Everyone agrees the ACA isn't perfect, but let's 'fix and innovate; not 'repeal and replace'.

The House Republicans' campaign to repeal the Affordable Care Act and shrink Medicaid funding has produced a lot of drama-and an unexpected realization for repeal proponents: People like the ACA. And they're pretty fond of Medicaid, too.

Improving cardiovascular care through outpatient cardiac rehabilitation: an analysis of payment models that would improve quality and promote use.

BACKGROUND: Much attention has been paid to improving the care of patients with cardiovascular disease by focusing attention on delivery system redesign and payment reforms that encompass the healthcare spectrum, from an acute episode to maintenance of care. However, 1 area of cardiovascular disease care that has received little attention in the advancement of quality is cardiac rehabilitation (CR), a comprehensive secondary prevention program that is significantly underused despite evidence-based guidelines that recommending its use. PURPOSE: The purpose of this article was to analyze the applicability of 2 payment and reimbursement models-pay-for-performance and bundled payments for episodes of care--that can promote the use of CR. CONCLUSIONS: We conclude that a payment model combining elements of both pay-for-performance and episodes of care would increase the use of CR, which would both improve quality and increase efficiency in cardiac care. Specific elements would need to be clearly defined, however, including: (a) how an episode is defined, (b) how to hold providers accountable for the care they provider, (c) how to encourage participation among CR providers, and (d) how to determine an equitable distribution of payment. CLINICAL IMPLICATIONS: Demonstrations testing new payment models must be implemented to generate empirical evidence that a melded pay-for-performance and episode-based care payment model will improve quality and efficiency.

A quality improvement framework for equity in cardiovascular care: results of a national collaborative.

Disparities in the quality of cardiovascular care provided to minorities have been well documented, but less is known about the use of quality improvement methods to eliminate these disparities. Measurement is also often impeded by a lack of reliable patient demographic data. The objective of this study was to assess the ability of hospitals with large minority populations to measure and improve the care rendered to Black and Hispanic patients. The Expecting Success: Excellence in Cardiac Care project utilized the standardized collection of self-reported patient race, ethnicity, and language data to generate stratified performance measures for cardiac care coupled with evidence-based practice tools in a national competitively selected sample of 10 hospitals with high cardiac volumes and largely minority patient populations. Main outcomes included changes in nationally recognized measures of acute myocardial infarction and heart failure quality of care and 2 composite measures, stratified by patient demographic characteristics. Quality improved significantly at 7 of the 10 hospitals as gauged by composite measures (p < .05), and improvements exceeded those observed nationally for all hospitals. Three of 10 hospitals found racial or ethnic disparities which were eliminated in the course of the project. Clinicians and institutions were able to join the standardized collection of self-reported patient demographic data to evidence-based measures and quality improvement tools to improve the care of minorities and eliminate disparities in care. This framework may be replicable to ensure equity in other clinical areas.

Measuring healthcare disparities and racial segregation in Missouri nursing homes.

Measuring and, ultimately, addressing disparities in long-term care quality continue to be a challenge. Although literature suggests that disparities in healthcare quality exist and nursing homes remain relatively segregated, healthcare professionals and policymakers stand to benefit from improvements in measuring both racial segregation and healthcare disparities. This paper quantifies the relationships between healthcare disparities and racial segregation using the disparities quality index and dissimilarity index. Results suggested that the more segregated the nursing homes, the greater the observed disparities. Multivariate regression analysis indicated that the proportion of Black residents in nursing homes is the variable that best predicts disparities.

How health care organizations are using data on patients' race and ethnicity to improve quality of care.

CONTEXT: Racial and ethnic disparities in the quality of health care are well documented in the U.S. health care system. Reducing these disparities requires action by health care organizations. Collecting accurate data from patients about their race and ethnicity is an essential first step for health care organizations to take such action, but these data are not systematically collected and used for quality improvement purposes in the United States. This study explores the challenges encountered by health care organizations that attempted to collect and use these data to reduce disparities. METHODS: Purposive sampling was used to identify eight health care organizations that collected race and ethnicity data to measure and reduce disparities in the quality and outcomes of health care. Staff, including senior managers and data analysts, were interviewed at each site, using a semi-structured interview format about the following themes: the challenges of collecting and collating accurate data from patients, how organizations defined a disparity and analyzed data, and the impact and uses of their findings. FINDINGS: To collect accurate self-reported data on race and ethnicity from patients, most organizations had upgraded or modified their IT systems to capture data and trained staff to collect and input these data from patients. By stratifying nationally validated indicators of quality for hospitals and ambulatory care by race and ethnicity, most organizations had then used these data to identify disparities in the quality of care. In this process, organizations were taking different approaches to defining and measuring disparities. Through these various methods, all organizations had found some disparities, and some had invested in interventions designed to address them, such as extra staff, extended hours, or services in new locations. CONCLUSION: If policymakers wish to hold health care organizations accountable for disparities in the quality of the care they deliver, common standards will be needed for organizations' data measurement, analysis, and use to guide systematic analysis and robust investment in potential solutions to reduce and eliminate disparities.

Barriers to effective self-management in cardiac patients: the patient's experience.

OBJECTIVE: This paper identifies common obstacles impeding effective self-management among patients with heart disease and explores how for disadvantaged patients access barriers interfere with typical management challenges to undermine patients' efforts to care for their illnesses. METHODS: We convened 33 focus group discussions with heart patients in 10 U.S. communities. Using content analysis, we identified and grouped the most common barriers that emerged in focus group discussions. RESULTS: We identified nine major themes reflecting issues related to patients' ability to care for and manage their heart conditions. We grouped the themes into three domains of interest: (1) barriers that interfere with getting necessary services, (2) barriers that impede the monitoring and management of a heart condition on a daily basis, and (3) supports that enable self-management and improve care. CONCLUSION: For disadvantaged populations, typical problems associated with self-management of a heart condition are aggravated by substantial obstacles to accessing care. PRACTICE IMPLICATIONS: Ensuring disadvantaged patients with chronic heart conditions are linked to formal systems of care, such as cardiac rehabilitation programs, could better develop patients' self-management skills, reduce barriers to receiving care and improve the overall health outcomes of these patients.

Measuring equity: an index of health care disparities.

OBJECTIVE: To create an index that would serve as a simple tool to measure the quality of hospital care by race and ethnicity. STUDY DESIGN: Following extensive review of existing disparities indices, we created a disparities quality index (DQI) designed to easily measure differences in the quality of care hospitals deliver to different populations. The DQI uses performance data already collected by virtually all hospitals. It highlights areas where there are large numbers of patients in a specific population receiving potentially lower-quality care. SETTING: Data were collected from 2 acute care hospitals that participated in a multihospital collaborative. DATA COLLECTION/EXTRACTION METHODS: We applied the DQI to 2 hospitals' quality data, specifically to their performance on the Hospital Quality Alliance measure for patients with heart failure who were receiving angiotensin-converting enzyme inhibitor or angiotensin receptor blocker. RESULTS: The DQI was simple to apply and was able to measure differences in the care of different ethnic groups. It also detected changes in disparities over time. CONCLUSIONS: The DQI can help hospitals and other providers focus on the domain of equity in their quality-improvement efforts. Further testing is required to determine its applicability for community-wide equity projects.

Private gain and public pain: financing American health care.

Health care spending comprises about 16% of the total United States gross domestic product and continues to rise. This article examines patterns of health care spending and the factors underlying their proportional growth. We examine the "usual suspects" most frequently cited as drivers of health care costs and explain why these may not be as important as they seem. We suggest that the drive for technological advancement, coupled with the entrepreneurial nature of the health care industry, has produced inherently inequitable and unsustainable health care expenditure and growth patterns. Successful health reform will need to address these factors and their consequences.

The profitability of Medicare admissions based on source of admission.

OBJECTIVES: This study investigates whether admissions from the emergency department (ED) have lower dollar margins than elective admissions under Medicare and explores two possible reasons for differences in margins. METHODS: The authors developed patient-level Medicare dollar margins (calculated as patient revenue minus cost) for 1,159,243 Medicare admissions from 321 hospitals using data from the 2003 Nationwide Inpatient Sample (NIS) and the Medicare Impact File. Differences in margins between ED and elective admissions were explored across a number of diagnosis-related groups (DRGs) using t-tests. Chi-square tests were used explore whether ED admission was more common among patients in low-profit DRGs and/or patients with greater severity of illness. RESULTS: The average Medicare dollar margins were -$712 (95% confidence interval [CI] = -$729 to -$695) for ED admissions and $22 (95% CI = -$2 to $47) for elective admissions. Medicare dollar margins for ED admissions were lower than those of elective admission for the most common DRGs. ED admission was associated with greater patient severity of illness. CONCLUSIONS: Source of admission is a financially meaningful classification. Because Medicare payment policy does not recognize differences in cost based on patients' route of admission, hospitals may have a financial incentive to favor elective admissions over ED admissions.

Assumed equity: early observations from the first hospital disparities collaborative.

Disparities in healthcare represent a failure in the equity domain of quality. Although disparities have been well documented, little has been written about how hospitals might use improved data collection and quality improvement techniques to eliminate disparities. This article describes early findings from the planning phase of the first hospital-based disparities collaborative. The authors also discuss the changes in policy and practice that may speed hospitals in placing disparities and equity on their quality agendas.