Reducing Racial and Ethnic Health Disparities: Estimating the Impact of High Health Center Penetration in Low-income Communities

The health disparities literature suggests that although the lack of health insurance is the most basic barrier to health care, improved access to clinically appropriate care is key, particularly in the case of minority and low-income populations where the health risks are greatest. This study examines the relationship between health center penetration into medically underserved communities and the reduction of state-level health disparities. Health centers were developed with the express aim of serving medically underserved persons. Their doubling represents a significant health priority of the Bush Administration and one that enjoys bipartisan Congressional support

Medicaid Payment and Delivery Reform: Insights from Managed Care Plan Leaders in Medicaid Expansion States

Issue: Managed care organizations (MCOs) are integral to Medicaid payment and delivery reform efforts. In states that expanded Medicaid eligibility under the Affordable Care Act, MCOs have experienced a surge in enrollment of adults with complex needs.Goal: To understand MCO experiences in Medicaid expansion states and learn about innovations related to access to care, care delivery, payment, and integration of health and social services to address nonmedical needs.Methods: Interviews with leaders of 17 MCOs in 10 states that have seen large Medicaid enrollment growth and have undertaken payment and delivery reforms.Findings and Conclusions: MCO leaders regard their ability to enroll and serve the Medicaid expansion populations as a signal achievement. They have focused on identifying and helping high-risk populations and addressing the social determinants of health. MCOs are testing value-based payment strategies that link payment with performance and are increasingly focused on engaging patients in their care. Leaders report common challenges: setting appropriate payment rates; managing members whose needs differ from traditional Medicaid beneficiaries; ensuring access to specialty care; and effectively implementing payment reform and practice transformation. All point to the need for a stable policy environment and a strong working relationship with state Medicaid agencies

Personalised trails and learner profiling within e-learning environments

This deliverable focuses on personalisation and personalised trails. We begin by introducing and defining the concepts of personalisation and personalised trails. Personalisation requires that a user profile be stored, and so we assess currently available standard profile schemas and discuss the requirements for a profile to support personalised learning. We then review techniques for providing personalisation and some systems that implement these techniques, and discuss some of the issues around evaluating personalisation systems. We look especially at the use of learning and cognitive styles to support personalised learning, and also consider personalisation in the field of mobile learning, which has a slightly different take on the subject, and in commercially available systems, where personalisation support is found to currently be only at quite a low level. We conclude with a summary of the lessons to be learned from our review of personalisation and personalised trails

Medicare Competitive Acquisition: Implications for Persons with Diabetes

Nearly one in five Medicare beneficiaries has diabetes and these patients face major challenges in managing their health. The high diabetes rate among beneficiaries also means that the Medicare program itself is highly vulnerable to the high costs of uncontrolled diabetes. As a result, great care must be taken when implementing any new cost containment strategy that has the potential to disrupt access to preventive health care. This is particularly in the case of the Medicare Competitive Acquisition Program for Durable Medical Equipment and Supplies (DMEPOS), because of its potential impact on access to products needed for a basic preventive service, diabetes testing supplies. Yet despite these concerns over both beneficiary health and program costs, the DMEPOS program, as it is now being implemented, lacks the types of basic patient safeguards considered standard in competitive bidding arrangements such as Medicare Advantage and Medicare Part D

Association between insulin monotherapy versus insulin plus metformin and the risk of all-cause mortality and other serious outcomes: a retrospective cohort study

Aims To determine if concomitant metformin reduced the risk of death, major adverse cardiac events (MACE), and cancer in people with type 2 diabetes treated with insulin. Methods For this retrospective cohort study, people with type 2 diabetes who progressed to insulin with or without metformin from 2000 onwards were identified from the UK Clinical Practice Research Datalink (≈7% sample of the UK population). The risks of all-cause mortality, MACE and incident cancer were evaluated using multivariable Cox models comparing insulin monotherapy with insulin plus metformin. We accounted for insulin dose. Results 12,020 subjects treated with insulin were identified, including 6,484 treated with monotherapy. There were 1,486 deaths, 579 MACE (excluding those with a history of large vessel disease), and 680 cancer events (excluding those in patients with a history of cancer). Corresponding event rates were 41.5 (95% CI 39.4–43.6) deaths, 20.8 (19.2–22.5) MACE, and 21.6 (20.0–23.3) cancer events per 1,000 person-years. The adjusted hazard ratios (aHRs) for people prescribed insulin plus metformin versus insulin monotherapy were 0.60 (95% CI 0.52–0.68) for all-cause mortality, 0.75 (0.62–0.91) for MACE, and 0.96 (0.80–1.15) for cancer. For patients who were propensity-score matched, the corresponding aHRs for all-cause mortality and cancer were 0.62 (0.52–0.75) and 0.99 (0.78–1.26), respectively. For MACE, the aHR was 1.06 (0.75–1.49) prior to 1,275 days and 1.87 (1.22–2.86) after 1,275 days post-index. Conclusions People with type 2 diabetes treated with insulin plus concomitant metformin had a reduced risk of death and MACE compared with people treated with insulin monotherapy. There was no statistically significant difference in the risk of cancer between people treated with insulin as monotherapy or in combination with metformin

Highlights: Analysis of the Proposed Rule on Designation of Medically Underserved Populations and Health Professional Shortage Areas

For decades, the federal government has targeted health care funding, resources and staff to meet the health care needs of areas designated as medically underserved areas and health professional shortage areas. Areas that qualify may, for example, receive federal funding to support the establishment and operation of community health centers, or receive National Health Service Corps (NHSC) physicians and clinicians. In addition, physicians who practice in these health shortage areas may receive higher payments under Medicare. These designations thus affect the availability of health care in thousands of urban and rural areas all across the United States. Community health centers provide care for more than 16 million patients

Analysis of the Proposed Rule on Designation of Medically Underserved Populations and Health Professional Shortage Areas

Numerous safety net programs and health care providers depend on Medically Underserved Area and Population (MUA/P) and Health Professional Shortage (HPSA) designations to qualify for federal funding, physician subsidies and placement, and health-related investments to improve access to care for communities and populations at high risk of poor health. These resources are particularly critical for federally-qualified health centers at a time when the number of uninsured is growing and the capacity of the safety net shrinking. On February 29, 2008, the Department of Health and Human Services (HHS) released a proposed regulation to alter the way these designations are made. This report provides the first up-to-date analysis of the effects of the new regulations; the impact analysis contained in the Federal Register notice was based on 1999 data, while this one uses data from 2005

Medicaid and Case Management to Promote Healthy Child Development

This policy brief presents options for financing and delivering case management services to low-income and special-needs children in Medicaid. The analysis builds on a literature review of case management, a review of the legal underpinnings of Medicaid case management, and consultation with experts in the fields of health care finance and program operations. It aims to inform the policy community about the importance of case management for assuring the health and development of our youngest and most vulnerable children

Collaborative trails in e-learning environments

This deliverable focuses on collaboration within groups of learners, and hence collaborative trails. We begin by reviewing the theoretical background to collaborative learning and looking at the kinds of support that computers can give to groups of learners working collaboratively, and then look more deeply at some of the issues in designing environments to support collaborative learning trails and at tools and techniques, including collaborative filtering, that can be used for analysing collaborative trails. We then review the state-of-the-art in supporting collaborative learning in three different areas – experimental academic systems, systems using mobile technology (which are also generally academic), and commercially available systems. The final part of the deliverable presents three scenarios that show where technology that supports groups working collaboratively and producing collaborative trails may be heading in the near future