Ellie Andres

Medicaid Covered Births, 2008 Through 2010, in the Context of the Implementation of Health Reform

BACKGROUND Medicaid is a major source of public health care financing for pregnant women and deliveries in the United States. Starting in 2014, some states will extend Medicaid to thousands of previously uninsured, low-income women. Given this changing landscape, it is important to have a baseline of current levels of Medicaid financing for births in each state. This article aims to 1) provide up-to-date, multiyear data for all states, the District of Columbia, and Puerto Rico and 2) summarize issues of data comparability in view of increased interest in program performance and impact assessment. METHODS We collected 2008-2010 data on Medicaid births from individual state contacts during the winter of 2012-2013, systematically documenting sources and challenges. FINDINGS In 2010, Medicaid financed 45% of all births, an increase of 4% [corrected] in the proportion of all births covered by Medicaid in 2008. Percentages varied among states. Numerous data challenges were found. CONCLUSIONS/IMPLICATIONS FOR RESEARCH AND POLICY Consistent adoption of the 2003 birth certificate in all states would allow the National Center for Health Statistics Natality Detail dataset to serve as a nationally representative source of data for the financing of births in the United States. As states expand coverage to low-income women, women of childbearing age will be able to obtain coverage before and between pregnancies, allowing for access to services that could improve their overall and reproductive health, as well as birth outcomes. Improved birth outcomes could translate into substantial cost savings, because the costs associated with preterm births are estimated to be 10 times greater than those for full-term births.

Reducing hospital readmissions among medicaid patients: a review of the literature.

Reducing hospital readmissions is a key approach to curbing health care costs and improving quality and patient experience in the United States. Despite the proliferation of strategies and tools to reduce readmissions in the general population and among Medicare beneficiaries, few resources exist to inform initiatives to reduce readmissions among Medicaid beneficiaries. Patients covered by Medicaid also experience readmissions and are likely to experience distinct challenges related to socioeconomic status. This review aims to identify factors related to readmissions that are unique to Medicaid populations to inform efforts to reduce Medicaid readmissions. Our search yielded 254 unique results, of which 37 satisfied all review criteria. Much of the Medicaid readmissions literature focuses on patients with mental health or substance abuse issues, who are often high utilizers of health care within the Medicaid population. Risk factors such as medication noncompliance, postdischarge care environments, and substance abuse comorbidities increase the risk of readmission among Medicaid patients.

Underserved patients' perspectives on patient-centered primary care: does the patient-centered medical home model meet their needs?

The patient-centered medical home (PCMH) has gained significant interest as a delivery system model that can improve health care quality while reducing costs. This study uses focus groups to investigate underserved, chronically ill patients’ preferences for care and develops a patient-centered framework of priorities. Seven major priorities were identified: (a) communication and partnership, (b) affordable care, (c) coordinated care, (d) personal responsibility, (e) accessible care, (f) education and support resources, and (g) the essential role of nonphysician providers in supporting their care. Using the framework, we analyzed the PCMH joint principals as developed by U.S. medical societies to identify where the PCMH model could be improved to better meet the needs of these patients. Four of the seven patient priorities were identified as not present in or supported by current PCMH joint principles. The study discusses how the PCMH model can better address the needs of low-income, disadvantaged patients.

Appropriate Use of Non–English-Language Skills in Clinical Care

AN ESTIMATED 25 MILLION US RESIDENTS HAVE LIMited English proficiency (LEP) and in a 2006 national survey of 2022 internists, 54% reported encountering patients with LEP at least weekly, with many seeing LEP patients every day. Legal guidance related to Title VI of the Civil Rights Act requires that physicians and hospitals take reasonable steps to ensure effective communication with these patients. Hence, when a patient with LEP presents for care, the encounter must either be conducted with a clinician who speaks the patient’s language or indirectly through a trained interpreter. Untrained interpreters, such as patients’ friends or family members, are sometimes used, although this practice is risky for reasons of competence and confidentiality. While no national data are available on physicians’ non– English-language skills, in some local surveys, more than 80 percent of physicians report some proficiency in 1 or more non-English languages. Direct communication between language concordant patients and physicians is associated with improved quality, adherence and satisfaction, and reductions in emergency department utilization and costs. We recently worked with the Commission to End Health Care Disparities to develop a set of recommendations for policymakers, organizations, and clinicians to promote the appropriate use of physicians’ non–English-language skills. The recommendations were based in part on interviews with bilingual physicians in a variety of practice settings and an expert panel review using a patient safety approach to care improvement. The commission recognized that the responsibility for ensuring quality of communication ultimately rests with physicians and encouraged use of their non−English-language skills to interact in the patient’s preferred language, but cautioned against relying on inadequate language skills. The course of this work, however, revealed that language skills are often interpreted for practical purposes as a dichotomous construct—even modest skills are often deemed good enough to “get by.” In contrast, recommendations from leaders in the field have advocated for graduated measures of language proficiency. Physicians’ non–English-language skills are extremely heterogeneous, ranging from those who speak just a few words of 1 or more non-English languages to those who are native speakers and received their medical training in another language. Similarly, the communication demands of certain clinical interactions are greater than others— conversations about end-of-life care or informed consent for surgery implicitly pose greater miscommunication risks compared with more routine encounters. As a result of this variability, some physicians are probably always able to appropriately provide care to patients in languages other than English, others might be able to do so in some circumstances, and others have such limited skill that they never should attempt medical communication without an expert assistant (ie, a trained interpreter). This more nuanced understanding of language proficiency makes it similar in nature to many other skills necessary for the appropriate and effective practice of medicine. Physicians commonly have some level of skill in specific areas (rheumatology, cardiology, surgery, etc) that usually is sufficient for many routine interactions, but they also are prepared to involve an expert consultant if the clinical situation evolves to exceed their skill level. If bilingual physicians should consider trained interpreters as expert consultants, how should physicians decide whether their non–English-language skills are adequate to provide appropriate care in particular situations and when should they call for consultative assistance? This turns out not to be an easy task. A qualitative study of 20 resident physicians found that most overestimated their ability to provide care in another language. Another study of 25 physicians who provide care directly in a nonEnglish language (most often Spanish) based on skills that are frequently inadequate (ie, skills obtained in high school or middle school, “medical Spanish” courses, or during short visits abroad and reinforced only by occasional medical or nonmedical use) found the physicians value direct communication with patients very highly, and believe patients do too. However, these physicians might also underappreciate the value provided by using trained interpreters, and cli-

Medication Information for Patients with Limited English Proficiency: Lessons from the European Union

Misuse or misunderstanding of medication information is a common and costly problem in the U.S. The risks of misunderstanding medication information are compounded for the large and growing population of individuals with limited English proficiency that often lacks access to this information in their own language. This paper examines practices related to translation of medication information in the European Union that may serve as a model for future U.S. policy efforts to improve the quality and availability of medication information for individuals with limited English proficiency.

Maternity Leave Access and Health: A Systematic Narrative Review and Conceptual Framework Development

Background Maternity leave is integral to postpartum maternal and child health, providing necessary time to heal and bond following birth. However, the relationship between maternity leave and health outcomes has not been formally and comprehensively assessed to guide public health research and policy in this area. This review aims to address this gap by investigating both the correlates of maternity leave utilization in the US and the related health benefits for mother and child. Methods We searched the peer-reviewed scholarly literature using six databases for the years 1990 to early 2015 and identified 37 studies to be included in the review. We extracted key data for each of the included studies and assessed study quality using the “Weight of the Evidence” approach. Results The literature generally confirms a positive, though limited correlation between maternity leave coverage and utilization. Likewise, longer maternity leaves are associated with improved breastfeeding intentions and rates of initiation, duration and predominance as well as improved maternal mental health and early childhood outcomes. However, the literature points to important disparities in access to maternity leave that carry over into health outcomes, such as breastfeeding. Synthesis We present a conceptual framework synthesizing what is known to date related to maternity leave access and health outcomes.

Improving the Quality of Language Services Delivery: Findings from a Hospital Quality Improvement Initiative

&NA; Over 24 million individuals in the United States speak English “less than very well” and are considered limited English proficient (LEP). Due to challenges inherent in patient–provider interactions with LEP patients, LEP individuals are at risk for a wide array of negative health consequences. Evidence suggests that having an interpreter present to facilitate interactions between LEP patients and health professionals can mitigate many of these disparities. This article presents the results and lessons learned from Speaking Together: National Language Services Network, a quality improvement (QI) collaborative of the Robert Wood Johnson Foundation to improve the quality of language services (LS) in hospitals. Using five LS performance metrics, hospitals were able to demonstrate that meaningful improvement was possible through targeted QI efforts. By the end of the collaborative, each of the hospitals demonstrated improvement by more than five percentage points on at least one of the five recorded quality metrics. Lessons learned from this work, such as the helpful use of quality metrics to track performance, and the engagement of physician champions and executive leadership to promote improvement can be utilized in hospitals across the country because they seek to improve care for LEP patients.

Hospital Language Service Programs: A Closer Look at Translation Practices

Much of the information we have about the delivery of language services for patients with limited English proficiency (LEP) relates to interpreter services. Very little is known about hospitals’ experiences responding to LEP patients’ needs for written materials in their preferred languages. This study describes the translation practices of 35 hospitals with large interpreter services programs to inform guidance for the effective delivery of translation services in health care settings. We conducted in-depth telephone interviews with hospital staff members responsible for overseeing translation services at their hospitals. Translation practices varied considerably among study participants, with participants relying on a combination of interpreters serving as translators and contract translators to translate between 5 and 5,000 documents per year. This study showcases examples of hospitals with surprisingly robust translation service programs despite limited external funding. The variance in translation practices underscores a lack of guidance in this area.

Medicaid payment innovations to financially sustain comprehensive childhood asthma management programs at federally qualified Health Centers

Background. One in 7 children in the United States is diagnosed with asthma, the leading cause of chronic childhood disease. Although a manageable condition when recommended medication regimens are followed and environmental control measures implemented, asthma remains the third most common reason for hospitalization among non-newborn hospital stays. As the primary health care home to a fifth of all low-income children who are especially vulnerable to asthma, federally qualified health centers play a critical role in providing comprehensive and preventive asthma care to their pediatric patients. Many health centers rely on the asthma education and counseling services of traditional and nontraditional providers, such as clinicians and community health workers, who may or may not be certified as asthma educators, as essential elements of asthma management and control. Asthma counselors are particularly valuable for patient home assessments and tailored education and counseling that are recommended component...