Breaking the Barriers to Specialty Care: Practical Ideas to Improve Health Equity and Reduce Cost - Increasing Specialty Care Availability

Tremendous health outcome inequities remain in the U.S. across race and ethnicity, gender and sexual orientation, socio-economic status, and geography—particularly for those with serious conditions such as lung or skin cancer, HIV/AIDS, or cardiovascular disease.These inequities are driven by a complex set of factors—including distance to a specialist, insurance coverage, provider bias, and a patient's housing and healthy food access. These inequities not only harm patients, resulting in avoidable illness and death, they also drive unnecessary health systems costs.This 5-part series highlights the urgent need to address these issues, providing resources such as case studies, data, and recommendations to help the health care sector make meaningful strides toward achieving equity in specialty care.Top TakeawaysThere are vast inequalities in access to and outcomes from specialty health care in the U.S. These inequalities are worst for minority patients, low-income patients, patients with limited English language proficiency, and patients in rural areas.A number of solutions have emerged to improve health outcomes for minority and medically underserved patients. These solutions fall into three main categories: increasing specialty care availability, ensuring high-quality care, and helping patients engage in care.As these inequities are also significant drivers of health costs, payers, health care provider organizations, and policy makers have a strong incentive to invest in solutions that will both improve outcomes and reduce unnecessary costs. These actors play a critical role in ensuring that equity is embedded into core care delivery at scale.Part 2: "Increasing Specialty Care Availability"Solutions such as telemedicine, innovative partnerships between specialists and primary care physicians, and centralized local referral networks improve access to specialty care

Impact of the Economy on Health Care

Reviews research on how economic downturns affect healthcare access, costs, and outcomes. Examines changes in employer-based insurance, limitations on COBRA and public programs, impact on the healthcare sector, and implications for healthcare utilization

Breaking the Barriers to Specialty Care: Practical Ideas to Improve Health Equity and Reduce Cost - Striving for Equity in Specialty Care Full Report

Tremendous health outcome inequities remain in the U.S. across race and ethnicity, gender and sexual orientation, socio-economic status, and geography—particularly for those with serious conditions such as lung or skin cancer, HIV/AIDS, or cardiovascular disease.These inequities are driven by a complex set of factors—including distance to a specialist, insurance coverage, provider bias, and a patient's housing and healthy food access. These inequities not only harm patients, resulting in avoidable illness and death, they also drive unnecessary health systems costs.This 5-part series highlights the urgent need to address these issues, providing resources such as case studies, data, and recommendations to help the health care sector make meaningful strides toward achieving equity in specialty care.Top TakeawaysThere are vast inequalities in access to and outcomes from specialty health care in the U.S. These inequalities are worst for minority patients, low-income patients, patients with limited English language proficiency, and patients in rural areas.A number of solutions have emerged to improve health outcomes for minority and medically underserved patients. These solutions fall into three main categories: increasing specialty care availability, ensuring high-quality care, and helping patients engage in care.As these inequities are also significant drivers of health costs, payers, health care provider organizations, and policy makers have a strong incentive to invest in solutions that will both improve outcomes and reduce unnecessary costs. These actors play a critical role in ensuring that equity is embedded into core care delivery at scale.

Stresses to the Safety Net: The Public Hospital Perspective

Every year, more than 10 million people receive care from public hospitals and health systems – a complex and diverse set of providers that share a mission to deliver health services to individuals, regardless of insurance coverage or ability to pay. Together with federally funded health centers, free clinics, public health departments and scores of individual physicians and other health practitioners, public hospitals provide critical access points for the nation\u27s uninsured population and form a vast patchwork of providers that is commonly referred to as the health care safety net. Despite their importance, there is no single or stable source of financial support for public hospitals\u27 service to their communities. Safety net financing is fragmented; consequently, providers must knit together resources from many different funding sources to create a stream of revenue to cover the costs of providing a very broad range of services. Part 1 of this report describes those sources of revenue, demonstrating the significant role Medicaid plays in supporting the current public hospital safety net, documenting that nearly 40% of all safety net revenues are from Medicaid. It also highlights trends affecting the health of the safety net over the past decade. Part 2 describes particular challenges that safety net hospitals and health systems are experiencing as they attempt to rebound from the economic downturn of the early 2000s

A National Summit on Women Veteran Homelessness: A Leadership Dialogue

The National Summit on Women Veteran Homelessness brought together noted researchers, policy and practice experts, and women veterans with the lived experience of homelessness in a day and a half of facilitated dialogue sessions. Our purpose was threefold. First, we wanted to call attention to the growing national problem of homelessness among women veterans. Second, we wanted to better understand the unique challenges facing women veterans who have lost their homes or are at risk of homelessness. Finally, we sought to gather information and ideas for solutions to prevent and end homelessness among women veterans. Rich information was obtained from these sessions that will help us to understand the complex conditions that can result in women veteran homelessness, isolate the key areas where action to remediate the issues is required and create comprehensive and sustainable solutions that reduce the risk of women veteran homelessness and help those who are already homeless to achieve full reintegration into their communities. This report begins with a summary of presentations delivered by three experts who provided background on the demographics of homeless veterans, key programs at the U.S. Department of Veterans Affairs (VA), a research perspective on the challenges homeless women veterans face and litigation and advocacy as tools for change. The core of the report, called the Summit Dialogue Sessions, summarizes three roundtable discussions centered on the following themes: 1) pathways to homelessness for women veterans; 2) strategies for exiting homelessness; and 3) approaches to preventing women veterans from falling into homelessness. The report then turns attention to the list of actionable tasks which grew out of the roundtables, as well as two facilitated "fishbowls" in which subgroups of Summit participants explored specific issues related to policy, practice and research. Together, these offer not only a record of the work accomplished at the Summit, but also a pathway to future research, policy and program initiatives that hold the hope and potential for preventing and ending women veteran homelessness

Collaborating to Create Elder Friendly Communities in New Hampshire: A Scan of the Current Landscape

The fact that the population of the United States is aging is no surprise; the demographic projections are well documented. There have never been as many older adults living as there are today, and this number will only increase. Northern New England is aging more rapidly than the rest of the country, with Vermont, Maine, and New Hampshire having the oldest populations in term of median age (U.S. Census, 2014). New Hampshire is expected to be the fastest aging state in New England through 2030, with nearly one-third of its population being over the age of 65 (Norton, 2011). This phenomenon is anticipated to place substantial pressure on publicly-funded health programs and long-term services and supports in the Granite State. But the story of the aging of the population is not only about increased numbers. As longevity increases, the average age of the older population will see a dramatic increase. The number of persons over the age of 85 in the United States is expected to increase five-fold by 2040. As the possibility for functional limitations and disability increases with age, the need for long-term, formal, and informal supports is expected to increase as the number of older adults, particularly those over the age of 85 increases. In addition, women continue to live longer than men; on average, life expectancy for women is three years longer than for men. These factors create a complex picture of aging, which includes a growing population of older adults, a majority of whom will be women; and a growing number of those over the age of 85, who are more likely to require some type of assistance as they age. It is a mistake to look at our aging population in a singular way. Although we tend to make generalizations about older adults, as a group, they are more physiologically and socially diverse than any other age group (Brummel-Smith & Mosqueda, 2003). As we age, we become more and more diverse, as there are no two people who have had the same life experiences, shaping who we are over our lifetimes. The baby boomers (those born between 1946 and 1964) are likely to be the most diverse cohort of older adults we have seen to date, and it is likely that they will redefine our conception of age and aging. Older adults bring a diverse set of skills, talents, and knowledge that should be tapped as a significant natural resource to support a new and exciting vision of aging

State of Health Equity Movement, 2011 Update Part C: Compendium of Recommendations DRA Project Report No. 11-03

State of Health Equity Movement, 2011 Update Part C: Compendium of Recommendations DRA Project Report No. 11-0

Impact of climate change and bioenergy on nutrition

Food security has deteriorated since 1995 and reductions in child malnutrition are proceeding too slowly to meet the Millennium Development Goal (MDG) target for halving hunger by 2015. Three major challenges threaten to drastically complicate efforts to overcome food insecurity and malnutrition: climate change, the growing use of food crops as a source of fuel and soaring food prices. Food security has four dimensions: food availability, access to food, stability of supply and access and safe and healthy food utilization. It is a key factor in good nutrition, along with health, sanitation and care practices. Globally, one billion people are currently without access to safe water and over 2 billion lack adequate sanitation facilities. Present global food supplies are more than adequate to provide everyone with all the needed calories, if the food were equally distributed. But over 820 million people in developing countries have calorie-deficient diets; over 60 percent live in Sub-Saharan Africa and South Asia.Climate change, Bioenergy, Nutrition, food security, Food prices, Sustainable development,

Equity Implications of Health Sector User Fees\ud in Tanzania : Do we Retain the User Fee or do we Set the User F(r)ee?

\ud Early 2004, Research for Poverty Alleviation (REPOA) commissioned ETC Crystal to examine the equity implications of health sector user fees in Tanzania, with particular reference to proposed and actual charges at dispensary and health centre level. This year, Tanzania will review its Poverty Reduction Strategy. With the findings of the user fee study, REPOA aims at making a valuable contribution to the review process and provide country-specific insight into one of the most debated issues in health financing. The focus and design of the study was formulated in close cooperation with the Research and Analysis Working Group of REPOA. The strategies for data collection comprised: (1) a comprehensive literature analysis literature, (2) semi-structured interviews with resource persons from the government of Tanzania, multi- and bilateral donors, research institutes and NGOs in Dar Es Salaam, and (3) a case study in Kagera Region, including both document analysis and semi-structured interviews with resource persons from the MOH, NGOs, FBOs, health workers and health care consumers from vulnerable and poor population groups. The study team developed multiple tools for data collection and analysis including: (1) a data matrix for categorisation and identification of key issues, (2) guidelines for the interviews in Dar Es Salaam, (3) guidelines for data collection and interviews in Kagera Region, and (4) a tool for the analysis of poverty reduction strategy documents. A total number of 170 user fee-related documents were assessed, including those covering the experience from neighbouring countries. Seventy-nine resource persons participated in the study. Resources generated by user fees and their use at hospital, district council and PHC levels. The study team found that reliable, transparent user fee income data for district, hospital and PHC level were difficult to obtain. Based on what information is available, the team concludes that revenues raised from user fees at the hospital level have been lower than what has been projected. Furthermore, the data reflect huge variations between facilities and a decline in the revenues from cost sharing. The reasons of the reported decline are unclear. The data reflecting the contribution of user fees and CHF to the health budget at district council level show huge variations as well. The reported user fee income proportion for the district health budget was on average 10.5%. The study team could not establish how the income from cost sharing and the CHF was re-distributed by the council to PHC facilities or priority areas. A worrying finding was that some councils did not spend all health resources in the health sector. The study team observes an urgent need for: (1) more accurate and comprehensive record keeping at local council level, and (2) more costing and tracking studies to obtain a better insight into cost sharing and expenditures and to adequately inform policy making. Contribution of user fees and CHFs to the health resource envelope. The study team concludes that the national projections of the cost sharing schemes do not reflect an accurate picture, since the data are based on the inaccurate financial data received from the districts. It is likely that the actual and projected data on user fees, CHFs and HSF are underestimations of the real income collected at the different facility levels. This means that the MOH faces a loss of income that cannot be redistributed to the health sector. It also implies that people (both wealthy and poor) are likely pay more than what is officially reported. The actual potential and use of the non-reported user fees are not known. The total contribution of the cost sharing schemes (excluding NHIF) to the national health resource envelope for FY03/04 is 1.67 Billion Tshs. This equals a contribution of 0.6% to the overall budget for the health sector. In total, this is US$1.56 million. Given the size of the total health budget (US$ 260 million), it can be concluded that the officially reported user fees contribute a small proportion only. The actual revenue generated does not meet the initial expectations. Contribution of revenues generated to improved services. The study team found limited positive evidence that user fees in Tanzania have in general achieved their original objectives of sustainability, drug availability, quality of care, equity and access for the poor. More specifically, the study team found that government-run PHC facilities appeared to face severe shortages of drugs and supplies. In addition, user fees were not always retained at PHC level, but deposited in the HSF account which mainly benefits the purchase of supplies for the district hospital. Positive results were seen for reinvestment of CHF funds. In total, 50% of the health workersand patients reported improvements in drugs availability, diagnostic facilities and maintenance. However, equity criteria for the distribution of available resources from the user fee income to PHC level are not systematically followed. Impact of user fees on access to health services. The study team concludes that presently, the user fees in Tanzania are regressive and contribute to substantial exclusion, self exclusion and increased marginalisation. The team has collected evidence which shows that user fees have disproportionally affected access to health care for poor and vulnerable population groups, more specifically: (1) pregnant women from poor households, (2) under-five children from poor households, (3) orphans and especially double orphans, (4) widows, (5) people older than 60 years, (6) people with disabilities, and (7) AIDS patients. Further extension of fees to dispensary and health centre level. Also at the PHC level, the study team found that fees have negatively impacted the use of health care by the rural poor population, particularly women and children. Given the importance of the public PHC facilities for poor people (government health centres are the main choice for out-patient care for the poor), the study team expects that the further extension of user fees to PHC level without effective exemption and waiver mechanisms will contribute to further exclusion and selfexclusion. Effectiveness of exemption and waiver mechanisms. The study team identifies the ineffectiveness of the present exemption and waiver mechanisms as the core problem in the user fee debate in Tanzania. A functional exemption and waiver system is actually non-existent putting vulnerable and poor people at risk by practically denying them access to public health\ud services. This applies both to (1) the exemption and waiver system in health facilities and (2) the exemption mechanisms instituted for the CHFs. In both situations, poor people just do not receive the exemptions to which they are entitled to! Revenue collection appears to prevail over protecting the poor and vulnerable. Some hospitals have even tried to hide the waivers in their statistics in order to have, on paper, a better performance with their user fee income. The study team recommends that, should the government of Tanzania decide to maintain its user fee policy, priority is given to the design of an effective exemption and waiver system combined with: (1) sufficient resources to compensate for the unknown money lost (since it not recorded properly), and (2) a serious effort to make it work. However, there is substantial evidence that exemption and waiver systems do not guarantee increased access to health services for poor people unless major adjustments in the design, implementation and funding for adequate exemption and waiver systems take place. In the light of recent developments in Uganda and Kenya, it seems a much more realistic approach to compare the costs of (1) the suspension of user fees at PHC level against the required costs for (2) improved exemption and waiver systems or (3) improved NSHIF approaches in the contest of abolishment of fees and to opt for the most pro-poor and cost-effective approach within the shortest possible time frame. The potential and impact of Community Health Funds. The introduction of the CHF has not provided the expected benefits for poor people. There are a number of constraints the study team thinks should be urgently addressed, including the delays in the introduction of the CHFs and the weak management at the district and lower levels. More importantly, the study team found that poor people often cannot afford to pay the CHF premium because it is too high and has to be paid at once. If membership of the CHF becomes compulsory and poor people are not effectively exempted from paying CHF premiums and co-payments, the impact of the CHF can be disastrous and lead to double exclusion of poor people. Another issue of concern is related to the link between user fees and the CHF. According to the CHF Act, the user fees paid at public health centres and dispensaries form a source of income to the CHF. The premium paid to the CHF will receive WB matching funds, putting pressure on the PHC facilities to raise income through user fees. This indicates a complicated dilemma since it means that if user fees will be suspended or abolished at PHC level, the CHFs will not be able to take off as planned and will not receive part of their required resources. This points to the need to assess the mix of financing mechanisms and their interactions, rather than look at them as stand-alone policies. Tanzania has opted for a system of multiple risk-pooling schemes for the health sector. There is an urgent need to review the ongoing processes and assess their impact on the overall health system and the vulnerable members of the population. Scenarios. Reviewing the available literature, the study team observes that the abolition of user fees for education in Tanzania, and for health in South Africa and Uganda, has had impressive results in terms of attendance and access. Recently, Kenya also decided to abolish user fees for health. However, when reviewing the stakeholder’s attitudes towards abolition, the study team concludes that the necessary support for such a decision seems to lacking in Tanzania at present. The study shows that Tanzania is at a cross road. Tanzania can opt for two strategic directions. One strategy can be to continue on the road of the multiple risk pooling strategies. The other strategy can be to follow the abolishment of user fees at either (1) all levels or (2) at PHC levels. Both strategies will require substantial support from external donors and will require major adjustments in the current funding mechanisms. However, given the negative equity implications for poor people with the multiple risk pooling systems and the complicated, time consuming, costly and unreliable administration that is required for user fee systems and CHF, evidence indicates that it seems a more pro-poor and pragmatic strategy to abolish the user fees for poor people either (1) temporarily till improved exemption and waiver systems have been designed and introduced or (2) as long as the poverty situation in Tanzania requires. In case Tanzania will opt for the continuation of a multiple risk pooling system, then a number of key conditions will have to be met in order to ensure access to health services for poor people. It will be crucial to assess the mix of financing mechanisms and their interactions rather than look at them as stand-alone policies. Considering the severe poverty situation in Tanzania, it is concerning to find that many stakeholders continue promoting and supporting user fees in the absence of effective exemption and waiver systems. This does not correspond with the commitment to reducing poverty in Tanzania as articulated in the PRS. Consequently, immediate political action is required. Abolition of user fees can be considered as a pro-poor option to reduce exclusion and self-exclusion among the poor and vulnerable. The studies illustrate, that the abolition of fees needs to be combined with considerable efforts in other areas, such as changed levels of funding (internally and externally), improvements in the allocation and disbursement of funds, improved human resource development, improved incentive schemes for health workers and improved quality of services. This indicates the importance of a broad, strong political support and donor support. The developments in Uganda and Kenya might have created a momentum for Tanzania to rethink the current multiple risk pooling strategies in the context of the PRS Review and to opt for more pro-poor health strategies. It should be noted that in the current political situation strengthening the existing exemption and waiver systems seems to be the most preferred scenario at this moment. However, in the light of all the constraints mentioned and in the context of positive developments in Uganda and recent decisions taken in Kenya, the study team would like to recommend to include the suspension of user fees at PHC level in the next PRS document for Tanzania as a real pro-poor health strategy for Tanzania. The study team considers the Poverty Reduction Strategy Review Process as an excellent opportunity to lobby the government and the development partners on these issues, and to demand that a specific Plan of Action is included in the second Poverty Reduction Strategy Paper. The study team hopes that the findings of this study will contribute in such a positive and constructive way to the Tanzania PRS Review Process. The outcomes of this study confirm that in Tanzania, user fees are an issue to be carefully (re)considered when designing national pro-poor health policies in Poverty Reduction Strategies. Considering the severe poverty situation in Tanzania, it is concerning to find that many stakeholders\ud continue promoting and supporting user fees in the absence of effective exemption and waiver systems. This does not correspond with the government’s commitment to reduce poverty in Tanzania. Consequently, immediate political action is required.\u