What's New with HCFO - May 15, 2009 (Print All Articles)

Social Determinants of Health

An individual’s health is determined by many factors and the health care system is just one piece in a complex web. Outside the realm of the clinical health care setting, individuals’ health is affected by the environment in which they live, their socioeconomic status, education, access to insurance and providers, and their personal behaviors. These factors are collectively known as social determinants, and play a key role in shaping a person’s health and well-being. As the economy continues to remain uncertain and policymakers look to health reform, it is critical that social determinants be recognized for the unique role they play in shaping the health of every individual regardless of income, race, or location.

Insurance coverage is a critical social determinant of health and one that can radically affect a person’s health. States regulate which types of insurance products are available for purchase by employers and individuals, so the types of products and plans available vary depending on the state in which you live. Medicaid and the Children’s Health Insurance Program (CHIP) also vary by state; while a core set of individuals and services may be covered, many program details, including payment rates, vary. Consequently, the supply and access to providers also varies by locale. Provider access has been a large issue for the Medicaid program. Currently, HCFO has funded Thomas Buchmueller, Ph.D., from the University of Michigan to look at the effect of public insurance coverage and provider reimbursement on access to dental care for children. More information on this study can be found at www.hcfo.net/grantees/grant.cfm?GrantNo=65848.

Where you live matters to your health. Dartmouth researchers have shown that utilization of some services for Medicare beneficiaries varies by geographic area.1 Regardless of insurance coverage, in some cases an individual will have no guaranteed access to care due to insufficient provider supply. Dwindling primary care physicians coupled with increased demand for physician services could strain the availability of providers, regardless of payer source and type.2
 
Socioeconomic status is a strong health determinant. Often, neighborhoods that are lacking basic necessities, such as grocery stores, are located in low income areas. Thus, vulnerable populations often do not have access to fresh fruits and vegetables, staples of a healthy diet.3 Low income neighborhoods often may lack sufficient resources to rectify these issues. Individuals living in these lower income neighborhoods often have worse health outcomes. A report by the Robert Wood Johnson Foundation details how poor adults are nearly five times more likely to be in poor or fair health compared with individuals in the highest-income brackets.4

In addition, when assessing an individual's propensity toward disease, education is also important. A report by the Robert Wood Johnson Foundation has shown that adults with lower levels of education have higher proportions of physical inactivity compared to higher educated individuals.5 This gap has persisted over time and does not appear to be narrowing.6 This same pattern is repeated when smoking rates and education are compared. In fact, in terms of cigarette smoking rates, the gap that exists between college graduates and those with lower levels of education appears to be widening.7

At the core of factors affecting health is personal behavior. Not smoking, exercising, eating a balanced diet, controlling stress, and getting enough sleep may be the most important components of good health. Some people are more activated to live a healthy lifestyle and remain in compliance with medical treatment. HCFO grantee Judith H. Hibbard, Dr.P.H., from the University of Oregon, has also looked at consumer activation in terms of consumer-driven health plans. The study examined whether or not enrollment in these plans increased consumer engagement by seeking information about health, cost, and quality.8 HCFO grantees Penny Feldman, Ph.D., Visiting Nurse Service of New York, and Linda Gerber, Ph.D., Weill Cornell Medical College, are currently looking at how patient activation occurs, and under what circumstances in those who suffer from high rates of chronic illness. The findings from this project will hopefully provide recommendations for overcoming patient-related barriers to self-management. More information on this grant can be found at www.hcfo.net/grantees/grant.asp?GrantNo=64666.

As health reform takes shape in the coming months, it will be important to keep in mind the important role of social determinants of health. While many of the issues that affect health are systematically embedded in society, there are some individual characteristics that can be altered to promote healthier lifestyles. Better nutrition, physical activity, and not smoking can dramatically improve health outcomes. Given the systemic issues that then create barriers for people to engage in these healthy behaviors, it will become increasingly important to identify ways to improve education, reduce geographic variation, and strengthen neighborhoods. While health reform will look to create quality, affordable, and accessible health care, it is also important to remember the social determinants that lie outside the realm of the health system that in the end impact health. Understanding all the factors that influence health will help to improve health outcomes in the long run.

HCFO Sponsored Work on Insurance Coverage

Despite the complexities in understanding the social determinants of health, the HCFO program currently has several studies underway which will help to inform policymakers on how social determinants affect health and well-being. For other HCFO grants, see www.hcfo.net.

Title: The Effect of Public Insurance Coverage and Provider Reimbursement on Access to Dental Care: Evidence from the SCHIP Expansion
Institution: University of Michigan
Principal Investigator: Thomas C. Buchmueller, Ph.D.
Grant Period: April 2009 - March 2011

The researchers will examine the role that public health insurance plays in improving access to dental care for poor and near-poor children. Specifically, they will study low-income children to assess how Medicaid/SCHIP eligibility generosity affects dental care utilization. They will investigate how changes in program features and market conditions affected the supply of dental care to the publicly insured, addressing the following research questions: 1) What is the effect of public insurance on the probability a child has an annual dental visit? What is the effect on the total number of visits per year? 2) How does the effect of public insurance on dental utilization vary with key program parameters? 3) How do changes in public dental insurance programs affect provider participation? 4) What was the public dental health insurance environment in the states prior to SCHIP, and how did it change as a result of SCHIP implementation? and 5) How did states change dental provider reimbursement rates with the implementation of SCHIP? The purpose of this project is to better understand the effects of public dental coverage in order to inform related Medicaid and SCHIP policymaking.

Title: Consequences of SCHIP for Household Well-Being
Institution: University of Michigan 
Principal Investigator: Helen Levy, Ph.D.
Grant Period: October 2008 - September 2009

The researchers will explore the consequences of State Children's Health Insurance Program (SCHIP) expansions, including "crowd out," the term used to describe the phenomenon of individuals dropping private health insurance coverage in response to expanded availability of public coverage. The researchers hypothesize that switching from private to public coverage reduces a family's out-of-pocket medical spending, freeing up more resources for other uses, making crowd-out a "windfall" not a "problem" for low-income families. They will address the following research questions: (1) How have expansions of SCHIP improved the material well-being of the low-income families the program is intended to assist, and (2) What categories of spending increase as a result of gaining eligibility for coverage? The objective of the proposed project is to reconsider the context for crowd-out and reframe the debate over SCHIP expansions with a renewed emphasis on the benefits rather than merely the costs of coverage expansions.

Title: Promoting Readiness and Interest in Self Management
Institution: Visiting Nurse Service of New York 
Principal Investigators: Penny H. Feldman, Ph.D./Linda M. Gerber, Ph.D.
Grant Period: July 2008 - September 2009

The researchers will investigate how patient activation occurs and under what circumstances in a historically under-represented population—black/African Americans—who suffer disproportionately high rates of chronic illness. Patient activation, or engaging patients in their care, can improve the quality of care and health outcomes for those living with chronic conditions. Specifically, the researchers will: 1) evaluate psycho-social and clinical/functional determinants that influence a change in patients’ activation levels over time; 2) examine patients’ perspectives on their involvement in their care; 3) investigate factors that may help or hinder home care nurses’ promotion of self management and patient engagement; and 4) provide recommendations to improve clinician education and patient interventions. The objective of the proposed project, funded under a special topic solicitation on consumer activation, is to promote patient-centered care by identifying and providing recommendations to overcome patient-related barriers to self-management and to cultivate facilitators of clinician involvement in promoting patient self care.

Title: Local Public Health Capacities to Address the Needs of Culturally and Linguistically Diverse Populations
Institution: Social and Scientific Systems, Inc.
Principal Investigator: Claudia Schur, Ph.D.
Grant Period: May 2008 - December 2009

The researchers will examine the public health needs of culturally and linguistically diverse populations. Specifically, they will develop detailed community multicultural profiles describing the cultural and linguistic diversity of populations served by local health departments (LHDs). They will then use these profiles to analyze the relationships between population characteristics and existing public health capacity and to identify and survey select communities for more in-depth information about serving these populations. They will seek answers to the following research questions: 1) How do jurisdictions with LHDs compare in terms of the composition of the population served? To what extent do communities include substantial numbers of racial/ethnic minorities, immigrants, and/or persons who speak a language other than English? 2) Does the structure and capacities of LHDs vary with respect to the multicultural profile of the populations they serve? How do LHD resources and activities correspond to local community characteristics? 3) What are the specific strategies that LHDs engage in to meet the needs of diverse populations? What types of strategies appear to be most successful? Are community partnerships used either for training purposes or for the delivery of culturally appropriate services? 4) What obstacles appear to be most difficult to overcome in serving different types of population subgroups? Which types of services are most difficult to deliver? What characteristics or combinations of characteristics of communities and LHDs create the most substantial obstacles? The objective of this project is to develop policy recommendations for implementation of promising strategies to better serve diverse populations.

Title: Medicare Spending, Disparities, and Returns to Healthy Behaviors
Institution: University of Maryland, Baltimore
Principal Investigator: Bruce C. Stuart, Ph.D.
Grant Period: March 2008 - August 2009

The researchers will examine persistently low cost Medicare beneficiaries and determine the extent to which health behavior, preventive services, race and socioeconomic status (SES) appear to be related to low spending. Specifically, the researchers will (1) estimate cost savings in traditional Medicare spending associated with persistently good health behavior and preventive measures; (2) identify population characteristics that can be used to optimally target preventive interventions; and (3) develop simulation models to show how selectively reducing beneficiary cost sharing for primary and secondary preventive measures can achieve significant costs offsets in reduced spending on traditional Medicare services – this mechanism is referred to as “value-based insurance design.” The objective of the proposed project is to identify which disease states and beneficiary segments show the greatest promise for improved compliance and persistency in use of preventive therapies.

Title: Incorporating Disparities into State Strategies to Monitor and Improve Health Status
Institution: Mathematica Policy Research Inc.
Principal Investigator: Marsha Gold, Sc.D.
Grant Period: January 2007 - March 2008

The researchers will examine state capacity to develop the 10 leading indicators defined in Healthy People 2010 overall and by geographic group. In particular, they will study: 1) the strengths and weaknesses of data available within states to adequately assess the health of a population that includes diverse groups; and 2) the organizational, political, and other forces that promote or impede use of such data to intervene in ways that improve the health of the state’s population. The three part study includes: 1) an inventory of state practices with respect to available data on leading indicators; 2) case studies of four states to learn about how the indicators and disparities in the indicators across subgroups are viewed in developing initiatives to improve public health; and 3) a dissemination plan for translating information in ways that would be useful to diverse audiences. The objective of this project is to further the vision articulated in HealthyPeople 2010, setting health goals that explicitly link overall improvements in public health to reduced disparities in health status across diverse subgroups of the population.

 

 


1 Fischer, E. et al. “Health Care Quality, Spending, and Outcomes: More Isn’t Always Better.”  A Dartmouth Atlas Project Topic Brief, February 27, 2009. Also see www.dartmouthatlas.org/atlases/Spending_Brief_022709.pdf.
2 Nicholson, S. “Healthcare Workforce Supply.” Forthcoming paper, January 2009.
3 California Newsreel. Unnatural Causes Documentary, 2008.
4 Robert Wood Johnson Foundation. Overcoming Obstacles to Health. Commission to Build a Healthier America, February 2008.
5 Ibid.
6 Ibid.
7 Ibid.
8 Minott, J. “How Valid Are the Assumptions Underlying Consumer-Driven Health Plans?” HCFO Findings Brief, AcademyHealth, Vol. XII, No. 4, May 2009. Also see http://www.hcfo.net/pdf/findings0509.pdf.

HCFO Releases a New Findings Brief

The driving assumptions behind consumer-driven health plans (CDHPs) are that consumers—faced with greater information and financial incentives—will make cost-effective decisions about their health care. To test whether these assumptions were true, Judith H. Hibbard, Dr.P.H., professor at the University of Oregon, and colleagues took advantage of a natural experiment, examining the behavior of employees at a large manufacturing company that began offering employees CDHPs in addition to preferred provider organization (PPO) plans. The researchers examined whether the employees newly enrolled in a CDHP became more active consumers and made cost-effective decisions about health care utilization relative to employees enrolled in the PPO.

Grantee Spotlight: Claudia Schur, Ph.D.


Claudia Schur, Ph.D., is vice president and director of the Center for Health Research and Policy at Social & Scientific Systems, Inc. (SSS). Dr. Schur has more than 20 years of experience in health policy research, survey design, and quantitative and qualitative analysis. Her research interests include access to care for vulnerable populations, the relationship between insurance coverage and health care expenditures, and the uninsured. She has led and worked on projects that have examined a wide array of topics, including public opinions of the health system, disease management, prescription drug expenditures and payment strategies for Part D, and access and quality of care for minority populations, persons living with HIV/AIDS, and the elderly.

Currently, Dr. Schur is the principal investigator on a HCFO grant that was funded under the special topic solicitation in public health systems research. Her project, “Local Public Health Capacities to Address the Needs of Culturally and Linguistically Diverse Populations,” is evaluating the public health needs of culturally and linguistically diverse populations and whether or not these needs are being met by local health departments (LHDs). Dr. Schur and colleagues will develop detailed community multicultural profiles describing the cultural and linguistic diversity of populations served by LHDs using census data and the 2005 National Association of County and City Health Officials (NACCHO) National Profile of LHDs. They will then use those profiles to analyze the relationships between population characteristics and existing public health capacity and to identify and survey select communities for more in-depth information about serving these populations. The project aims to provide a picture of linguistic and cultural diversity in local communities, identify local public health departments serving the most diverse communities, and collect information about innovative and successful approaches to serving diverse populations. “We hope that the resulting evidence from this project will formulate policy recommendations and strategies to help local health departments better serve multicultural populations,” says Schur.

Dr. Schur was co-director of the Health Policy and Evaluation department at the National Opinion Research Center (NORC) at the University of Chicago. Prior to working at NORC, Dr. Schur was the deputy director at the Project HOPE Center for Health Affairs. She also spent several years as an economist at the Agency for Healthcare Research & Quality (AHRQ). Dr. Schur received a Ph.D. in economics, with a particular focus on public finance, industrial organization, and applied microeconomics, from the University of Maryland. 

For more information about Dr. Schur’s grant, please visit www.hcfo.net/grantees/grant.cfm?GrantNo=64402.

Spotlight on Grantee Publications

Two articles resulting from grants co-sponsored by HCFO and the Commonwealth Fund and funded under a special topic solicitation on administrative costs were published in the May 14 Health Affairs Web exclusive. For more information about these articles, visit http://www.rwjf.org/coverage/product.jsp?id=42728.

Lawrence P. Casalino, M.D., Ph.D., chief of the Division of Outcomes and Effectiveness Research at Weill Cornell Medical College and formerly of the University of Chicago, and colleagues published the article, “What Does it Cost Physician Practices to Interact with Health Insurance Plans?” This article highlights findings from a HCFO-funded national survey of physician practices across the United States on time spent by practice staff on administrative activities.

Julie A. Sakowski, Ph.D., senior health services researcher at Sutter Health, and colleagues published the article, “Peering into the Black Box: Billing and Insurance Activities in a Medical Group.” This article highlights findings from a HCFO study led by Harold S. Luft, Ph.D., director of the Palo Alto Medical Foundation Research Institute and formerly of the University of California, San Francisco, that provided an in-depth look at the billing and insurance-related activities performed at a large multi-site, multi-specialty group practice in California.



Douglas Conrad, Ph.D., professor, and Lisa Perry, both of the University of Washington, published the article “Quality-Based Financial Incentives in Health Care: Can We Improve Quality by Paying for It?” in the April 2009 issue of Annual Review of Public Health. This article highlights findings from a HCFO-sponsored study that examines the effects of quality scorecards and financial incentives, developed by Premera, on physicians’ clinical quality, patient satisfaction, and efficiency.

The Center for Studying Health System Change released the research brief “Coordination of Care by Primary Care Practices: Strategies, Lessons and Implications,” by Ann S. O’Malley, M.D., senior health researcher, and colleagues. This article highlights findings from a HCFO-sponsored study that documented “best practices” that physician offices developed to coordinate care and identified the challenges and lessons learned. 

 

Grantees in the News

Findings from a HCFO study led by Alan Sager, Ph.D., professor at Boston University, were highlighted in the May 3 Compass Group, Inc. blog post “History on Hospital Closings Relevant to Current Health Care Reform.” This HCFO study updated a large longitudinal database of hospital trends to examine how the hospital industry changed between 1980 and 1995. Specifically, the researchers delineated how the different changes in hospital configuration varied by city size and region, analyzed the predictors of hospital closings, relocations, and mergers, and assessed the implications of hospital closures on cost and access. The blog discusses how these findings are germane to the current health care reform discussion.

Findings from three studies, co-funded by HCFO and The Commonwealth Fund, will be presented at an upcoming Institute of Medicine workshop, The Healthcare Imperative: Lowering Costs and Improving Outcomes, which will take place on May 21 and 22 at the Keck Center of the National Academies in Washington, D.C. The session on excess administrative costs in the health care system will feature results from:

  • Administrative Simplification Challenges and Opportunities: A Physicians Organization Perspective—analyzing the costs of administrative complexity for a large physician organization, examining the impact on quality, and identifying opportunities for improvement.
    Investigators: Gregg S. Meyer, M.D./ James L. Heffernan
  • Administrative Costs Associated with Third Party Payment—providing an in-depth look at the billing and insurance-related activities performed at a large multi-site, multi-specialty group practice in California.
    Investigators: Harold S. Luft, Ph.D./ Julie Sakowski, Ph.D./James G. Kahn, M.D.
  • Costs and Benefits of Physician Practices—conducting a national survey of physician practices across the U.S. on time spent by practice staff on specific activities, including prior authorization, pharmaceutical formularies, claims and billing, credentialing, contracting, and collecting and reporting quality data.
    Investigator: Lawrence Casalino, M.D., Ph.D.


 

New Data for Researchers

The National Center for Health Statistics (NCHS) has opened a Research Data Center (RDC) in Atlanta at a Centers for Disease Control and Prevention (CDC) facility. The new RDC will be open to CDC researchers and the public. The Atlanta RDC will provide access to the full NCHS data portfolio of restricted data and will also be a mechanism for providing access to other CDC surveillance data to external researchers.

NCHS and the U.S. Census Bureau have agreed to allow access to NCHS data at ten Census Bureau RDCs around the country and another RDC is expected to open at the University of Minnesota soon. NCHS data are being accessed on more than 25 research projects throughout this network. This represents a major step forward in NCHS's efforts to expand access to its data files. By making its data available through RDCs, NCHS can provide secure access to the full range of health and vital statistics information that it collects, while continuing to protect the confidentiality of the respondents and records. For more information about the NCHS RDC, visit www.cdc.gov/nchs/r&d/rdc.htm.

Announcements

Full Agenda Now Available for Annual Research Meeting

The 2009 Annual Research Meeting (ARM) offers a rich and exciting slate of invited and peer-reviewed research sessions, policy roundtables, methods workshops, poster presentations, and networking opportunities. With more than 150 sessions, the ARM is the premier forum for health services research.

This year’s meeting focuses on the need for better research translation and the connection between the research community and health care reform in the new administration. Keynote speaker, Dr. Julio Frenk, will address those issues in his opening talk, “Moving from Research to Policy in Health System Reform.”

The full agenda is now available online, including presentations selected from the call for abstracts. Register by May 27 to take advantage of standard conference pricing.


Special Opportunities for Students at the 2009 Annual Research Meeting

AcademyHealth is offering special opportunities for students in health services research and policy at the 2009 Annual Research Meeting (ARM) in Chicago. Take advantage of these opportunities to be a part of the premier forum for health services research.

  • Discounted Registration Rates
    Students who are enrolled full-time are eligible for discounted conference registration. Join AcademyHealth as student member for only $25 and register at the member rate. Students are also offered discounted rates to many of the Interest Group annual meetings.
  • Meet-the-Experts Student Breakfast—Sunday, June 28, 8:15–9:15 a.m.
    Meet informally with nationally known experts in health services research, policy, management, and clinical practice at the Meet-the-Experts Student Breakfast. This breakfast event is a great opportunity to ask questions, get career advice, and hear from experts. Registration is not required.
  • Résumé Review Services – Submissions Due May 31
    Request a meeting with established health services researchers and health policy professionals during the ARM. Complete the online form and receive expert advice on your résumé and career path. Additional career services will be available through the onsite Career Center.

Interest Group Annual Meetings
June 27 and June 30, Hilton Chicago

The following interest groups will host meetings in conjunction with the Annual Research Meeting (ARM) in Chicago. Designed to provide ample discussion around each of these topics, the meetings range from half-day to full-day and offer additional opportunities for presentations that enhance the main ARM program.

In addition, the Public Health Systems Research (PHSR) Interest Group will be holding a two-day meeting, June 30-July 1. Scientific sessions and poster presentations will take place on Tuesday, June 30. On Wednesday, July 1, the meeting will focus on methods, featuring a workshop and panels on PHSR data and use.

Registration for each of these meetings is done through the Annual Research Meeting registration page.

Building Bridges: Making a Difference in Long-Term Care 2009 Colloquium
June 27, Hilton Chicago

The sixth annual Long-Term Care (LTC) Colloquium, sponsored by The Commonwealth Fund and conducted by AcademyHealth, is June 27 at the Hilton Chicago in conjunction with the Annual Research Meeting. The Colloquium is the cornerstone of an initiative seeking to foster development of a network of LTC researchers, policy leaders, providers, consumer representatives, and funders through colloquia, policy seminars, and ongoing workgroup discussions. The topics of discussion include highlights from a commissioned paper on the intersection between LTC and end-of-life care, and a second topic that will be determined from the LTC call for commissioned papers. For more information visit the LTC Web site. 
 
Seminars in Health Services Research Methods
June 26-27, Hilton Chicago

AcademyHealth is offering five health services research methods seminars in conjunction with the Annual Research Meeting in Chicago. These pre-conference sessions are ideal for both new and experienced researchers who want to enhance their skills in research methodologies. Registration is now open for the following sessions:

Friday, June 26:

  • Issues in the Analysis of Complex Survey Data
  • Methods of Comparative Effectiveness Research

Saturday, June 27:

  • Introduction to Medicare Part D Data Research
  • Enhancing your Methodological Toolbox: An Introduction to Qualitative Research
  • Methods for Addressing Endogeneity and Selection Bias in Observational Studies

For full descriptions of each of the sessions, visit the ARM Web site.