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Health Gap Widens Between Appalachia And Rest Of The U.S.
http://khn.org/news/health-gap-widens-between-appalachia-and-rest-of-the-u-s/
Sandy Willhite doesn’t mind driving 45 minutes to the nearest shopping center. But living in Hillsboro, W.Va., became problematic when she had to travel nearly six hours for proper foot treatment.
“There just aren’t any quality surgeons or specialists in our area,” Willhite said, when explaining why she went to a doctor in Laurel, Md.
Getting health care is a common problem for the residents of Hillsboro, a tiny hamlet in the middle of Appalachia with a population of just under 250 residents.
And the Appalachian region is in dire need of health care. This section of the U.S., long acknowledged to be among the most economically disadvantaged in the country, is showing a growing gap in health outcomes with the rest of the United States.
A study released Monday in the journal Health Affairs found disparities widening sharply between Appalachia and the rest of the country, driven by higher rates of infant mortality, smoking, obesity and early deaths from motor vehicle accidents and drug overdoses.
“Although life expectancy increased everywhere in the United States between 1990 and 2013, less rapid declines in mortality and slower gains in life expectancy among people in Appalachia have led to a widening health gap,” the study said.
The study focused on the 428 counties within the 13 states that constitute Appalachia. Gopal Singh, an author of the study and a senior health equity adviser at the Health Resources and Services Administration, found that counties with high rates of poverty have the highest infant mortality rate and lowest life expectancy. These areas are seen mostly in central and southern Appalachia.
The researchers found Appalachia lagged behind the rest of the country on health measures in the early 1990s — but only slightly. Infant mortality rates were not statistically different. And life expectancy was about 75 years — just 0.6 years shorter than that outside of the region.
But when the researchers analyzed data from 2009 to 2013, they found the infant mortality rate for Appalachia to be 16 percent higher than the rest of the country and the difference in life expectancy was 2.4 years.
When researchers examined specific demographic groups, some of the disparities were much greater. For instance, they noted a 13-year gap in life expectancy between black men in high-poverty areas of Appalachia (age 70.4) and white women in low-poverty areas elsewhere in the country (83).
According to the study, the association between poverty and life expectancy was stronger in Appalachia than the rest of the country.
“You do see a more rapid improvement in the rest of the country compared to Appalachia, but there are specific reasons why Appalachia I guess continues to fall behind,” said Singh, the lead author.
The study points to specific health problems, including lack of access to doctors and other providers, high rates of preterm births and low-weight births, and high rates of smoking-related diseases, such as lung cancer, chronic obstructive pulmonary disease and heart disease.
“Smoking-related diseases accounted for more than half of the life-expectancy gap between Appalachia and the rest of the country,” the study said.
Dr. Joanna Bailey treats some of Appalachia’s patients every day as a family medicine physician in Wyoming County, W.Va. She grew up there and said the lifestyle plays a large role in health outcomes. “I treat a lot of diabetes; I see a lot of high blood pressure; I see a lot of heart disease. I see a lot of obesity, because it is a place where it has been normalized quite a bit.”
“I think that the culture is such that getting those conditions under control is difficult for many reasons,” Bailey said.
The economic issues compound the situation, she said.
“There’s the problem of poverty,” she added. “A lot of people are on disability and they rely on food stamps to get their food for the month.” Many of Bailey’s patients pay someone to drive them to the grocery store. She said it’s difficult to coach them to buy healthful groceries when the food is good only for a few days.
“By the end of the month, they are back to eating cereal and Hamburger Helper,” Bailey said.
She thinks the widening health gap in recent years has accelerated with an increasing number of young people leaving the area for job opportunities.
“We’re left with an older, sicker population who can’t work or don’t work, and those people are notoriously sicker,” Bailey said.
Both Bailey and Singh agree that addressing the health gap requires socioeconomic change. The communities need better higher-education opportunities and infrastructure improvements, such as improved roadways so patients can more easily get to larger towns and cities to access health care.
Until then, Willhite and her family will continue to drive hours for care, such as the foot doctor in Laurel, whom she had consulted when she lived in Maryland.
“There are just absolutely so many (health) issues here in this region, you can’t begin to put your finger on one,” Willhite said. “It’s like a big vicious circle.”
Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care
The United States Health System Falls Short
The United States spends far more on health care than other high-income countries, with spending levels that rose continuously over the past three decades (Exhibit 1). Yet the U.S. population has poorer health than other countries. 1 Life expectancy, after improving for several decades, worsened in recent years for some populations, aggravated by the opioid crisis. 2 In addition, as the baby boom population ages, more people in the U.S.—and all over the world—are living with age-related disabilities and chronic disease, placing pressure on health care systems to respond.
Timely and accessible health care could mitigate many of these challenges, but the U.S. health care system falls short, failing to deliver indicated services reliably to all who could benefit. 3 In particular, poor access to primary care has contributed to inadequate prevention and management of chronic diseases, delayed diagnoses, incomplete adherence to treatments, wasteful overuse of drugs and technologies, and coordination and safety problems.
This report uses recent data to compare health care system performance in the U.S. with that of 10 other high-income countries and considers the different approaches to health care organization and delivery that can contribute to top performance. We based our analysis on 72 indicators that measure performance in five domains important to policymakers, providers, patients, and the public: Care Process, Access, Administrative Efficiency, Equity, and Health Care Outcomes.
Our data come from a variety of sources. One is comparative survey research. Since 1998, The Commonwealth Fund, in collaboration with international partners, has supported surveys of patients and primary care physicians in advanced countries, collecting information for a standardized set of metrics on health system performance. Other comparative data are drawn from the most recent reports of the Organization for Economic Cooperation and Development (OECD), the European Observatory on Health Systems and Policies, and the World Health Organization (WHO).
4 Health Care Lessons the U.S. Can Learn from Top-Performing Countries
The recent Commonwealth Fund report, Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care, compared health care system performance in the United States with that of 10 other high-income countries. The U.S. ranked last in overall health system performance, yet as a nation we spend the most per person on health care. What can we learn from the top-performing countries? Report coauthors Eric C. Schneider, M.D., and David Squires discuss areas where the U.S. can improve in a New England Journal of Medicine “Perspective.” Here are four takeaways:
1
The best-performing health systems use universal coverage to ensure that everyone has access to care.
The United Kingdom, Australia, and the Netherlands provide universal coverage and very low out-of-pocket costs for both preventive and primary care.
2
Strengthening primary care is key to high performance.
Top-performing countries make primary care widely available, so that patients can get health services when they need them. Primary care services are available not just during regular business hours, but also at night and on weekends.
3
Streamlined payment and electronic record systems help patients and doctors.
In the U.S., health professionals and patients spend countless hours trying to sort out what benefits and services are covered by insurance and tracking down payments. The payment systems in other high-income nations use approaches such as paying providers a fee for comprehensive care of patients and standardizing lists of covered benefits and prescription drugs to make choices easier for both patients and doctors.
4
Spending more on the social safety net can reduce disparities in the delivery of care.
Compared to other countries, the United States spends relatively less on social services like affordable housing and transportation and more on medical services, even though research shows that social spending can improve the health of low-income patients, potentially reducing use of costly medical services.
Fitch: States will take the lead on Medicaid reform despite ACA repeal and replace failure
Some states had already begun negotiations with the Centers for Medicare and Medicaid Services on securing Medicaid waivers, Fitch said.
Despite the Senate’s failure to pass an ACA repeal and replace bill, state governments are moving ahead with their own efforts to revamp Medicaid, especially through waivers, according to a Fitch Ratings report.
Some states had already begun negotiations with the Centers for Medicare and Medicaid Services on securing Medicaid waivers granting them more flexibility. State waiver proposals could affect both Medicaid expansion beneficiaries and the traditional enrollees, the report said.
Arkansas, Indiana and Kentucky have submitted proposals to CMS asking to add work requirements to their Medicaid expansions. Other states including Arizona, Maine, Pennsylvania and Wisconsin are considering work requirements for at least some traditional Medicaid enrollees as well, Fitch said.
Fitch ratings agency said the Trump administration has indicated they are in favor of such measures.
Overall, Fitch said states have indicated their proposed Medicaid changes could reduce costs and also “support key policy goals.”
The states proposing these measures suggested they support “key policy goals” and could yield cost savings. “However, the actual amount of cost savings could be low as some health policy experts have raised questions about the efficacy of such work requirements given characteristics of the current Medicaid population. Adding work requirements could also add to state administrative burdens for oversight of the Medicaid program,” the agency said.
Fitch also projects states will continue to focus on controlling Medicaid spending as they look at their budgets. CMS predicted long-term rises in Medicaid spending due to growth in higher-cost traditional Medicaid-eligible populations, especially the elderly and disabled, and their most recent 10-year forecast for National Health Expenditures showed state and local government Medicaid spending will rise an average of 6.1 percent annually between 2017 and 2025.
“This is far ahead of Fitch’s expectations for national economic growth and state tax revenue growth, signaling continued pressure on states to manage their budgets accordingly,” Fitch said.
Aetna reports 52% surge in second quarter profit
CEO Mark Bertolini credits Medicare market, which he wants to expand in 2018.
Aetna’s government business in Medicare and Medicaid, and its exit from numerous Affordable Care Act exchange markets helped propel the insurer’s second quarter profits by 52 percent over last year.
Aetna reported second quarter profits of $1.2 million, compared to $791,000 for the same period in 2016.
“Specifically, operating results in our government business remain robust with government premiums representing more than half of the total healthcare premiums,” CEO Mark Bertolini said during the August 3 earnings call. “Medical cost trends remain moderate and we experienced favorable development of prior period healthcare cost estimates across all of our core products in the quarter.”
Helping to cut medical claims costs was a decision by the Hartford, Connecticut-based insurer to cut its participation in the ACA market from 15 states last year to a current four states.
In June, Aetna submitted bids to the Center for Medicare and Medicaid Services to expand Aetna’s reach from 56 percent of the Medicare population to 60 percent in 2018, according to Bertolini.
“As we discussed previously, our goal is to accelerate our geographic expansion in 2019 and beyond to serve more of this growing population,” Bertolini said. “Continuing on with our government business. Medicaid delivered another solid quarter, including stable revenue and underwriting results compared to the prior-year period, despite the exit from Missouri during the quarter.”
Aetna serves approximately 2.1 million Medicaid members, a decrease of approximately 250,000 compared to last year, due to its exit from the Missouri Medicaid program.
“Based on our continued outperformance, we are once again increasing our full-year 2017 earnings projections,” Bertolini said.
CMS Finalizes 2018 Meaningful Use Requirement Flexibilities
Revisions include a 90-day reporting period, exceptions for decertified EHR technology, and acceptable versions of certified EHR technology.
As part of a final rule for hospital inpatient reimbursement for 2018, CMS has also finalized a host of revision to the meaningful use requirements for eligible providers participating in the EHR Incentive Programs next year.
Chief among the revisions is the reduction of the EHR reporting period next year to 90 days for “new and returning participants attesting to CMS or their Stage Medicaid agency,” states the final rule to be published on August 14. The revised reporting period must comprise a continuous 90 days between Jan. 1, 2018 and Dec. 31, 2018.
According to the final rule, the motivation for finalizing revisions to meaningful use requirements in 2018 is “to continue advanced of certified EHR technology utilization, focusing on interoperability and data sharing.”
Many of the other finalized changes owe much to mandates included in the 21st Century Cures Act, such as an exception for Medicare payments adjustments for eligible professionals and hospitals affected by EHR decertification. For those providers unable to satisfy meaningful use requirements because their certified EHR technology is now or becomes decertify, they will be able to avoid meaningful use penalties (but also miss out on EHR incentives). EPs will have until Oct. 1, 2017 to submit their applications; hospitals, July 1, 2017 — barring further changes made by CMS.
Additionally, EPs who provide “substantially all” of their services in ambulatory surgical centers (ASC) will avoid Medicare payment adjustments in 2017 and 2018:
We proposed to define an ASC-based EP under § 495.4 as an EP who furnishes 75 percent or more (or alternatively, 90 percent or more) of his or her covered professional services in sites of service identified by the codes used in the HIPAA standard transaction as an ASC setting in the calendar year that is two years before the payment adjustment year. In addition, we proposed to use Place of Service (POS) Code 24 to identify services furnished in an ASC and requested public comment on whether other POS codes or mechanisms should be used to identify sites of service in addition to or in lieu of POS code 24. For the reasons discussed in section IX.G.4. of the preamble of this final rule, we are finalizing the definition of an ASC-based EP as an EP who furnishes 75 percent or more of his or her covered professional services in sites of service identified by POS 24.
As for the type of CEHRT required for meaningful use attestation, CMS has finalized a policy that allows eligible professionals to use 2014 Edition, 2015 Edition, of a combination of the two for the purposes of EHR reporting in 2018.
That being said, the federal agency determined that calls to revise meaningful use objectives and measures, meaningful use audits, the Merit-Based Incentive Payment System (MIPS), and CEHRT grant funding were beyond the scope of the final rule and therefore not met.
The federal agency faced considerable pushback from industry groups advocating for significant change to the EHR Incentive Programs. Last month, the American Hospital Association (AHA) called for the cancellation of Stage 3 Meaningful Use, which is set to begin in 2018. The association claimed that the phase’s meaningful use requirements were overly burdensome.
“These excessive requirements are set to become even more onerous when Stage 3 begins in 2018,” AHA stated in a letter to CMS. “They also will raise costs by forcing hospitals to spend large sums upgrading their EHRs solely for the purpose of meeting regulatory requirements.
Based on this final rule, the EHR Incentive Programs will carry on as planned.
Most Significant Epic, Cerner Health IT Achievements of 2017
Epic and Cerner continue to dominate the healthcare industry and this year the two health IT companies have made key additions to their portfolios.
Epic Systems and Cerner Corporation solidified their status as top dogs in the health IT industry in 2017.
Both health IT companies scored massive contracts this year, with Epic continuing to gain popularity among the private sector and Cerner expanding its presence in the public sphere.
Cerner and Epic have also found success expanding their health IT offerings into other areas of care management, including population health and revenue cycle management. The companies have proven their ability to stay ahead of the curve by continuing to add more products and technologies to their arsenal in keeping with developments in the industry.
Over midway through 2017, here are a few of the most significant achievements of the year by the biggest players in health IT:
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