The role of payment and financing in achieving health equity

Objective

The aim was to identify healthcare payment and financing reforms to promote health equity and ways that the Agency for Healthcare Research and Quality (AHRQ) may promote those reforms.

Data Sources and Study Setting

AHRQ convened a payment and financing workgroup–the authors of this paper–as part of its Health Equity Summit held in July 2022. This workgroup drew from its collective experience with healthcare payment and financing reform, as well as feedback from participants in a session at the Health Equity Summit, to identify the evidence base and promising paths for reforms to promote health equity.

Study Design

The payment and financing workgroup developed an outline of reforms to promote health equity, presented the outline to participants in the payment and financing session of the July 2022 AHRQ Health Equity Summit, and integrated feedback from the participants.

Data Collection/Extraction Methods

This paper did not require novel data collection; the authors collected the data from the existing evidence base.

Principal Findings

The paper outlines root causes of health inequity and corresponding potential reforms in five domains: (1) the differential distribution of resources between healthcare providers serving different communities, (2) scarcity of financing for populations most in need, (3) lack of integration/accountability, (4) patient cost barriers to care, and (5) bias in provider behavior and diagnostic tools.

Conclusions

Additional research is necessary to determine whether the proposed reforms are effective in promoting health equity.     

Negotiating horizontality in medical South–South cooperation: The Cuban mission in Rio de Janeiro’s urban peripheries

ABSTRACT

For more than 50 years, Cuba has been one of the most important players in the field of international medical cooperation in the Global South. Between 2013 and 2016, Cuba maintained one of its largest cooperations with Brazil: nearly 11,400 Cuban physicians were sent to work within the framework of the Brazilian health programme ‘More-Doctors-for-Brazil’, which was implemented to improve Brazil’s precarious public health sector. This paper inquires into the manifold challenges of horizontal connectivity in this medical South–South cooperation. We will trace these back to deep-rooted contentions about the epistemological approaches to medical practice and professional recognition within and between Cuban and Brazilian arenas of public health, which do not, however, conform to a simplistic socialism–capitalism dichotomy. Rather, this particular South–South cooperation reveals significant differences in how powerful the postcolonial legacies of medical assistance remain in Global Health settings. This paper explores how these legacies may impact on the moral and professional legitimacy of the individuals involved in South–South partnership. Using ethnographic findings in newly established family clinics situated in urban poverty regions in Rio de Janeiro’s North, we will also show how prolonged local interactions may create new spaces of horizontal encounters and connectivity in international medical cooperation.     

医联体药师团队参与COPD患者长期用药安全评估管理工作模式的实践研究

摘 要 目的：探讨医改新形势下医联体药师团队参与慢性阻塞性肺疾病(COPD)患者长期用药安全评估新型管理模式,为药师参与慢病管理提供参考。方法: 选取在我院及医联体所辖5家社区卫生服务中心就诊且符合入选标准的126例COPD患者,由我院临床药师带动指导社区药师共同参与,与医生协作,对患者进行为期1年的安全用药干预管理,包括：用药安全综合评估与分级管理、追踪随访与用药指导,全程化处方审核、建立共享数据库等。结果:该工作模式干预1年后,患者安全用药认知能力及用药依从性较干预前均显著提高（P＜0.01）,患者COPD疾病控制情况（CAT评分）明显改善（P＜0.05或P＜0.01）,药师有效辨识并干预不合理处方能力显著提升（P＜0.01）。结论: 医联体药师团队参与COPD患者长期用药安全评估管理工作模式对于保障COPD 患者安全用药,提高药物治疗效果,提高药师团队专业服务水平具有显著作用。     

中国三明市医改下药品费用影响因素分析

目的：探讨三明市医药卫生体制改革期间药品费用变化情况,并分析药品价格、药品用量和用药结构对药品费用变化的影响,以期为今后药品费用改革决策提供视角和参考。方法：收集三明市1家医院（实验组）和福建其他地区18家医院（对照组）在2011-2016年期间的药品采购数据,采用"A.M"指数体系进行因素分析。结果：自2011年起实验组药品总费用保持平稳,年均增长率为1.4%,对照组涨速较快,年均增长率为6.4%;实验组和对照组价格因素及用量因素变化趋势一致、变化速度相近;在结构因素方面,实验组保持平稳,对照组涨速较快。结论：三明市医改明显降低了药品价格并抑制了"同类别药品高价药替代低价药"的趋势,控制结构因素是抑制药品费用上涨的有效手段。     

Redpilling: A professional reflects on white racial privilege and drug policy in American health care

ABSTRACT

The landscape of American health care is changing under the weight of new knowledge that health care workers—physicians, nurses, and so on—are abusing the drugs that they use within health care. In this article, the author uses ethnographic data (including his own work in American pharmacies over the past two decades) to contextualize how health care’s drug abuse epidemic is racially coded to ignore the fact that White Americans are the primary drug abusers—what he calls “redpilling.” In pointing out the racial contexts of health care’s drug abuse, the author asks whether our national “war on drugs” ought to be recast to see how White racial privilege—the privilege of White Americans to comfortably perform certain actions (and get away with them if they are illegal or morally wrong)—mandates that we move the lens of drug policy from ghettos and ethnic communities to American health care where we have been historically positioned to not identify White American health care workers who work while high.     

The relationship between habit and healthcare professional behaviour in clinical practice: a systematic review and meta-analysis

Theories of behaviour used to understand healthcare professional behaviour often focus on the deliberative processes that drive their behaviour; however, less is known about the role that implicit processes such as habit have on healthcare professional behaviour. This systematic review aimed to critically appraise and synthesise research evidence investigating the association between habit and healthcare professional behaviour. A search of five databases (PsycINFO, EMBASE, Scopus and CINAHL) was conducted up until 29 February 2016 to identify studies reporting correlations between habit and healthcare professional behaviours. Meta-analyses were conducted to assess the overall habit-behaviour association across all behaviours. A subgroup analysis assessed whether the habit-behaviour relationship differed depending on whether the behaviour was objectively measured or assessed by self-report. We identified nine eligible studies involving 1975 healthcare professionals that included 28 habit-behaviour correlations. A combined mean r₊ of 0.35 (medium effect) was observed between habit and healthcare professional behaviour. The habit-behaviour correlation was not affected by whether behaviour was measured objectively or by self-report. This review suggests that habit plays a significant role in healthcare professional behaviour. Findings may have implications for considering health professionals’ habit when promoting the provision of evidence-based health care, and for breaking existing habit when de-implementing outdated, non-evidence-based practices.     

Healthcare Utilization is High in Adult Patients Relapsing after Allogeneic Hematopoietic Cell Transplantation

Disease relapse is the leading cause of death for patients with acute leukemia (AL) and myelodysplastic syndrome (MDS) who undergo allogeneic hematopoietic cell transplantation (HCT). Relapse post-HCT is associated with poor prognosis; however, inpatient healthcare utilization of this population is unknown. Here we describe survival, intensity of healthcare utilization, and characteristics associated with high resource use at the end of life (EOL). Adult patients with AL/MDS who underwent HCT at a large regional referral center with subsequent relapse between 2005 and 2015 were included in this retrospective study. We compared the distribution of demographic and clinical characteristics of patients as well as healthcare utilization over 2 years postrelapse and at EOL by postrelapse disease-directed therapeutic interventions. We created a composite score for EOL healthcare utilization intensity by summing the presence of any of the following criteria: death in the hospital, use of chemotherapy, emergency department, hospitalization, intensive care unit, intubation, cardiopulmonary resuscitation, or hemodialysis in the last month of life. Higher scores indicate more intense healthcare use at EOL. Multivariable linear regression analysis was used to determine variables (demographic characteristics, postrelapse treatment group, advance directives documentation, palliative care referral, time to relapse) associated with EOL healthcare utilization intensity. One hundred fifty-four patients were included; median age at relapse was 56 years (interquartile range [IQR], 39 to 63), 55% were men, 79% had AL, and median time from HCT to relapse was 6 months (IQR, 3 to 10). After relapse, 28% received supportive care only, 50% received chemotherapy only, and 22% received chemotherapy plus cell therapy (either donor lymphocyte infusion, second HCT, or donor lymphocyte infusion plus second HCT). With the exception of time until relapse and Karnofsky Performance Status, baseline characteristics (gender, age, race, graft-versus-host disease, year of treatment) did not significantly differ by postrelapse treatment group. One hundred thirty-six patients (88%) died within 2 years of relapse; survival differed significantly by postrelapse treatment group, with those receiving disease-directed treatment showing lower risk of death. Healthcare use in AL/MDS patients after post-HCT relapse was high overall, with 44% visiting the emergency department at least once (22% at least 2 times), 93% hospitalized (55% at least 2 times, 16% at least 5 times), and 38% using the intensive care unit (median length of stay 5, days; IQR, 3 to 10). Use was high even among those receiving only supportive care. For those patients who died, the mean intensity score for EOL healthcare use was 1.8 (standard deviation, 1.8). Most patients (70%) had a marker of high-intensity healthcare utilization at the EOL or died in hospital. In multivariable analysis, an increase in age (estimate -.03 (95% CI, -.06 to -.003) and having AL versus MDS were significantly associated with a decreased EOL healthcare intensity score; no other variables were associated with intensity of EOL healthcare use. Healthcare utilization after post-HCT relapse is associated with receipt of disease-directed therapy but remains high across all groups despite known poor prognosis. Interventions are needed to minimize nonbeneficial treatments and promote goal-concordant EOL care in this seriously ill patient population.