U.S. Is Many Different Communities When it Comes to Health

The following excerpt comes from the November 1, 2017, article by Sternberg in US News and World Report.


The jigsaw puzzle of U.S. counties fits neatly together into a pleasing whole, displaying America as a land of many parts.

Within those parts, people in adjacent communities may have similar lifestyles and incomes. They may eat similar foods, enjoy the same music, picnic in the same parks and vacation at the same campgrounds or beaches.

But look more closely and you’ll find people living in neighboring communities often live very different lives. Residents in one county may suffer many more days of poor physical or mental health – or both – than those in the county next door. People in many communities even live longer than those in communities nearby, a pattern that extends nationwide.

Which is why community health assessments – including a new U.S. News ranking of the nation’s Healthiest Communities, to debut in March – are so valuable for identifying trouble spots and targeting remedies to where they’ll do the most good.

Think of them as diagnostic scans of what ails America, from soaring rates of obesity, hypertension, and diabetes to pervasive mental health problems and opioid abuse. The overlapping epidemics are having a profound impact nationwide. For the first time in nearly a century, life expectancy has begun to decline in major population groups, and not just in poor underprivileged neighborhoods. Death rates rose for white men, white women, and black men, and remained essentially unchanged for black women and Hispanic men and women.

“This is the first time we’ve really seen fairly marked decreases in life expectancy in key groups and not simply the socially disadvantaged,” says Dr. William Stead, chief strategy officer at Vanderbilt University Medical Center and McKesson Foundation professor of biomedical informatics.

In most measures of population health, the world’s richest country lags behind other developed countries, despite trillions spent each year on medical care.

“Waves of chronic disease are reaching historic rates,” says Tyler Norris, chief executive of the Well Being Trust, a $100-million nonprofit funded by Providence St. Joseph Health to help improve the nation’s mental and physical health. Chronic diseases not only reduce productivity, he says, they have driven health care costs so high that they are “unaffordable no matter who you are.”

Eighty percent of the growth in Medicare spending – now totaling nearly $650 billion a year – is due to chronic disease, says Kenneth Thorpe, of the Rollins School of Public Health at Emory University and chairman of the Partnership for Chronic Disease.

Tragically, this chronic-disease epidemic of diabetes, hypertension, heart disease, stroke, arthritis and other ailments is occurring against the backdrop of a revolution in medical care, one that ushered in countless innovations including antibiotics, blockbuster drugs, high-tech surgery and genetic medicine.

The roots of the problem run deep, anchored in national neglect of festering social problems and each community’s history, culture, economy, schools, hospitals, neighborhoods and sense of place. These so-called social determinants offer a way of assessing community health. They show that poor health and other social problems are more heavily concentrated in some neighborhoods than others, variations that may not be apparent when examined at the national or state levels.
Read the full article.

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Food Security, Social Determinants of Health Lower Hospital Use

The following excerpt comes from the November 1, 2017, article by  Sara Heath on Patient EngagementHIT.


Implementing public programs to supplement food security in low-income patients can help reduce hospital use within that population, according to a study published in both BMC Geriatrics and Population Health Management. This data suggests that addressing the social determinants of health can directly improve health outcomes.

Currently, nearly one-third of senior patients live on income less than 200 percent of the poverty line, a fact which the Maryland-based research team said impacts that healthcare industry. Low-income patients have a higher propensity for utilizing hospitals and the emergency department.

Previous efforts to meet health needs include expanding access to primary care, but researchers added that caring for social needs is also essential for health improvement.

“Excess hospital utilization in this population was once believed to be preventable by improving health care access,” the research team said. “However, disparities exist among older adults who have health insurance through Medicare, and are not attributable to access to primary care providers.”

Previous research has suggested that 85 percent of patient health is determined by the social determinants of health, as opposed to genetic makeup or other health-related factors such as healthcare access.

The social determinants of health include social factors like housing, education level, and food security, among others.

The Supplemental Nutrition Assistance Program (SNAP) is one such program suitable for addressing food security. The federally-funded program has proven effective in expanding food access for low-income individuals, and shown that food access may be tied to health outcomes, the team posited.

“By targeting financial support toward food needs, SNAP can improve access to a higher quality diet for food insecure adults,” the researchers explained.

“There is evidence of reduced caloric intake, poorer dietary quality, and greater risk of hypoglycemia for low-income adults at the end of the month when funds run low,” the research team continued. “Therefore, greater SNAP benefits may facilitate chronic disease management for nutrition-sensitive conditions, which may account for evidence of reduced chronic disease hospital utilization.”

The team looked at nearly 6,900 patients over the age of 65 who were dually eligible for Medicare and Medicaid between 2009 and 2012. Matching data about days spent in the hospital, healthcare costs, and emergency department visits with SNAP enrollment data showed that the program has an impact on healthcare.

SNAP benefits reduced the likelihood for hospitalization by 14 percent, and reduced the likelihood of each individual day in the hospital by 10 percent.

The program also reduced the likelihood of nursing home admissions by 23 percent, and reduced each additional day in the nursing home by 8 percent.

SNAP benefits had no statistically significant effect on ED utilization, but the researchers maintained that the results nonetheless showed great potential for SNAP in healthcare.

Specifically, the results proved that more than just increasing access to care can help reduce hospital and ED utilization.

“It is notable that all had access to both Medicare and Medicaid because policy makers have increased access to health care for low-income groups thinking that that alone would reduce high hospital utilization in low-income groups,” the researchers pointed out.

Read the full article.

 

Why insurance really is a life or death issue, especially for minorities

The following excerpt comes from the article by Dr. Valerie Montgomery Rice posted on CNN on October 19,2017.


The study released this week by the American Cancer Society highlighted the significant role health insurance plays in the widening chasm of disparities in breast cancer mortality.

Progress on this front has been made. The Affordable Care Act (ACA) has resulted in the lowest uninsured rate ever recorded in our nation’s history: 8.8% down from 16% in 2009 before the ACA was signed into law, according to the Council for Economic Advisers and National Center for Health Statistics. It has provided life-saving preventive and diagnostic screenings, access to higher quality care and appropriate treatments, as well as increased opportunities for diverse women to participate in clinical trials.

As we recognize National Breast Cancer Awareness Month this month and continue the national debate over health reform, it is worth noting the impact that a lack of health insurance coverage has on women reaching their optimal level of health or health equity.

I began my medical career as an obstetrics and gynecology resident in the late 1980s at Atlanta’s Grady Memorial Hospital. Emergency rooms in hospitals such as Grady were a last resort for uninsured patients who, in many cases, struggled with undiagnosed cancer, high-risk pregnancies, heart disease, diabetes and other life-threatening diseases.

The disparities in coverage and access to quality care for patients whose cards were stacked against them were striking, especially for women battling breast cancer, which is the most common cancer among women in the United States and is the second leading cause of cancer deaths.

While a host of factors increase women’s risk for breast cancer, such as genetics, age, sex and race, studies show that these factors are exacerbated for underserved communities, black women in particular, where the disease can be a catastrophic difference between life and death.

Mammogram screening is universally accepted as the best weapon for early breast cancer detection. Covered by the ACA as a preventive service at no cost to the consumer, mammogram screenings are the first line of defense. With the elimination of cost we expected an increase in mammograms, particularly among minority women. We hoped it would lead to a decrease in racial/ethnic disparities in breast cancer. And now many studies have confirmed the ethnic gap narrowed between women who received screening prior to ACA, and after.

Why does this matter? If we know that early detection is the key to lowering breast cancer mortality rates among all women, then access to appropriate screenings, early treatment and counseling should be considered the standard of care.

Read the full article.

The Imperative for Learning Health Systems to Address Health Literacy

The following excerpt comes from the article by Cindy Brach posted October 11, 2017, on the Prevention Policy Matters Blog at Health.gov.


“Learn or perish” would be an apt slogan for health systems today. The rate of change in health care is high. Technological advancements, research, innovation, and market dynamics all drive the soaring complexity of the health care system. In order to survive, health systems must learn how to adapt, and in the process – we argue – address health literacy.

Integrating Knowledge into Practice

One aspect of a learning health system (LHS), according to the charter and vision of the Institute of Medicine’s (IOM) Roundtable on Evidence-Based Medicine, is “to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider.” This means that integrating new knowledge into practice requires adaptation to the unique context of patients and their families.  

The current model of translating knowledge into practice consists of clinicians keeping up with the research literature, consulting the practice norms of their community, deciding which care is appropriate (i.e., “choosing wisely”), prescribing tests and treatment, with the expectation that patients will be compliant. As clinicians increasingly work for large health systems, care has become more standardized. Evidence reviews inform the development of clinical decision support tools, and performance metrics enable physicians to better understand their personal practice patterns and improve where necessary.  

Under the emergent LHS model, however, clinicians elicit patient goals and preferences, use data to tailor evidence to the patient, and engage in shared decision making. This requires physicians and the health care team to be clear communicators who engage and support patients and families as integral partners in medical decisions.  

Want To Engage Patients? Be Health Literate

Engaging patients in their own health and health care fundamentally relies on health literacy—that is, their ability to obtain, process, communicate, and understand basic health information and services. Because many Americans have difficulty understanding health information as currently delivered, LHSs must reduce the cognitive demands placed on patients and the complexities of the health care system. To disrupt what has been called the cycle of crisis care, caused by the failure to deliver understandable information and simplify health care tasks, LHSs have to:  

  • Structure their delivery systems to take health literacy universal precautions, i.e., assume that all patients are at risk of not understanding.
  • Educate their workforce in communication, engagement, and shared decision making skills so that they can clearly convey tailored evidence and help patients make informed choices that are congruent with their values and goals.
  • Collect data to assess whether they are being health literate organizations that make it easier for people to navigate, understand, and use information and services to take care of their health.

Read the full article.

5 Things About the Importance of Addressing Social Determinants of Health

The following excerpt comes from the article by Laura Joszt that first appeared on AJMC.com on October 13, 2017.


More and more, physicians and other health providers are realizing that they cannot be responsible for just what happens inside the 4 walls of their clinic. The lives people live every day for the rest of the year have a profound impact on their health. Social determinants are the factors that contribute to a person’s health, such as where they live and work, their housing situation, and their access to healthy food.

Here are 5 reasons more people are paying attention to addressing social determinants of health.

  1. Holistic care

The United States spends more per capita on healthcare than any other developed nation and has no better outcomes. Other countries in the Organization for Economic Co-operation and Development spend more on social care than healthcare. Research has shown that higher social spending improves outcomes in conditions like obesity, asthma, mental illness, and type 2 diabetes.

  1. Food insecurity

A recent study in JAMA Internal Medicine found that addressing food insecurity was associated with significantly lower healthcare expenditures. The study looked at participation in the Supplemental Nutrition Assistance Program (SNAP), which serves 1 in 7 Americans and helps them buy food for their house.

  1. Community partnerships

With so much of a person’s life taking place outside of the health provider’s reach, community partnerships are key to ensure that once patients leave the doctor’s office, they have resources at hand to help.

  1. Focusing on education

Some public interventions focus on education because children receiving quality education are less likely to engage in risky or unhealthy behaviors. In the 1960s, the Perry Preschool Project in Michigan showed that disadvantaged 3- and 4-year-olds who received high-quality preschool education were less likely to smoke or abuse drugs or other substances. In addition, those children grew up to have a higher education, income, and health insurance coverage.

  1. Additional investment needed

Significant investments need to be made into interventions that address social determinants of health in order to make a difference. But, the investment is worth it, according to speakers at the 2016 annual meeting of America’s Health Insurance Plans.
Read the full article.

Why Medicaid Is The Platform Best Suited For Addressing Both Health Care And Social Needs

The following excerpt comes from the article by Katharine Witgert published September 7, 2017 on the Health Affairs Blog.


...The Medicaid program provides a plausible platform upon which to build a health infrastructure that incorporates the social determinants of health. Medicaid could provide a common entry point that links individuals and families not just to health care services, but also to social services that affect their health. Indeed, state Medicaid leaders have long embraced this concept and are experienced in building bridges that link health and social programs to meet the comprehensive needs of their citizens.

Where Medicaid Leads In Addressing Social Determinants

Medicaid programs have long been leaders in addressing social determinants of health. A range of innovations for incorporating social determinants of health have been tested in Medicaid programs across the country. State Medicaid programs make referrals to social services, directly connect individuals to needed services, align systems to share goals, and invest future savings to the health care system into social services programs. For example:

  • In Pennsylvania, the online health and human services programs eligibility system known as COMPASS allows individuals and families to simultaneously apply for Medicaid, the Children’s Health Insurance Program (CHIP), and the health insurance marketplace, together with programs that administer food stamps, school lunches, child care assistance, and other benefits. There is evidence from a range of social programs that transaction costs—the difficulty of applying—significantly influence take-up rates. Single applications can facilitate access.
  • Colorado’s Medicaid program divides the state into seven Regional Care Collaborative Organizations, each of which connects beneficiaries to health care providers as well as social and community services. The goal is to link every beneficiary with a primary care provider who not only serves as a central point of contact for medical care, but also assesses a person’s nonmedical needs.
  • Louisiana, meanwhile, has embedded permanent supportive housing into Medicaid home- and community-based services, allowing for better integrated care for individuals who are homeless or at risk of homelessness.
  • Recognizing the mutually reinforcing roles of health and education—health status influences a child’s ability to learn, for instance—Oregon began aligning its health care and early education systems around 2011. The Medicaid program and early learning systems share goals, staffing, and funding.

Additionally, Massachusetts, New York, Oregon, Utah, and Vermont are all testing strategies not only to link Medicaid and social services, but also to use Medicaid funds to actually deliver supportive services that affect social determinants of health. These value-based delivery system reforms include the creation of accountable care organizations, health homes, community health teams, and accountable communities for health.

Most recently, the Centers for Medicare and Medicaid Services (CMS) launched an initiative called Accountable Health Communities to better manage the health-related social needs of Medicare and Medicaid enrollees. The initiative will test whether systematically identifying and addressing the social determinants of health through screening, referral, and community navigation services will impact health care costs and reduce health care utilization. Over the next five years, the model will provide support to community organizations that link enrollees to services that address housing instability, food insecurity, utility needs, interpersonal violence, and transportation needs. As CMS begins to test this model, there is reason for optimism, given Medicaid’s track record of integrating health care and social services.

Read the full article.

Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference?

The following excerpt comes from the Issue Brief written by Susan L. Hayes, Pamela Riley, David Radley, and Douglas McCarthy.  It was originally posted to the Commonwealth Fund website on August 24, 2017.


Historically, in the United States, there has been a wide gulf between whites and members of minority groups in terms of health insurance coverage and access. Proponents of the Affordable Care Act (ACA) hoped that law’s major insurance coverage expansions and reforms would begin to bridge those gaps.

Evidence suggests that uninsured rates have declined among blacks and Hispanics under the ACA, but have these coverage gains reduced disparities between whites and ethnic and racial minorities? This brief seeks to answer that question and to examine if disparities in access to coverage and care are different in states that expanded Medicaid and states that did not.

We compared national averages between 2013 and 2015 for white, black, and Hispanic adults on three key measures of health care access to determine the effect of the ACA’s major coverage expansions on disparities:

  • the share of uninsured working-age adults ages 19 to 64
  • the share of adults age 18 and older who went without care because of costs in the past year
  • the share of adults age 18 and older without a usual source of care.

These measures align with those reported in the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition.

Additionally, we sought to determine if there were differences in disparities in states that chose to expand their Medicaid programs under the ACA and states that did not. For each indicator, we calculated the average rate for white, black, and Hispanic individuals in 2013 and in 2015 in two groups of states: the group of 27 states that, along with the District of Columbia, expanded their Medicaid programs under the ACA between January 1, 2014, and January 1, 2015, and the group of 23 states that had not expanded Medicaid as of that time.

As the current administration and Congress weigh how to move forward after the recent failed attempt to repeal and replace the ACA, it is useful to examine how successful the law has been in making health care available to racial and ethnic groups that have historically been left out.

Findings include:

  • Racial and Ethnic Disparities in Adult Uninsured Rates Narrowed After the ACA’s Major Coverage Expansions
  • Racial and Ethnic Disparities in Rates of Adults Who Went Without Care Because of Costs Narrowed After the ACA’s Major Coverage Expansions
  • Racial and Ethnic Disparities in Rates of Adults Without a Usual Source of Care Narrowed After the ACA’s Major Coverage Expansions
  • Disparities Between Hispanic and White Adult Uninsured Rates in Medicaid Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Black and White Adult Uninsured Rates in Medicaid Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Hispanic and White Adults Who Went Without Care Because of Costs in Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Black and White Adults Who Went Without Care Because of Costs in Expansion States vs. Nonexpansion States, 2013–2015
  • Disparities Between Hispanic and White Adults Without a Usual Source of Care in Medicaid Expansion States vs. Nonexpansion States, 2013–2015

Download the full issue brief.

The Interplay of Community Trauma, Diet, and Physical Activity

The following excerpt comes from the Discussion Paper by Howard Pinderhughes* posted August 7. 2017 on the National Academy of Medicine website.


Diet- and activity-related illnesses—such as heart disease, stroke, cancer, and type 2 diabetes—can shorten life spans and adversely impact quality of life. Over the past 15 years, the public health field has made important progress in addressing these illnesses by shifting the focus from individual behavior to the broader social and economic forces that shape health. There is now widespread agreement among experts in the field that in order to improve health outcomes and reduce the impact of these illnesses, we must pursue strategies, practices, and policies that are multifaceted, comprehensive, and focused on community- and institutional-level change.

There is a growing understanding that community conditions—the places where we live, work, and play—have a significant impact on our health and that adverse community experiences (community trauma) affect our food and activity behaviors. Advances in understanding the connection between adverse childhood experiences and health have revolutionized the field of trauma-informed care, which has now become an important standard practice in communities across the country. But we must also seek to illuminate how adverse community experiences impact healthy eating and activity, and to develop integrated solutions. Adverse community experiences are destructive factors—such as racial, residential, and economic segregation; violence; structural racism and discrimination; intergenerational poverty; and public and private disinvestment—that traumatize entire communities. For example, experiencing and witnessing community violence can negatively impact the ability to eat healthfully and be active. Violence and fear of violence reduce social interactions that would otherwise contribute to community cohesion, thus reducing support for healthy eating and active living. The pervasive presence of community trauma can become a significant barrier to efforts to improve population health and health equity, including those that address eating- and activity-related diseases. When people don’t feel safe in their communities, they are less likely to walk to the grocery store, use local parks, access public transportation, and let their children play outside. Healthy food retailers and recreation businesses are less likely to invest in communities perceived as unsafe.

An analysis of the production of health inequities across multiple determinants of health revealed that adverse community factors—which decrease opportunities for healthy eating and activity—are rooted in structural violence in the form of government policies and business practices. These policies and practices have led, for example, to the over concentration of unhealthy food outlets in communities of color and communities with low to average household incomes. In the case of food retail, public policies such as those of the Federal Housing Administration incentivized suburban home ownership, which resulted in white middle-class flight to the suburbs and a concentration of poverty in the inner cities. Supermarkets, grocery stores, and many other businesses followed the white middle-class population in migrating to the suburbs. This flight (along with financial policies and practices, including redlining) left a void for unhealthful food outlets to fill. The high cost and scarce availability of land in dense urban areas contributed to the migration of businesses out of the cities and resulted in loss of jobs and tax revenues, and has influenced decisions about the siting of grocery stores and supermarkets. Additionally, there has been limited availability of loans for local residents in underserved neighborhoods so that they might open businesses that sell and promote healthy food options. These adverse community experiences have resulted in limited economic opportunities for residents and a poor food system in which chain restaurants and stores fill the gap with less healthy or unhealthful food options.

Read the full Discussion Paper.

*References have been removed from the excerpt. Please visit the full paper for more details.

Useful Resource: “Health Equity Change Makers” Toolkit

The Office of Minority Health’s web port “Health Equity Change Makers” using stories to highlight the impact of health disparities and ways in which individuals and groups can make changes. The portal includes a toolkit “designed to provide ideas and resources for activities that you can do — at home, at work, and in the community– to help end health disparities and accelerate health equity.” The toolkit topics cover:

Visit the Health Equity Change Makers web portal to see the full toolkit.

 

Annual Report on Healthcare Quality and Disparities

In July, the Agency for Healthcare Research and Quality (AHRQ) posted the 2016 National Healthcare Quality and Disparities Report on its website. Mandated by Congress, this annual report “provides a comprehensive overview of the quality of healthcare received by the general US population and disparities in care experienced by different racial and socioeconomic groups.”  Based on over 250 quality measures, the report covers a wide range of healthcare services and settings. The key findings from the report were:

Access: While most access measures (65%) tracked in this report did not demonstrate significant improvement (2000-2014), uninsurance rates (measured as uninsured at the time of interview) decreased from 2010 to 2016.

Quality: Quality of health care improved overall from 2000 through 2014-2015 but the pace of improvement varied by priority area:

  • Person-Centered Care: About 80% of person-centered care measures improved overall.
  • Patient Safety: Almost two-thirds of patient safety measures improved overall.
  • Healthy Living: About 60% of healthy living measures improved overall.
  • Effective Treatment: More than half of effective treatment measures improved overall.
  • Care Coordination: About half of care coordination measures improved overall.
  • Care Affordability: About 70% of care affordability measures did not change overall.  

Disparities: Overall, some disparities were getting smaller from 2000 through 2014-2015, but disparities persist, especially for poor and uninsured populations in all priority areas:

  • While 20% of measures show disparities getting smaller for Blacks and Hispanics, most disparities have not changed significantly for any racial and ethnic groups.
  • More than half of measures show that poor and low-income households have worse care than high-income households; for middle-income households, more than 40% of measures show worse care than high-income households.
  • Nearly two-thirds of measures show that uninsured people had worse care than privately insured people.

See the table of contents and description of the report.

Download the full report.