The Users' Guide to the Health Reform Galaxy

Robert Otto Valdez makes Christmas appeal to the U.S. Senate

Robert Otto Valdez, PhD, executive director of the Robert Wood Johnson Foundation Center for Health Policy at the University of New Mexico, channels FDR and Jimmy Stewart to make the case for expanding Medicare to achieve universal health coverage.

I was reminded the other day watching “Mr. Smith Goes To Washington” that
sometimes you just need to say what needs to be said until the Senate hears what is
right. This is right: We all have a right to life and liberty. These are founding principles
of our nation; they define our social contract to one another. And one cannot have life
and liberty without good health. ALL those living and working in the USA must have
access to quality health care and healthy communities, lest we break the social
contract itself. The Senate’s debates on health insurance reform must restore our
nation’s social contract in accord with these principles.

President Franklin Delano Roosevelt commented that “the test of our progress is not
whether we add more to the abundance of those who have much; it is whether we
provide enough for those who have too little.” The Senate would be wise to heed
these words as they debate health insurance options for our nation. History shows
that private enterprise and the profit motive do not ensure the well-being of every
individual - public commitment is essential to achieve our ideals as a society.

We would do well to recognize our own history with the Social Security program,
the cornerstone of our nation’s economic security. At first, coverage was
limited to only a few. Only gradually, over several decades, was the program
expanded to its present nearly universal form. Today, it is recognized as our nation’s
most important anti-poverty program, the major or only source of income for many
seniors.

Health reform could hurt minority groups if not done right

Bruce Siegel, director of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care, writes that equity should be an important component of health reform.

Health care reform could actually hurt minority groups unless Congress makes some fixes. Without an explicit focus on equity, reform could leave millions of these Americans behind.

The goal of the reform bills in the House and Senate is to dramatically expand access to coverage, including for minority groups, which are traditionally under-insured. But the bills also envision measuring doctors’ and hospitals’ results and paying them based on how well they perform. And while that is a laudable goal, it could also hurt minority groups if not done right. If, for instance, we start measuring and penalizing hospitals depending on how many patients need to be admitted again, hospitals could have incentives to turn away the poorest and sickest patients; who tend to also be people of color. And safety net hospitals that underperform, already overburdened and underfunded, would be further deprived of resources.

The issue looms large given that racial and ethnic minority groups will be in the majority in the U.S by 2050. They already account for half the uninsured, are poorer in health, suffer more disease and are more likely to get inferior care. There are also equity implications in the transformation taking place in provider reimbursement as the notion gains ground that we need to systematically and rigorously examine how well our doctors and hospitals perform and pay them accordingly.  Especially important, in the interest of attaining quality care for all patients, is measuring how well the system treats minority groups.

Reforming health care in rural America

Keith J. Mueller, PhD, director of the Nebraska Center for Rural Health Research and the Rural Policy Research Institute (RUPRI)’s Center for Rural Health Policy Analysis, writes about a new report prepared by the RUPRI Health Panel, Assuring Health Coverage for Rural People through Health Reform.

The benefits of living in rural America may be many, but enjoying stable, comprehensive health insurance is not necessarily among them. The 50 million Americans who live outside metropolitan areas are more likely to be uninsured or underinsured than their urban counterparts. In order to improve the health care of all Americans, regardless of geography, policy makers need to pay attention to these differences.

The challenges rural Americans face in obtaining health insurance are partly due to the structure of the rural economy. Simply put, jobs in rural communities are less likely to come with health benefits than those in urban America. Rural workers also pay more for health insurance plans than workers at urban businesses.

For health reform to work for all Americans...

Bruce Siegel, director of the Robert Wood Johnson Foundation’s (RWJF) Aligning Forces for Quality (AF4Q) initiative and the RWJF legacy program, Expecting Success: Excellence in Cardiac Care (Expecting Success), writes about collecting race, ethnicity and language data.

In the medical profession, we diagnose problems before we attempt to treat them.  It shouldn’t be any different when we try to fix our health care system.

As Congress focuses on expanding health coverage and reducing cost and waste in the health care system, an important question is: how will we make health care not only more efficient, but better for patients and families from all racial and ethnic backgrounds? 

It starts with working with the best possible data. We need to know who’s  not receiving high quality care so we can target our efforts. Reams of research have shown that racial and ethnic disparities persist despite efforts to reduce them. To address these gaps in care, hospitals, medical practices and health plan members  need precise and standardized data on patients’ race, ethnicity and primary language. 

Reducing disparities and enhancing data collection have been discussed in many of the health reform proposals in Congress. If included in the final legislation and as health care systems continue to work to close the gap, guidance and best practices on how to do this will be needed.

The Office of Management and Budget (OMB) has a standard set of race and Hispanic ethnicity categories that are widely used (race categories: Black or African American, White, Asian, American Indian or Alaska Native, and Native Hawaiian or Other Pacific Is¬lander;  ethnicity categories: yes or no in reference to Hispanic/Latino ethnicity), but that is not enough.

A recent report by the Institute of Medicine (IOM) recommends that health care organizations continue to use the OMB categories and add more detailed ethnicity categories (known as granular ethnicity and based on a patient’s ancestry), which will help organizations better identify disparities and move away from broad categorizations of people. For example, in very diverse communities such as Miami, “black” can mean a lot of things and include many cultures, making more specific categories such as Haitian or Bahamian useful. The IOM also recommends using categories to assess language needs (ratings of spoken English language pro¬ficiency and a patient’s preferred language for health-related encoun¬ters).  Understanding a patient’s language needs will increase the ability to communicate in medical settings, which is critical to providing and receiving high-quality care. The report suggests that organizations list location-relevant categories and provide a space for patients to self-identify their ethnicity or language if it is not listed.

With better information, health care organizations can better understand the populations they serve, detect disparities in care, design actual solutions to improve care and evaluate progress. Through our work with two RWJF programs, Expecting Success and Speaking Together: National Language Services Network (Speaking Together), we have done just that. We have found that more detailed data enables us to better develop targeted quality improvement interventions for more specific populations.

As part of the Expecting Success program, we worked with 10 hospitals to develop and share tools for improving cardiac care for African-American and Hispanic patients with acute myocardial infarction or congestive heart failure. Hospital leaders want to believe that their hospitals provide equal care regardless of a patient’s race, ethnicity or primary language, but few know for sure. Without uniform standards for collecting this information, there is no way of knowing if all patients receive the same level of care.

The Expecting Success hospitals established standardized collection of patient race, ethnicity and language data. For the first time ever, the hospitals analyzed 23 cardiac care quality indicators by patient race, ethnicity and language. Although some had to face the reality that there were disparities in care in their hospitals, they were better equipped to address these gaps.

Several questions arose as the hospitals analyzed their race, ethnicity and language data such as “Why are some Hispanic patients consistently not receiving all discharge instructions?” and “Why are readmission rates so much higher for minority patients?”. These questions prompted the hospitals to design interventions to specifically address these issues. As they developed these and other programs, they were able to compare data on core measures before and after implementation to help assess their efficacy and adapt their approach as needed.

In Speaking Together, an initiative modeled after the Expecting Success program, we worked with 10 hospitals to improve the quality and availability of language services. For many patients whose first language is not English, language services are integral to getting the right care at the right time. An organization’s ability to provide appropriate language services depends on its ability to accurately screen for language needs of its patients and to identify patients’ preferred language for health care encounters—data collection is  fundamental. Without this information, we are trying to diagnose and treat a problem with a limited exchange of information.

At the beginning of Speaking Together, several hospitals were collecting language data, but there was room for improvement. To increase screening for patient language needs, hospitals used a combination of efforts, including using data to open a discussion with the leaders of registration and scheduling; training staff on screening for language needs; programming reminders in the registration and scheduling screens to prompt staff to complete the language field; using scripts for language screening; and integrating demographic information with other electronic systems in the organization. At one hospital, screening rates went from 60 percent to more than 80 percent. At another hospital, screening rates improved from approximately half of patients screened to nearly all patients screened. The data collected through these screening efforts enabled the hospitals to more accurately identify which languages were spoken by their patients, improve their overall language services and deliver safer, higher quality care.

In both of these projects, the ability to reduce disparities began with the knowledge that we gained through data collection. As we work to reform our health system to improve care for all, we need to ensure that our health care organizations are actively collecting information on our patients’ race, Hispanic and granular ethnicity, and language needs. We know the symptoms of poor-quality, unequal care, but to truly diagnose it and treat it, we need the data.

Getting to the bottom of regional disparities in health care spending

Sharon Arnold, vice president at AcademyHealth and the director of RWJF’s Health Care Financing and Organization initiative, writes about what we need to know before we can act.

Of all of the questions facing policymakers and experts on health reform, none is perhaps as difficult as the prospect of controlling health care costs.  Most analysts and policymakers agree that health care costs are growing too rapidly, but more importantly, research also shows that we are perhaps not getting a sufficient return on value for the dollars spent on health care.  Seminal work from researchers at Dartmouth has demonstrated that there is significant geographic variation in health care spending by Medicare, and that health outcomes in high spending areas do not appear to be better than outcomes in lower spending areas. 

It's the waste, stupid.

(Today Mike Painter, who has written for us before on health care quality and value, now takes a look at the issue of health care spending and waste in the health care system, and references analysis conducted using the PROMETHEUS payment model.  RWJF is sponsoring a lunch briefing in DC today to give stakeholder groups an overview of the PROMETHEUS model and other payment reform approaches, and the webcast of this event will be available in the next few days on this site.)

A recent Wall Street Journal editorial strongly challenged the notion that there is enormous waste in American health care.  In the article the editors acknowledge that dramatic variation in health care spending exists across the country—but point out that the precise reason for that variation remains uncertain.  They also note that much of the data about regional variation comes from the Dartmouth Atlas—and that work, they point out, is limited in that it only examines Medicare data.  And they cite work from Richard Cooper at the Wharton School that directly challenges some of the Dartmouth Atlas conclusions—essentially arguing that the Dartmouth observed regional variation is actually simply an artifact of Medicare.   They conclude that “Dr. Cooper’s assault on the Dartmouth Atlas is controversial but compelling. He argues that the less-is-more theory is based on the flawed premise that when a region's outcomes did not improve as spending increased, the difference is simply classified as ‘waste’ – even if it isn't.”

And yesterday, at a Brookings Institution-sponsored conference on comparative effectiveness, Peter Orszag, mentioned prominently in the WSJ article, initiated the beginnings of a response to the editorial—noting that he did not believe that the Wharton research was correct.