As health care delivery system reform continues, the Centers for Medicare and Medicaid Services (CMS) has an important opportunity and a critical role to play in promoting health equity. Agency for Healthcare Research and Quality (AHRQ), 2014 National Healthcare Quality and Disparities Report, Publication No. One recent day at the end of March, he visited Vincent Berry, a 28-year-old man who’s paralyzed from the waist down, a condition resulting from a years-ago gunshot wound after a drug deal went sour. Part of it is spurred by the 2010 federal health reform, which introduced a number of changes in how Medicare pays hospitals. Similar efforts are underway on the state level, through Medicaid payments and health insurance regulations. Challenges persist, though, in figuring out how to finance community health worker programs and regulate the growing workforce. The American Hospital Association doesn’t systematically track how many health systems have launched community health worker programs. Community health workers are often uniquely positioned to help their clients — the hospital patients. Hopkins got a federal grant from the Center for Medicare & Medicaid Innovation to launch its program in 2012. Meanwhile, state and federal regulators are grappling with how to set standards for community health workers’ training and certification.
More than 20 states have instituted regulations or created oversight committees, according to Sharon Moffatt, interim executive director of the Association of State and Territorial Health Officials. Moving into a realm usually reserved for health care regulators, the California health marketplace Thursday unveiled sweeping reforms to its contracts with insurers, seeking to improve the quality of care, curb its cost and increase transparency for consumers. The attempt to impose quality and cost standards on health plans and doctors and hospitals appears to be the first by any Obamacare exchange in the nation.
Among the biggest changes: Health plans will be required to dock hospitals at least 6 percent of their payments if they do not meet certain quality standards, or give them bonuses of an equal amount if they exceed the standards. The plan, to be implemented over seven years, is based on a similar strategy pursued by the federal agency that oversees the government-run Medicaid and Medicare health insurance programs.
The California Hospital Association, in a statement issued late Thursday, said it supported the exchange’s decision to phase in the plan incrementally. The exchange, known as Covered California, will also require health plans to identify hospitals and doctors that are performing poorly on a variety of quality metrics or charging too much for care.
Some doctors have noted that provider networks in many of the health plans sold by Covered California are already thin and warned that cutting the networks even more would only exacerbate the problem.
The insurers are not happy about transparency provisions that involve disclosing the rates they negotiate with their providers. But Covered California officials believe that scrutinizing the negotiated rates will help the exchange identify high-cost providers and allow policyholders with high deductibles to see the differences in price before undergoing a medical procedure. Nicole Evans, spokeswoman for the California Association of Health Plans, said that in some rural areas, where hospitals are few and far between, eliminating even one that is deemed to be underperforming might seriously compromise access to medical care. Evans added, though, that she was pleased Covered California would at least allow exceptions to this rule. Health plans and doctors must share data to better track and treat patients with chronic conditions such as diabetes. Plans are obliged to monitor and reduce health disparities among all their patients, starting with four major conditions: diabetes, hypertension, asthma and depression.
They also are required to better manage the price of high-end pharmaceuticals and aid consumers in reducing the cost of expensive drug treatments. The health plans must help consumers better understand their diseases and treatment choices — and their share of the costs for those treatments.
Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.Kaiser Health News (KHN) is a national health policy news service. By teaming with community organizations, doctors and hospitals can deliver high-quality care at good value to disadvantaged people at risk for poor health, according to a new report from a panel of experts. The report released Thursday by the National Academies of Sciences, Engineering and Medicine was produced to aid Medicare officials studying how to fairly pay hospitals that disproportionately serve patients with social risk factors for health problems. Federal officials have announced the plan to move Medicare from a system in which doctors and hospitals are paid based on the volume of services they provide. Some research has found that hospitals serving disadvantaged patients may be more likely to receive poor quality ratings and receive financial penalties, the report said. The National Academies panel said some common themes emerged from its review of 60 case studies and peer-reviewed research.
A health system in that context may prepare a comprehensive needs assessment, according to the report, but its vision will be different if the assessment is grounded by a commitment to health equity and includes social needs as well as clinical needs. Sutter Health, long accused of abusing its market power in California, is squaring off against major U.S.
The latest fight has erupted over Sutter’s demand that employers sign an arbitration agreement to resolve disputes.
All this comes amid growing concern nationwide about the financial toll from industry consolidation as big health systems amass market clout by acquiring more hospitals, outpatient facilities and physician offices. The current fight centers on larger employers that tend to self-insure because they have the financial resources to pay their own medical claims. Sutter, a Sacramento-based nonprofit, has 24 hospitals, 34 surgery centers and more than 5,000 physicians in its network.
Bill Kramer, executive director of national health policy at the Pacific Business Group on Health, agreed that Sutter’s threat to pull all of its facilities from an insurance network took employers by surprise. The lawsuit over antitrust violations and unfair competition alleges that Sutter’s hospital prices in San Francisco have exceeded those of competitors by as much as 56 percent.
Employers began expressing concerns about Sutter’s move in recent weeks after insurers raised the issue.
California Attorney General Kamala Harris has been investigating Sutter and other big medical providers for several years over potential harm to consumers. Melnick and other experts say the lack of competition in Northern California helps explain why health insurance premiums are about 25 percent higher, on average, compared to the southern part of the state.
This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California Health Care Foundation.Kaiser Health News (KHN) is a national health policy news service. That’s according to the Leapfrog Group, a nonprofit organization known for rating hospitals on patient safety. Almost 40 percent of potentially harmful drug orders weren’t flagged as dangerous by the systems, Leapfrog found. According to 2015 figures from the federal Agency for Healthcare Research and Quality, about 1 of every 20 patients in hospitals suffers harm because of medications. But it’s difficult to know how many of those missed errors result in actual harm, Mobley acknowledged. The survey, Mobley suggested, underscores the need for hospitals and patients to be vigilant when it comes to overseeing their medications.
And hospitals are increasingly taking such steps to make medication errors less common, said Jesse Pines, who directs the Office for Clinical Practice Innovation at George Washington University and is a professor of emergency medicine. Patients, meanwhile, should make sure to have someone with them when they go into the hospital, who can check out what drugs they’re being prescribed, Mobley said. Hospitals can try to customize their medication ordering systems to do things like identify frequently ordered drugs or better match the patients they’re likely to treat. A number of Leapfrog’s surveys have come under scrutiny from some hospitals, who question their methodology and metrics.
Drug treatment providers in California and elsewhere have relied for decades on abstinence and therapy to treat addicts. Faced with a worsening opiate epidemic and rising numbers of overdose deaths, policymakers are ramping up medication-assisted treatment. President Barack Obama last week said he’d allocate more money for states to expand access to the medications. California already plans to expand access to medications as it launches an overhaul of the state’s substance abuse treatment system for low-income residents.
While medication is not for everyone, it can be critical for some people with severe addiction, said Marlies Perez, chief of the substance use disorder compliance division for the state Department of Health Care Services. The best-known medication, methadone, blocks the effect of certain drugs and lessens withdrawal symptoms. The medications are available across the country but must be prescribed by physicians with special training. Obama’s proposal would allow qualified doctors to prescribe buprenorphine to 200 patients, up from 100. The use of medication in treatment conflicts with the 12-step and Narcotics Anonymous philosophy of addiction recovery, which is based on abstinence, experts said.
Medication is one of the most successful, evidence-based treatments available, and more access should have a big impact on those with substance abuse disorders, said John Connolly, deputy director for substance abuse prevention and control for the Los Angeles County Department of Public Health.
Stephen Kaplan, director of behavioral health and recovery services for San Mateo County, said the county has increased its use of medication. Kaplan said he respects providers who believe that replacing one drug with another is not true recovery.
Health care spending was growing well in excess of inflation virtually every year — and as costs continued to increase without limit, neither the quality we experienced as patients nor the quantity of people covered was getting better. The passage of the ACA disrupted our trajectory as for the first time in many years there became no such things as business as usual. What is most striking about these national improvements in cost, quality, and access to care since the ACA is that none of these measures had improved in decades.
That comprehensive view of care that is a hallmark of the PACE program is a strong example of what we need as a nation. So as we enter our next chapter of health care reform, there are three important ingredients that will be critical in shaping our success.
First, when we say patient-centered or consumer-driven, it has to mean something that improves, empowers and engages the life of the consumer. As I look at the PACE program and all that it represents, I believe you can show us the way.
In order to put meaning behind a truly consumer-oriented health care system, we first must have a renewed understanding for who we as a country are taking care of and what their needs are.

And this really hit me when I had the privilege to visit On Lok in San Francisco last year.
What I saw at On Lok was a staff that was caring, a kitchen which prepared a diverse set of ethnic meals, vans that brought people in from all over the city to an array of activities, and an interaction with family caregivers in what appeared to be an extension of the family.
Nowhere is this more apparent than when I look at how we care for the elderly and how we afford the care our seniors will need. Our agenda is not to sit back and expect all this change to happen on its own, but to help people succeed. Investing in prevention as we now move to make community-based diabetes prevention more prevalent. For the many reasons I described, a locally-based, patient-centered and comprehensive commitment to patients is vital to our future.
With your help, this next chapter will take what we’ve started and impact people more comprehensively, while building a smarter system that can ultimately sustain our needs as a country. Nearly a third of people without health insurance, about 10 million, live in families that received a federal earned income tax credit (EITC) in 2014, according to a new study. But the Internal Revenue Service doesn’t tell those tax filers that their low and moderate incomes likely mean their households qualify for Medicaid or subsidies to buy coverage on the insurance exchanges. That’s a lost opportunity to identify people who are eligible but not receiving government assistance to gain health coverage, the researchers say. While the Affordable Care Act has driven down uninsured rates to historic lows the past few years, about 33 million Americans remain uninsured, according to latest Census data. The Urban Institute said the federal government could do more to find the uninsured by tapping into data it collects from other assistance programs. The earned income tax credit is the most common government assistance benefit reported by the uninsured but there are others, the report said.
Blumberg cautioned that just sending a letter to tax filers about their health insurance options might not nudge them to sign up.
A difficulty involves uninsured people in the 20 states that did not expand Medicaid under Obamacare, said Tricia Brooks, senior fellow at the Georgetown University Center for Children and Families. A better course for the IRS is to target those who qualified for the earned income tax credit in the states that did expand Medicaid, she said.Kaiser Health News (KHN) is a national health policy news service. It may seem like a no-brainer to include patients’ assessments of their physical and mental conditions and quality of life into medical care, but such patient-generated data has traditionally been confined to research rather than clinical settings. Each April, in recognition of National Minority Health Month, we commemorate past achievements, acknowledge current efforts, and outline our continued journey towards health equity and equality for all. Five years ago, the Affordable Care Act established three additional offices of minority health within six HHS agencies.
From Coverage to Care is an ongoing initiative designed to help consumers understand their healthcare coverage and how to access the care they need.
Doctors could play a key role in instead helping patients find appropriate and affordable care by talking to them about their out-of-pocket costs.
The researchers analyzed transcripts of almost 2,000 physician-patient conversations regarding breast cancer, rheumatoid arthritis and depression treatment. Overall, researchers noted two ways in which doctors dismissed patients’ financial woes. And, without such a long-term plan, patients may eventually stop taking the medication, or take it irregularly.
That said, navigating a patient’s financial circumstances and medical needs in the course of a 15-minute visit is tricky, said Jonathan Kolstad, an assistant professor of economic analysis and policy at the University of California, Berkeley.
Berry’s doing well medically, but he lives with his aging grandmother, in the upstairs bedroom of a narrow apartment where he relies on help from friends and family to be able to leave.
Health insurers, too, are starting to show interest in figuring out how they might pay for these services. When visiting patients, he avoids business clothes that might render him unapproachable, opting for a shirt and lanyard showing he’s from Hopkins, but also jeans and brown walking shoes.
Some health systems are using grants from private foundations or the federal Centers for Medicare & Medicaid Services to get started. That adds financial incentives for Hopkins and other hospitals, encouraging them to use strategies such as outreach by community health workers. The University of Maryland Medical Center, in West Baltimore, for instance, started its community health worker project last year after it was penalized by Medicare for failing to meet national standards regarding how many patients it readmitted within 30 days of discharge.
Still, the hospital is looking into expanding it, said Charles Callahan, vice president of population health.
But Missouri, the Hopkins community health worker, said knowing the city, its resources and residents matters most.
The plans must dump the providers from their networks as early as 2019 if they don’t mend their ways. And, they say, some hospitals and physicians might balk at the stringent new requirements and decline to participate in Covered California networks.
Health plans have long resisted efforts that would let competitors or the public see the deals they make with doctors and hospitals. For instance, it suggests that offering prices to consumers does not necessarily encourage them to use the most expensive doctors or hospitals. Those factors include low income, social isolation, disadvantaged neighborhoods and limited health literacy.
The goal is a value-based payment system to encourage a better quality of care, better health outcomes and control costs. One was what can be accomplished when doctors and hospitals partner with social service agencies, public health agencies, community organizations and the community itself, the panel said. His members include big employers such as Wells Fargo, Intel and Chevron as well as government agencies like the California Public Employees’ Retirement System. Industry giants Anthem and Aetna are urging customers to accept arbitration in order to remain in the network while rival Blue Shield of California said it opposes Sutter’s request. They often hire an insurer to negotiate with hospitals and other providers for discounted rates as part of their health plan network for employees.
Arbitration is widely used by companies of all types to help resolve disputes and avoid costly litigation. It also says an overnight hospital stay at Sutter hospitals in San Francisco or Sacramento costs at least 38 percent more than a comparable stay in the more competitive Los Angeles market. While a vast majority of hospitals surveyed had some kind of computer-based medication system in place, the systems still fall short in catching possible problems. These included medication orders for the wrong condition or in the wrong dose based on things like a patient’s size, other illnesses or likely drug interactions.
But there’s been pushback from many doctors and advocates, who say design issues can make the software difficult to use or even counterproductive.
Participants would put in information for fake patients and submit a set of medication orders to see which ones got flagged. To that end, hospitals and safety experts should figure out what are the best practices when it comes to customizing tools like medication ordering software. Here, Mobley said, the survey may inflate the number of hospitals with a computer-based medication ordering system.
He also proposed that physicians be able to prescribe one of the most effective anti-addiction drugs, buprenorphine, to more patients. The state recently embarked on a five-year demonstration project on the premise that addiction is a chronic disease and should be treated as such.
It is highly regulated and can only be prescribed by clinics that have government approval. There are only about 30,000 authorized doctors nationwide, and they can only prescribe to a limited number of patients. The state is also trying to better link treatment centers with trained prescribing doctors so that physicians can consult with one another on treatment options for their patients. About two years ago, the county began a pilot project to prescribe naltrexone to people with severe alcoholism who hadn’t been successful in traditional treatment. But from a policy standpoint, Kaplan said, the medications are effective and should be more integrated into overall recovery for people with substance abuse disorders. I want to thank you for having me here and I hope you have had, and have, productive meetings here in Washington. 20 million Americans have since gained coverage; the uninsured rate is now lower than 10% and if more states expand Medicaid, millions more would have the security of coverage. As you know better than anyone, delivering care that accounts for the entire needs of the patient is not simply an operational change; it requires a different way of thinking and we need to get on that path across all sectors where a patient gets care. The health care consumer is more diverse, more mobile and more demanding than ever before. To be crystal clear, it’s all of our jobs to allow us to afford all the high quality care we as Americans will need.
Secretary Burwell last year committed the federal government to change how we pay for care.
And, 64 representing 1.6 million people, are in 2-sided or full risk models, up from 19 just last year and zero before the ACA.
Our health care needs are too complex and too interdependent and the interests and needs of patients and the care provider community too diverse and heterogeneous.
We are calling for the same level of quality care delivery that are targeted at the needs of populations and are culturally-competent for all races, ethnicities, geographies, and other ethnic, sexual or gender-based minorities. Leaders around the country must seize the mantle of change to reduce unnecessary costs and unnecessary admissions; reduce waste where they see it, redesign care processes and coordinate patient care to better manage chronic disease. Models of care – whether PACE or ACO or Medical Home -may all be in iterations of what will ultimately become the most successful models. I believe PACE is a model with great promise and I want to affirm my commitment to cultivating that promise.
The challenge is not simply to grow the program, but to define the brand by educating the public and making PACE a clear part of the solution. And I have a public email address so I have learned that many of them wake up every day thinking about me too.
It was released last week by the nonpartisan Urban Institute, a Washington-based research group.

New Jersey and Maryland check state income tax filings to find those likely eligible for Medicaid, the state-federal health insurance program for poor. To receive the credit, workers must file a tax return, even if they are otherwise exempt from doing so. About 23 percent of the uninsured live in households in which at least one child received subsidized lunch at school.
In fact, since 2014 all tax filers must report whether they have health insurance on their annual tax forms, she said.
But she said the IRS could invite interested filers to request a federal health law navigator contact and enroll them.
Many adults who get the credit in those states may not qualify for Medicaid, although some may qualify for premium subsidies on health plans sold on the exchanges. Clinicians have typically focused more on physical exams, medical tests and biological measures to guide patient care.
Patricia Franklin, a professor of orthopedics and physical rehabilitation at UMass who coauthored the Health Affairs study, and colleagues incorporated that template into a project funded by the federal Agency for Healthcare Research and Quality that implemented patient-reported outcomes for knee and hip replacements in more than 150 surgeons’ offices in 22 states. But many health care-related events happen in between those visits, and they can be recorded in the tracking tool.
While several HHS agencies already had offices of minority health, the Office of Minority Health (OMH) at the Centers for Medicare & Medicaid Services (CMS) was an office newly established through the Affordable Care Act.
Additionally, the CMS Equity Plan for Improving Quality in Medicare is CMS’ first strategic equity plan. It will take the support of partners from the federal to the community level.  We encourage you to join us on the path to health equity by using the resources discussed in this blog, bookmarking the CMS OMH website, joining our listserv, and of course building on your own health equity activities!
But when doctors are reluctant to talk about medical costs, a patient’s health can be undermined. In theory, that’s supposed to make them sharper consumers and empower them to trim unnecessary health spending.
They identified instances in which patients suggested that the cost of care might be difficult to afford and assessed how doctors responded. They either did not acknowledge the concerns patients expressed or only half-addressed them.
He pointed to a separate analysis of those same conversations, which found that doctors discussed medical costs with patients about 30 percent of the time; and, in only about 40 percent of those discussions did doctors and patients brainstorm about ways to make medication more affordable.
If a patient comes in with heartburn and indigestion, a good internist will immediately start probing for signs of coronary disease, Ubel said. As it becomes more commonplace, patients may push doctors for more help in making cost-based decisions, Ubel said. In March 2016, CMS OMH launched a newly developed interactive tool to increase understanding of geographic disparities in chronic disease among Medicare beneficiaries. Missouri has been trying to help him secure independent, wheelchair-accessible housing that will make it possible for him go to school or pursue other activities that might move his life forward. Often hired by the local health department, they take on diverse public health initiatives — running diabetes or nutrition education programs, counseling patients to stick to their medication regimens or teaching new mothers about vaccinations.
New York Presbyterian Hospital, affiliated with Columbia University, started its community health worker pilot a decade ago, using grant funding.
The plans could choose not to cut the hospitals or doctors, but they would have to explain in writing why, and detail what the providers are doing to address their deficiencies. The report is the second of five commissioned for the Department of Health and Human Services.
But when it comes to how effective the systems are, the findings are unsurprising, both Haskell and Ratwani said. Buprenorphine, which can be prescribed in doctors’ offices, produces mild opioid effects while also easing withdrawal symptoms. I want to talk today about some of the essential changes for our health care system over the next number of years as we move to the next chapter of the implementation of the ACA and this is the perfect audience to do it. I think it has as much to do with how we react to and implement the law as the law itself; how we keep pressing forward for better and better results. Our commitment to quality must become imbedded and we must find ways to reach all the people that are still left behind and left out of the system. If we appeal to everyone’s self interest better, we can make a certain amount of progress. This must be measured and highly transparent and we are putting forward more and better data this month as part of National Minority Health Month. We are still at the stage where Marketplace plans are still experimenting with how to offer benefits and networks in ways that deliver affordability to consumers, and drug companies are seeking to define and deliver value in new models. Over the last five years, we have seen demand grow and we at CMS are committed to providing support for further growth. We need to collect and report on quality metrics so that we can demonstrate a definite proposition that more comprehensive care will led to both better outcomes and lower overall spending. Louisiana and West Virginia, among several, have sent letters to food stamp recipients to invite them to sign up for Medicaid.
The publication of the Agency for Healthcare Research and Quality’s annual National Healthcare Quality and Disparities Report illustrates our commitment to track our progress.
Launched in 2015, this equity plan identifies six priorities and provides an action-oriented, results-driven approach for advancing health equity by improving the quality of care provided to racial and ethnic minority and other underserved Medicare beneficiaries. A study published in Monday’s Health Affairs explores the dynamics that can trigger that scenario.
But previous work has shown it often leads them to skimp on both valuable preventive care and superfluous services alike. By contrast, physicians aren’t primed to pick up on cues that patients may face financial strains.
That reduces how much expensive, often-not-profitable care hospitals need to give, yielding a financial payoff.
Since then, program leaders have convinced the hospital not only to pay for the program but to expand it, citing healthier, more satisfied patients.
And, for those that are, hospitals may have other safeguards in place to catch mistakes before they actually hurt patients.
Six years ago, prior to the ACA, our health care system was not doing the job for the people who needed it the most. As I think about all the work left to be done… we are now trying to evolve the broader system closer toward the principles that have driven PACE for decades by treating people and their needs comprehensively, patient by patient, community by community. Being treated in a comfortable setting — at home or in the community is often better than an institution. As I have seen when I visited On Lok, this is something you all know how to do if we commit to it. If we either give up or retrench in these early innings, we risk seeing our progress slip or becoming outmoded as new solutions develop. We are committed to proposing a regulatory update which will assist the path to growing successful. The passage of the Affordable Care Act and the enrollment of millions of Americans, including many people of color in health plans, illustrate our continued advancement towards better care and healthier communities. To help achieve this aim, the CMS Office of Minority Health ensures that the voices and needs of minority and underserved populations are present in the development, implementation, and evaluation of CMS programs and services. Last month, CMS OMH launched an interactive web based tool for mapping Medicare disparities. It provides users with a quick and easy way to identify areas with large numbers of vulnerable populations to target interventions that address racial and ethnic disparities.
An early study of the program found patients who participate are less likely to keep returning to the hospital and have better outcomes. Our next chapter must be driven by leaders with a commitment to success beyond their own organizations.
For us, this is aimed at facilitating more interdisciplinary care, increasing operational flexibility, improving access to community-based providers, and improving our enforcement processes. We are dedicated to working on behalf of all CMS beneficiaries, while strategically focusing on racial and ethnic minorities, individuals with disabilities, and Lesbian, Gay, Bi sexual and Transgender (LGBT) minorities.
The Mapping Medicare Disparities Tool contains health outcome measures for disease prevalence, costs, and hospitalization for 18 specific chronic conditions, emergency department utilization, readmissions rates, mortality and preventable hospitalizations. The MMD Tool is expected to help government agencies, policymakers, researchers, community-based organizations, health providers, quality improvement organizations, and the general public analyze chronic disease disparities, identifying how a region or population may differ from the state or national average.
High-priced technology or medication is no replacement for understanding and managing a patient’s needs. We issued a report to Congress last year on the topic of opening the PACE program to for-profits and facilitating conversions as appropriate. CMS OMH activities include: From Coverage to Care, the CMS Equity Plan for Improving Quality in Medicare, strengthening CMS data collection and analysis, and working across the agency to embed a focus on health equity into new and existing programs and policies. But to do so, the institutions that make up our health care system will need to compete on how best to solve real life problems for real life consumers and build real relationships.
And as you heard from Tim this morning, we are working through options on the PACE Innovation Act and look forward to new opportunities to test PACE-like models for new populations. At this still early stage in the evolution of PACE, bad apples sometimes still define the overall brand, often unfairly. It’s a model the health plans, hospitals, clinics, and government institutions would be wise to pay attention to. And third is to create the innovation that helps manage the population challenge that we as a country are facing. The cry for high-quality patient-focused services is growing more intense for our parents and ourselves. At full potential, PACE will not only be successful but become one aspect of the solution that solve bigger and bigger portions of our national challenge.

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