental practice that cares primarily for patients receiving Medicaid. The authors do not assess the effectiveness of the incentive system on provider and staff member performance.

METHODS

The data come from use of care files and integrated electronic health records, provider and staff member surveys, and interviews and community surveys from 6 counties. Quarterly individual- and team-level incentives focused on 3 performance metrics.

RESULTS

The program was challenged by many complex administrative issues. The key issues included designing a P4P system for different types of providers and administrative staff members who were employed centrally and in different communities, setting realistic performance metrics, building information systems that provided timely information about performance, and educating and gaining the support of a diverse workforce. Adjustments are being made in the incentive scheme to meet these challenges.

CONCLUSIONS

This is the first report of a P4P compensation system for dental care providers and supporting staff members. The complex administrative challenges will require several years to address.

PRACTICAL IMPLICATIONS

Large, capitated dental practice organizations will employ more dental care providers and administrative staff members to care for patients who receive Medicaid and patients who are privately insured. It is critical to design and implement a P4P system that the workforce supports.

Care delivery and compensation system changes: a case study of organizational readiness within a large dental care practice organization in the United States

Background

Dental care delivery systems in the United States are consolidating and large practice organizations are becoming more common. At the same time, greater accountability for addressing disparities in access to care is being demanded when public funds are used to pay for care. As change occurs within these new practice structures, attempts to implement change in the delivery system may be hampered by failure to understand the organizational climate or fail to prepare employees to accommodate new goals or processes. Studies of organizational behavior within oral health care are sparse and have not addressed consolidation of current delivery systems. The objective of this case study was to assess organizational readiness for implementing change in a large dental care organization consisting of staff model clinics and affiliated dental practices and test associations of readiness with workforce characteristics and work environment.

Methods

A dental care organization implemented a multifaceted quality improvement program, called PREDICT, in which community-based mobile and clinic-based dental services were integrated and the team compensated based in part on meeting performance targets. Dental care providers and supporting staff members (N = 181) were surveyed before program implementation and organizational readiness for implementing change (ORIC) was assessed by two 5-point scales: change commitment and efficacy.

Results

Providers and staff demonstrated high organizational readiness for change. Median change commitment was 3.8 (Interquartile range [IQR]: 3.3-4.3) and change efficacy was 3.8 (IQR: 3.0-4.2). In the adjusted regression model, change commitment was associated with organizational climate, support for methods to arrest tooth decay and was inversely related to office chaos. Change efficacy was associated with organizational climate, support for the company’s mission and was inversely related to burnout. Each unit increase in the organizational climate scale predicted 0.45 and 0.8-unit increases in change commitment and change efficacy.

Conclusions

The survey identified positive readiness for change and highlighted weaknesses that are important cautions for this organization and others initiating change. Future studies will examine how organizational readiness to change, workforce characteristics and work environment influenced successful implementation within this organization.

Electronic supplementary material

The online version of this article (10.1186/s12903-017-0448-4) contains supplementary material, which is available to authorized users.