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SUMMARIES OF RECENT
Commonwealth REPORTS
May 2005 - Oct 2005
REPORT CARDS CAN HELP MINORITY PATIENTS ACCESS QUALITY PROVIDERS
Although they may not be able to eliminate disparities, report cards can improve underserved minority patients' access to high-performing doctors. In "Quality Report Cards, Selection of Cardiac Surgeons, and Racial Disparities: A Study of the Publication of the New York State Cardiac Surgery Reports," Dana Mukamel, Ph.D., and colleagues examined the impact of New York State Cardiac Surgery Reports on patients' access to doctors with lower risk-adjusted mortality rates. Prior research has shown that nonwhite patients in NY do not enjoy the same access to high-quality cardiac surgeons as white patients do. But explicit quality-of-care measures made available to cardiac patients enrolled in Medicare fee-for-service apparently did help to level the playing field, at least somewhat, the study showed. Surgeon report cards influenced patients' choices, the researchers found, and in particular gave black patients similar access to information on surgeon quality as whites have. Continued use of report cards, the authors say, could play an important role in reducing inequities in access to better care.
The full report may still be available at CLICK HERE
STATES EXPERIMENTING WITH WAYS TO HELP UNINSURED
Many states are examining options and crafting policies to cover their uninsured populations. To help grantee states share their findings and results with other state and federal policymakers at the Economic and Social Research Institute (ESRI) have compiled a report. ESRI's S Silow-Carroll and T Alteras find that most states awarded planning grants are exploring strategies that build on employment-based coverage, generally through publicly funded premium assistance. Some states uncovered support among employers and providers for tax credits to subsidize the employer and/or employee share of the premium. Others are exploring premium assistance through Medicaid and the State Children's Health Insurance Program (CHIP). In addition to employment-based strategies, states are improving outreach and enrollment for people eligible for but not enrolled in existing programs; using federal waivers to extend Medicaid/CHIP coverage to parents and other adults; establishing health savings accounts; reinsuring private coverage; imposing a full employer mandate; and assessing single-payer and multipayer universal coverage models. [EINO: it is important to note that many of the critics of state work on UHC have relied on the argument that ERISA would not allow exceptions so that states could evolve novel approaches. As we have said all along their crystal balls are filled with supposition and poor reasoning.]
The full report may still be available at CLICK HERE
HSAs UNLIKELY TO HELP MANY UNINSURED AMERICANS
Health savings accounts (HSAs) coupled with high-deductible health insurance plans are being promoted by some as a way to make patients more cost-conscious while also making coverage more affordable for the uninsured. But two new Commonwealth Fund reports find that these benefits are unlikely to materialize on any sizable scale.
Fewer than 1 million of the nation's 45 million uninsured are likely to gain health coverage through HSAs and high-deductible plans, say Columbia University researchers Sherry Glied and Dahlia Remler in The Effect of Health Savings Accounts on Health Insurance Coverage. HSAs could also lead to destabilization in the group health insurance market, the authors note, if small businesses begin to offer only high-deductible plans because their higher-wage employees prefer them.
The full report may still be available at CLICK HERE
HOW HIGH IS TOO HIGH? IMPLICATIONS OF HIGH-DEDUCTIBLE HEALTH PLANS
In "How High Is Too High?" it is concluded that providing tax incentives for the purchase of high-deductible health plans will have little effect on the uninsured rate, because premiums for these plans are still too high for most uninsured Americans two-thirds of whom have incomes below the federal poverty level. Davis and coauthors MM Doty and A Ho report that premiums for high-deductible plans in the individual market range from 6 % to 20 % of income for individuals living at 200 % of the federal poverty level or less. Factoring in out-of-pocket costs, low-income families would be at risk for spending up to 30 % of their income under high-deductible plans. High deductibles create a barrier to essential care for many lower-income individuals. Policymakers could better target the uninsured and ensure access to care for lower-income individuals by permitting employers to lower deductibles for low-wage workers and exempting primary as well as preventive care from deductibles.
The full report may still be available at CLICK HERE
FOUR OF 10 SENIORS DO NOT TAKE MEDICATION AS PRESCRIBED
Four of 10 seniors say they haven't taken all the drugs their doctors prescribed in the past year either because costs were too high, they didn't think the drugs were helping, or they didn't think they needed them. "Prescription Drug Coverage and Seniors: Findings from a 2003 National Survey" found that many deal with complex and costly drug regimens. Of the 89 % who reported taking prescription drugs in the past year, nearly half (46%) take five or more, more than half (54%) have more than one doctor who prescribes medicine, and about a third (35%) use more than one pharmacy. Among seniors with at least three chronic health conditions, nearly three of four take five or more medications regularly and more than half do not take all their drugs as prescribed. The survey, conducted prior to the enactment of the Medicare Modernization Act, found that slightly more than one in four seniors reported having no prescription drug coverage. Coverage rates varied widely across states, with seniors in Louisiana (35%) and Washington (36%) more than twice as likely to lack coverage as seniors in New York (16%).
The full report may still be available at CLICK HERE
MORE YOUNG ADULTS LACK HEALTH INSURANCE
Between 2000 and 2003, the number of 19-to-29-year-olds lacking health coverage rose by 2.2 million, to 13 million. As a result, these young adults who often lose coverage after graduating from high school or college are more likely than their covered peers to forgo medical care or have health problems. Policy changes that could extend coverage to uninsured young adults and prevent others from losing it include: 1) Extending dependents' eligibility for private coverage through age 23; 2) Extending eligibility for Medicaid and the State Children's Health Insurance Program through age 23 and 3) Ensuring that colleges and universities require and offer insurance coverage to both full- and part-time students.
The full report may still be available at CLICK HERE
AT LEAST 16 MILLION AMERICANS UNDERINSURED IN 2003
Some 45 million uninsured American adults lack health insurance [official census data counting only those who were uninsured from Jan 1 - Dec 31, about half those who experienced a period of uninsurance]. However, at least 16 million more were underinsured in 2003, meaning they did not have enough financial protection to cover their health expenses [only counts those who tested their poor coverage and proved themselves underinsured during the year, a fraction of those underinsured]. "Insured But Not Protected: How Many Adults Are Underinsured?" by C Schoen, MM Doty, SR Collins, and AL Holmgren found that the estimated 61 million [according to their extremely conservative methods of calculation] with no insurance, sporadic insurance, or insurance that exposed them to catastrophic medical costs were at increased risk for not being able to obtain the quality care they needed. [EINO: great study, but misleading in its estimate of problem which claims to assess risk of exposure to catastrophic costs. Those at risk are ALL of those in same pool as the few (16 million) who were proven to have inadequate insurance and this would be greater by several-fold. This is important, because correct estimation would show that MOST AMERICANS experience uninsurance or underinsurance in any given month. All of us with inadequate mental health, physical therapy and long-term care coverage are underinsured. That's most working Americans.]
Half of the underinsured and uninsured went without at least one of four needed medical services, double the rate of those with adequate insurance.
Two-thirds of the sicker adults who were underinsured and three-fourths of sicker adults who were uninsured went without needed care.
Nearly half of underinsured adults with chronic disease or poor health did not take their medications as prescribed.
The full report may still be available at CLICK HERE
OLDER AMERICANS CONCERNED ABOUT FINANCIAL AND HEALTH SECURITY
Concerned about their financial and health security, a substantial majority of older Americans would favor setting aside a portion of their earnings in a special supplemental account to save for future medical expenses not covered by Medicare. "Will You Still Need Me? The Health and Financial Security of Older Americans" by SR Collins and colleagues, shows that many adults ages 50 to 70 fear they will not have enough income and savings to afford needed medical care in their retirement. To offset costs, nearly 70 % support dedicating 1 % of their earnings [an upper-income and non-insurance "solution" which avoids pooling risk] to a new Medicare Health Account to help pay for uncovered medical expenses.
The full report may still be available at CLICK HERE
US HEALTH SYSTEM IS FRAUGHT WITH WASTE AND INEFFICIENCY
Despite spending two-fold per capita on health care what any other country does, the US health system is fraught with waste and inefficiency. The chartbook paints a stark picture of a fragmented system beset by widespread disparities in access to and quality of care. "A Need to Transform the US Health Care System: Improving Access, Quality, and Efficiency" points to promising opportunities for reforming the health system including: 1) management of high-cost care, enhancements in care coordination, disease management, and developing networks of high performing providers under Medicare, Medicaid, and private insurance.
Particularly problematic is the large number of individuals lacking ready access to health services. Over a third of the population is uninsured [very conservatively estimated] unstably insured, or underinsured. With health care costs on the rise, affordability is a key concern for many working families. Gaps in insurance coverage and high out-of-pocket spending hinder patients' access to care and lead to skipped medical tests, treatments, and follow-up appointments. In turn, these access problems produce preventable pain, suffering, and death as well as more expensive care.
The full report may still be available at CLICK HERE
Commission chair James J. Mongan, M.D., president and CEO of Partners HealthCare, noted that "the disconnect between people wanting the new things that medical science can produce, yet not being sure that they are willing or able to pay for them." In his presentation, A Tale of Two Health Systems, Mongan said this disconnect "will lead to more of a focus on the value equation in health care, and to more of a focus on a high-performing health system.". However, the US health care system underperforms on any number of measures. By World Health Organization statistics, we rank well below 20 other nations in attainment of key health objectives. Look within our own country and you'll see great disparities among races, with an infant mortality rate of 13.3 per thousand for black babies, more than double the rate for white babies. Look further at the numbers and you'll see that we are the most costly system in the world, with 15 % of gross domestic product (GDP) going to health care in 2003, well ahead of our closest competitor, Switzerland, at 11.5 % of GDP and the European median of 8.6 %. And in terms of access to care, the US is the only nation without universal coverage.
The full report may still be available at CLICK HERE
REINSURANCE: AN ANSWER TO UNAFFORDABLE PREMIUMS?
In 2004, health plan premiums in the Healthy New York insurance program were 40 % lower than the average small-group HMO premium in NYC, and two-thirds lower than the self-pay individual market premium. How did state officials achieve such impressive results? A big reason is reinsurance, according to a leading expert. Katherine Swartz says that state-provided reinsurance in essence, insurance for insurance companies can allow insurers to lower premiums significantly by relieving them of the risk of enrolling large numbers of people with catastrophic medical costs. [EINO: Sure, if 1) you ignore the expense to taxpayers of taking over all the costs for those with costly chronic conditions and 2) you measure just the initial effects on premiums]. So far, however, only two states, New York and Arizona, have reinsurance programs in place. State-government-provided reinsurance relieves health insurers of the risk of "adverse selection" (disproportionate enrollments of individuals with extraordinarily high medical costs), particularly in the small group and individual markets. With such programs in place, insurers MAY INITIALLY significantly lower premiums, thereby making health coverage affordable for more people.
The full report may still be available at CLICK HERE
ELIMINATING DISPARITIES IN TREATMENT AND THE STRUGGLE TO END SEGREGATION
"Eliminating Disparities in Treatment and the Struggle to End Segregation" DB Smith makes the case for transforming health care reform into a civil rights issue. Current efforts to eliminate racial and ethnic disparities in health care treatment fail to address the effect of segregation on disparities. By reviewing the history of civil rights era efforts to integrate US health care, he offers lessons for current disparity-reduction efforts. Policymakers need to make the reduction of health care segregation a measurable goal, reinvigorate regional planning, and take a more critical view of the impact of "consumer-driven" choice in the organization of health care.
In 1954, at the time of the Brown decision, the vast majority of black and white health professionals saw little promise that there would ever be any significant change. In most communities, racial integration in hospitals and health care was too difficult an issue, and efforts instead focused on the integration of schools and public accommodations, which seemed easier to achieve. Yet, a small network of activist black physicians and civil rights lawyers coalesced after the Brown decision and began to map out a campaign to include Title VI in the Civil Rights Act of 1964, which prohibited the provision of federal funds to organizations or programs that engaged in racial segregation or other forms of discrimination. The first significant test of Title VI enforcement came with the implementation of the Medicare program in 1966. More than 1,000 hospitals quietly and uneventfully integrated their medical staffs, waiting rooms, and hospital floors in less than four months.
However, outside the hospital, the rest of the health care system was never directly affected by the Medicare integration efforts. No effort to inspect nursing homes for compliance was ever mounted. Physicians were specifically exempted from compliance with Title VI. Until the recent resurgence of interest in health disparities, health care has been left to drift, unrestrained by concerns about segregation and responding only to changing market forces.
The full report may still be available at CLICK HERE
TOOLS FOR REDUCING RACIAL AND ETHNIC DISPARITIES IN HEALTH CARE
"Equity Measures and Systems Reform as Tools for Reducing Racial and Ethnic Disparities in Health Care" by SD Watson calls for a "systems reform" approach to reducing treatment disparities that includes the collection and reporting of performance data by patient race and ethnicity, which neither government agencies nor private accreditation bodies currently require. By failing to track performance data by race and ethnicity quality improvement initiatives not only miss inequities in treatment but likely overlook promising techniques for reaching particular patient populations.
Some of the disparities in health care result from individual provider and patient behavior: prejudice, stereotyping, poor communication, or uncertainty in decision-making. Others are attributable to institutional policies and structures. Whatever the causes, racial disparities in health care call for quality improvement initiatives.
The full report may still be available at CLICK HERE
CAREGIVERS PROVIDE CRUCIAL SERVICES YET RECEIVE LITTLE SUPPORT
Informal caregivers play an increasingly important role in the US health care system; in 2003, nearly one of 10 working-age adults was caring for a sick or disabled family member. Yet more than half of the nation's 16 million caregivers, or 9 million adults, have health problems of their own, and many cope with severe financial stress. In "A Look at Nonelderly Caregivers' Roles, Health Concerns, and Need for Support" A Ho, SR Collins, KD Davis and MM Doty say caregivers aged 19 to 64 are more likely to not be working, to miss days of work if they are employed, and to lack health insurance coverage than non-caregivers. As a result, many are financially vulnerable and struggle to obtain needed care. Given caregivers' vital function, policymakers should take steps to ease their burdens. Possible reforms include allowing caregivers to be covered under Medicaid or the State Children's Health Insurance Program, allowing early Medicare buy-in for caregivers of Medicare beneficiaries, or providing tax credits to help pay for caregivers' medical expenses.
The full report may still be available at CLICK HERE
HEALTH AND PRODUCTIVITY AMONG US WORKERS
Health problems among working-age Americans and their families carry an estimated price tag of $260 billion in lost productivity each year. "Health and Productivity Among US Workers" by K Davis, SR Collins, MM Doty, A Ho, and A Holmgren revealed: 1) Eighteen million adults ages 19 to 64 were not working and had a disability or chronic disease, or were not working because of health reasons; 2) Nearly two-thirds (64%) of workers reported missing days because of their own illness or that of a family member, for a total of 407 million days of lost time at work and 3) Half of workers reported a time when they were unable to concentrate at work because of their own illness or that of a family member, accounting for 478 million days. [EINO: How much of this lost productivity would be avoided with a genuinely universal system of coverage? and who has accurately counted this and other savings into figures for the 'cost' of establishing UHC?] The authors conclude that providing workers with the means to maintain their health and the health of family members, including affordable and comprehensive health insurance coverage and paid sick leave, could yield economic pay-offs for working families and the economy as whole.
The full report may still be available at CLICK HERE
SEEING RED: AMERICANS DRIVEN INTO DEBT BY MEDICAL BILLS
Both the high cost of health care and inadequate health insurance coverage are undermining the financial security of millions of Americans. An estimated 77 million Americans struggle with medical bills, have recent or accrued medical debt, or both. "Seeing Red: Americans Driven into Debt by Medical Bills" it's reported that while medical bill problems and debt are experienced most often by the uninsured, even many working-age adults who are continually insured have problems paying their medical bills and have medical debt [it's called underinsurance]. The study also found that working-age adults incur significantly higher rates of medical bills and debt than adults 65 and older. These financial burdens ultimately affect the likelihood that people will get the care they need. About 63% of those reporting medical bill problems or medical debt went without needed care because of the cost, compared with 19% of adults without any medical bill problems or debt.
The full report may still be available at CLICK HERE
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Commonwealth reports April 2005 and earlier
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