Renuka Tipirneni

The influence of race and ethnicity on complications and mortality after orthopedic surgery: a systematic review of the literature.

Background:The decision to perform orthopedic surgery requires substantial discretion and judgment. Similar conditions have been associated with health care disparities in other fields, but the extent of racial and ethnic disparities in orthopedics is unknown. Objective:To evaluate the quality of extant orthopedic literature on health care disparities. Research Design:This study is a systematic review. Subjects:Eligible studies reported complications and/or mortality stratified by minority group after orthopedic surgery in an American population. Measures:Queries of PubMed, Embase, Scopus, and Web of Science were performed. Included papers were abstracted regarding complication and/or mortality rates for whites and minority populations, statistical findings, and whether a health care disparity was reported. Statistical associations between study characteristics and the identification of disparities were evaluated using the &khgr;2 test. Results:The literature search returned 2604 studies, of which 33 met inclusion criteria. All but 3 works dealt with spine surgery or joint replacement. Twenty-one publications (64%) documented health care disparities. Forty-four percent of efforts investigating outcomes for Hispanics and 36% of works documenting results for non-whites recorded a disparity. Investigations reporting on African Americans were significantly more likely to identify health care inequalities (77%) as compared with non-white (P=0.02) cohorts. Conclusions:Patients from racial and ethnic minority populations seem to be at increased risk of complications and/or mortality following spine surgical or joint replacement procedures. There is insufficient evidence to support generalization to the entire orthopedic field. Studies specific to African American patients identify health care disparities at a significantly higher rate than those utilizing non-white cohorts.

Accountable Communities for Health: Moving From Providing Accountable Care to Creating Health

Lessons from community-oriented primary care in the United States can offer insights into how we could improve population health by integrating the public health, social service, and health care sectors to form accountable communities for health (ACHs). Unlike traditional accountable care organizations (ACOs) that address population health from a health care perspective, ACHs address health from a community perspective and consider the total investment in health across all sectors. The approach embeds the ACO in a community context where multiple stakeholders come together to share responsibility for tackling multiple determinants of health. ACOs using the ACH model provide a roadmap for embedding health care in communities in a way that uniquely addresses local social determinants of health.

Launching the Healthy Michigan Plan — The First 100 Days

The early experience with Medicaid expansion in Michigan, a Republican-controlled state that received a federal waiver to implement modifications, may provide useful insights as this new coverage option continues to be debated and implemented in other states.

Health System Loyalty Programs: An Innovation in Customer Care and Service

Many people belong to loyalty programs for coffee shops, hotel chains, or airlines. Despite a highly consumer-oriented approach in some health systems, similar types of loyalty programs have not been developed. Why this disconnect for customer loyalty between health care and other industries?

Care for Undocumented Immigrants — Rethinking State Flexibility in Medicaid Waivers

Care for Undocumented Immigrants Under President Trump, HHS has promised to grant states more flexibility in structuring their Medicaid programs. But in a contentious and uncertain policy environment, states may sense little room to advance policies related to the health of undocumented immigrants.

Access Is Necessary but Not Sufficient: Factors Influencing Delay and Avoidance of Health Care Services

Background: Despite recently expanded access to health insurance, consumers still face barriers to using their coverage to obtain needed health care. Objective: To examine the characteristics of those who delay or avoid health care due to costs. Methods: Participants were recruited via Amazon MTurk and completed a survey assessing demographic characteristics, financial toxicity, health care minimizer-maximizer tendencies, health insurance knowledge, numeracy, delaying/avoiding any care, and delaying/avoiding six common health care services (three preventive and three nonpreventive services). Validated measures were used when available. Delay/avoidance behaviors were categorized into delaying/avoiding any care, preventive care, and nonpreventive care. Logistic regression models examined 1) financial toxicity, 2) minimizer-maximizer tendencies, 3) numeracy, 4) health insurance knowledge, and 5) knowledge of preventive care coverage separately on three forms of delay/avoidance behaviors, controlling for chronic conditions, insurance status, and/or income where appropriate. Results: Of 518 respondents, 470 did not fail attention-check questions and were used in analyses. Forty-five percent of respondents reported delaying/avoiding care due to cost. Multivariable analyses found that financial toxicity was related to delaying/avoiding any care (odds ratio [OR] = 0.884, P < 0.001), preventive care (OR = 0.906, P < 0.001), and nonpreventive care (OR = 0.901, P < 0.001). A tendency to minimize seeking health care (OR = 0.734, P < 0.001) and lower subjective numeracy (OR = 0.794, P = 0.023) were related to delaying/avoiding any care. General health insurance knowledge (OR = 0.989, P = 0.023) and knowledge of preventive care coverage (OR = 0.422, P < 0.001) were related to delaying/avoiding preventive care. Conclusions: Many people delay or avoid health care due to costs, even when insured. Results suggest that there may be different reasons individuals delay or avoid preventive and nonpreventive care. Findings may inform interventions to educate consumers and support discussions about health care costs to facilitate appropriate health care utilization.

Mitigating the Risks of Medicaid Work Requirements

Mitigating the Risks of Medicaid Work Requirements Work requirements represent uncharted territory for Medicaid enrollees and their doctors. The effects on health will depend on how well the requirements focus on enrollees who are healthy and able to work and whether effective work-related training and support are implemented.

Cost Conversations Between Primary Care Providers and Patients with Expanded Medicaid Coverage

Patients face increasing out-of-pocket (OOP) costs for healthcare, which have been associated with medication non-adherence and poor health outcomes. While lowincome patients may frequently have concerns about OOP costs—even if they have insurance with generous covered benefits—they may not raise cost concerns with physicians. Little is known about cost conversations between primary care providers (PCPs) and low-income patients. Our objective was to determine the frequency, predictors, and PCPs’ perceptions of the impact of cost conversations with low-income patients in an expanded Medicaid program in Michigan (BHealthy Michigan Plan^ [HMP]), a state program for adults ages 19– 64 with incomes ≤ 138% of the federal poverty level (FPL) and includes limited cost-sharing for beneficiaries (≤ 2% of income).

Association of Access to Family Planning Services With Medicaid Expansion Among Female Enrollees in Michigan

Key Points Question Did Medicaid expansion in Michigan improve access to birth control and family planning services? Findings In this survey study of 1166 female Medicaid expansion enrollees of reproductive age in Michigan (sample weighted to 113 565 women), 35.5% reported increased access to birth control and family planning services. Those most likely to report increased access were women aged 19 to 24 (39.8%) and 25 to 34 (41.4%) years, women without health insurance coverage in the year preceding Medicaid expansion enrollment (42.6%), and women with a recent visit to a primary care clinician (36.8%). Meaning Results suggest that Medicaid expansion is associated with improved access to family planning services, which may enable low-income women to maintain optimal reproductive health.