TAG: "Health care reform"

Most California physicians support Affordable Care Act, study shows


Primary care doctors most likely to be in favor of the law, specialists least likely.

Gerardo Moreno, UCLA

By Enrique Rivero, UCLA

UCLA researchers have found that 77 percent of California primary care and specialty physicians understand the basics of the Patient Protection and Affordable Care Act and 59 percent support it. The survey, conducted by doctors from the UCLA Department of Family Medicine, was published in the peer-reviewed journal Family Medicine.

Researchers also found that a majority of the 525 doctors surveyed believe ACA will steer the country’s health care in the right direction.

The doctors’ stance on the law appeared to be closely correlated with their political affiliations and medical specialties.

A majority of those polled thought the ACA would either help their practice (25 percent) or have no effect at all (36 percent), while 39 percent thought their practice would be hurt by the legislation.

“The United States is in an unprecedented era of health care reform that is pushing medical professionals and medical educators to evaluate the future of their patients, their careers and the field of medicine,” said Dr. Gerardo Moreno, assistant professor of family medicine at the David Geffen School of Medicine at UCLA and the study’s senior author. “This survey provides us a snapshot of what physicians think about health care reform. Physicians are a trusted source of information for health policy issues and learning, so investigating what drives their opinions on the ACA is important.”

Among the other findings:

  • 67 percent of primary care doctors strongly or somewhat agree that the ACA steers United States health care in the right direction, compared with 56 percent of specialists.
  • 38 percent of generalists think the health reform act will help their practice, compared with 20 percent of specialists.
  • 29 percent of primary care physicians believe the law will hurt their practice, versus 43 percent of specialists.
  • 33 percent of generalists feel the ACA will not help their practice, compared with 37 percent of specialists.
  • Those who do not endorse the ACA are likelier to be compensated by billing only and not by salary, politically conservative and dissatisfied with the practice of medicine.
  • Physicians who favor the law are more likely to be compensated by salary, hold liberal political opinions and find satisfaction in their jobs.
  • Those who think the ACA will help their practice are likelier to be primary care doctors, compensated by salary, politically liberal and satisfied practicing medicine.

The researchers note that the survey results could have been influenced by the desire to give socially acceptable answers.

The study was funded by the UCLA Department of Family Medicine.

The study’s co-authors are Sheila Ganjian, Patrick Dowling and Jason Hove, all of UCLA. Ganjian is also associated with the Charles Drew University Medical Education Program.

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Insuring undocumented residents could help solve multiple health care issues


UCLA health policy care analysis finds four key problem areas for Latinos under ACA.

Alex Ortega, UCLA

By Mark Wheeler, UCLA

Latinos are the largest ethnic minority group in the United States, and it’s expected that by 2050 they will comprise almost 30 percent of the U.S. population. Yet they are also the most underserved by health care and health insurance providers.

Latinos’ low rates of insurance coverage and poor access to health care strongly suggest a need for better outreach by health care providers and an improvement in insurance coverage. Although the implementation of the Affordable Care Act of 2010 seems to have helped (approximately 25 percent of those eligible for coverage under the ACA are Latino), public health experts expect that, even with the ACA, Latinos will continue to have problems accessing high-quality health care.

Alex Ortega, a professor of public health at the UCLA Fielding School of Public Health, and colleagues conducted an extensive review of published scientific research on Latino health care. Their analysis, published in the March issue of the Annual Review of Public Health, identifies four problem areas related to health care delivery to Latinos under ACA:

  • The consequences of not covering undocumented residents.
  • The growth of the Latino population in states that are not participating in the ACA’s Medicaid expansion program.
  • The heavier demand on public and private health care systems serving newly insured Latinos.
  • The need to increase the number of Latino physicians and non-physician health care providers to address language and cultural barriers.

“As the Latino population continues to grow, it should be a national health policy priority to improve their access to care and determine the best way to deliver high-quality care to this population at the local, state and national levels,” Ortega said. “Resolving these four key issues would be an important first step.”

Insurance for the undocumented

Whether and how to provide insurance for undocumented residents is, at best, a complicated decision, said Ortega, who is also the director of the UCLA Center for Population Health and Health Disparities.

For one thing, the ACA explicitly excludes the estimated 12 million undocumented people in the U.S. from benefiting from either the state insurance exchanges established by the ACA or the ACA’s expansion of Medicaid. That rule could create a number of problems for local health care and public health systems.

For example, federal law dictates that anyone can receive treatment at emergency rooms regardless of their citizenship status, so the ACA’s exclusion of undocumented immigrants has discouraged them from using primary care providers and instead driven them to visit emergency departments. This is more costly for users and taxpayers, and it results in higher premiums for those who are insured.

In addition, previous research has shown that undocumented people often delay seeking care for medical problems.

“That likely results in more visits to emergency departments when they are sicker, more complications and more deaths, and more costly care relative to insured patients,” Ortega said.

Insuring the undocumented would help to minimize these problems and would also have a significant economic benefit.

“Given the relatively young age and healthy profiles of undocumented individuals, insuring them through the ACA and expanding Medicaid could help offset the anticipated high costs of managing other patients, especially those who have insurance but also have chronic health problems,” Ortega said.

The growing Latino population in non-ACA Medicaid expansion states

A number of states opted out of ACA Medicaid expansion after the 2012 Supreme Court ruling that made it voluntary for state governments. That trend has had a negative effect on Latinos in these states who would otherwise be eligible for Medicaid benefits, Ortega said.

As of March, 28 states including Washington, D.C., are expanding eligibility for Medicaid under the ACA, and six more are considering expansions. That leaves 16 states who are not participating, many of which have rapidly increasing Latino populations.

“It’s estimated that if every state participated in the Medicaid expansion, nearly all uninsured Latinos would be covered except those barred by current law — the undocumented and those who have been in the U.S. less than five years,” Ortega said. “Without full expansion, existing health disparities among Latinos in these areas may worsen over time, and their health will deteriorate.”

New demands on community clinics and health centers

Nationally, Latinos account for more than 35 percent of patients at community clinics and federally approved health centers. Many community clinics provide culturally sensitive care and play an important role in eliminating racial and ethnic health care disparities.

But Ortega said there is concern about their financial viability. As the ACA is implemented and more people become insured for the first time, local community clinics will be critical for delivering primary care to those who remain uninsured.

“These services may become increasingly politically tenuous as undocumented populations account for higher proportions of clinic users over time,” he said. “So it remains unclear how these clinics will continue to provide care for them.”

Need for diversity in health care workforce

Language barriers also can affect the quality of care for people with limited English proficiency, creating a need for more Latino health care workers — Ortega said the proportion of physicians who are Latino has not significantly changed since the 1980s.

The gap could make Latinos more vulnerable and potentially more expensive to treat than other racial and ethnic groups with better English language skills.

The UCLA study also found recent analyses of states that were among the first to implement their own insurance marketplaces suggesting that reducing the number of people who were uninsured reduced mortality and improved health status among the previously uninsured.

“That, of course, is the goal — to see improvements in the overall health for everyone,” Ortega said.

Other authors of the study were Arturo Vargas Bustamante of UCLA and Hector Rodriguez of UC Berkeley. Funding was provided by the National Heart, Lung, and Blood Institute (P50 HL105188).

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ACOs improving health care in California


Report: ACOs improve quality of care, increase patient satisfaction, may reduce costs.

California has more accountable care organizations (ACOs) than any other state in the country, with particularly rapid growth over the past two years. This is a good thing, according to the Berkeley Forum for Improving California’s Healthcare Delivery System, which released a report today (Feb. 17) with new evidence that ACOs improve the quality of care, increase patient satisfaction and may reduce costs.

“The next few years are likely to bring continued growth and diversity in accountable care models that move increasingly toward being paid for meeting cost and quality targets,” said Stephen Shortell, lead author of the report and chair of the Berkeley Forum. Shortell is also a professor and dean emeritus of the UC Berkeley School of Public Health.

ACOs are defined as medical groups that contract with Medicare and/or commercial insurers to care for a defined population of patients and that are held accountable to meet cost and quality criteria. In a 2013 report, Berkeley Forum leaders called for at least 50 percent of Californians to be receiving care under new payment models that encourage keeping people well by 2022; and having at least 60 percent of Californians receiving their care from integrated care systems, versus only 29 percent today.

“California is fortunate to have many integrated health care delivery systems at various stages of development. The advancement of these systems into accountable care organizations and partnerships should be viewed as an important and very positive innovation in payment and health care delivery,” said Tom Williams, immediate past-president of the Integrated Healthcare Association and vice president of accountable care operations and strategy at Stanford Health Care.

The report presents emerging evidence that suggests that the quality of care that ACOs provide is as good, and on some measures, better than that provided by other models of care. For the analysis, the team compared medical groups with an ACO contract to medical groups without an ACO contract on widely used HEDIS quality of care measures for asthma care, cancer screening, chlamydia screening, diabetes care, heart care and pediatric care. ACOs scored significantly better for cancer screening. In addition, patients receiving care from medical groups with ACO contracts had consistently higher satisfaction scores than patients receiving care from groups without ACO contracts. This included measures of access to care, overall coordination of care, actions to promote health, communication with doctors, helpfulness of office staff and overall ratings of care.

While full cost-savings data are not yet available, preliminary evidence from an ACO contract in Sacramento found savings of $20 million, with no increase in health insurance premiums for California’s CalPERS enrollees. The study also addressed the concern that as ACOs grow in size they may exert pressure to increase prices.

“At this point in time, our analysis indicates there is little evidence to support such concern,” said Richard Scheffler, report co-author and vice chair of the Berkeley Forum.

Based on existing and ongoing study, the report identifies six factors associated with more successful ACOs. These include:

  • Achieving sufficient size to spread costs,
  • Developing new models of caring for high complex/high risk patients,
  • Expanding the use of electronic health records,
  • Developing effective partnerships with post-acute care providers and specialists,
  • Motivating patients and families to become more engaged in their care, and
  • Using standardized and transparent quality of care data for the purposes of public reporting and internal quality improvement.

The Berkeley Forum for Improving California’s Healthcare Delivery System is a partnership between private and public sector leaders in California to address the challenge of developing a more affordable and cost-effective healthcare system that will contribute to improved population health for all Californians. The UC Berkeley School of Public Health serves as a neutral facilitator for discussions and as the analytic staff for this effort.

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Trending: Full-time employment with no health benefits


In 2012, nearly half of uninsured Californians were in families with a full-time worker.

By Venetia Lai, UCLA

Almost half of the 6.9 million Californians who lacked insurance in 2012 were in a family with a full-time worker, according to a new report from the UCLA Center for Health Policy Research.

The State of Health Insurance in California report also found that the number of adult workers with job-based health insurance declined between 2009 and 2012. Full-time workers saw a drop of 2.9 percentage points to 63.6 percent and part-time workers dropped 2.2 points to 39.6 percent.

The report is based on data from the 2011-12 California Health Interview Survey, which is the nation’s largest state-based health survey and one of the largest health surveys in the United States. Because the data were collected just before full implementation of health care reform, the latest State of Health Insurance in California report will serve as a baseline to gauge the effects of the Affordable Care Act.

“Health care reform filled a huge and growing gap in job-based insurance,” said Shana Alex Charles, lead author of the study and director of the Health Insurance Program at the Center for Health Policy Research. “Sadly, health insurance is no longer a guarantee provided by many employers.”

Latinos still in the medical “shadows”

According to the report, Latinos had the lowest rate of job-based health coverage — 33.9 percent, compared to 63.3 percent of whites — and the highest rate of not having insurance, 28.4 percent.

Although nearly a third of low-income adult Latinos had Medi-Cal, 1 in 4 still lacked a usual source of care, the report noted, and 17.2 percent of adult Latinos covered by job-based insurance didn’t see a doctor in 2011-12, a much higher rate than either non-Latino whites or African Americans.

“This report shows us where we were, and it wasn’t a good place,” said Gerald Kominski, director of the Center for Health Policy Research and co-author of the study. “From here on out we can accurately measure how California’s health improves under reform.”

Young adults gain job-based coverage in ACA reform

In an early example of the benefits of health care reform, the study found that adults ages 19-26 were the only age group that gained health coverage from 2009 to 2012, with job-based coverage for them jumping to from 23.2 percent to 27.1 percent. That was an increase of 254,000 people. This age group also experienced the largest drop in the rate of people without insurance; this rate went from 28.9 percent in 2009 to 26 percent in 2012.

But for older adults, the percentage of those covered by job-based insurance plummeted. In the 40- to 54-year-old age group, more than half a million people  lost job-based coverage — a drop from 49 percent in 2009 to 45.4 in 2012.

“With job-based coverage shrinking year after year and nearly a third of California’s Latino community without health coverage, California was poised and ready for the implementation of the Affordable Care Act,” said Robert Ross, president and CEO of The California Endowment, which co-funded the report along with the California Wellness Foundation. “I’m confident we’ll see improvements in health coverage rates when the 2014 enrollment numbers are crunched.”

High-deductible plans create “underinsurance”

Among people with insurance, high deductibles played a big role in whether people put off having medical procedures. Californians with high-deductible plans that they purchased directly from an insurance company delayed or went without needed medical care at a rate double that of those without high-deductible plans, 16.1 percent versus 6.6 percent.

While the share of workers carrying individually purchased insurance is small — about 5 percent of full-time workers and 9.5 percent of part-time workers — the burden falls on many who are small business owners, according to the report.

“These data underscore the importance of Covered California’s Small Business Health Options Program,” said Judy Belk, president and CEO of the California Wellness Foundation. “It makes getting health insurance much more affordable for small businesses. People should not have to put their health at risk because insurance premiums are too high.”

Other findings include:

White, middle class and uninsured. Among whites with a family income higher than 400 percent of the federal poverty level (about $92,200 for a family of four in 2012), 1 in 4 went without insurance all or part of the year.

Public health insurance programs protect millions. One-fifth of Californians under age 65 in 2012 — 6.4 million people — were insured by Medi-Cal and the Healthy Families programs. That included nearly 2.6 million low-income children ages 0-11. This represented an 8-percentage-point jump from 2009 — the biggest increase of any age group — to 40.3 percent covered. This increase underscores the importance of public health insurance programs in maintaining the health of children. Nearly 70 percent of children covered by Medi-Cal are Latino.

With the release of the report, policy analysts and health advocates have a tool to measure the extent to which ACA reforms changed health access and health outcomes among the state’s residents in 2014.

“While the clear early success of the ACA in enrolling young adults in private coverage is promising, our data show that even the insured have delays in care, problems affording deductibles, and other access barriers that we hope will be addressed,” Charles said.

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Study: Hospital mergers, acquisitions leading to increased patient costs


Counterintuitive findings published in Journal of the American Medical Association.

The trend of hospitals consolidating medical groups and physician practices in an effort to improve the coordination of patient care is backfiring and increasing the cost of patient care, according to a new study led by a UC Berkeley health policy expert.

The counterintuitive findings, published today (Oct. 21) in the Journal of the American Medical Association, come as a growing number of local hospitals and large, multi-hospital systems in this country are acquiring physician groups and medical practices.

“This consolidation is meant to better coordinate care and to have a stronger bargaining position with insurance plans,” said study lead author James Robinson, professor and head of health policy and management at UC Berkeley’s School of Public Health. “The movement also aligns with the goals of the Affordable Care Act, since physicians and hospitals working together in ‘accountable care organizations’ can provide care better than the traditional fee-for-service and solo practice models. The intent of consolidation is to reduce costs and improve quality, but the problem with all this is that hospitals are very expensive and complex organizations, and they are not known for their efficiency and low prices.”

Robinson teamed up with study co-author Kelly Miller, program analyst at Integrated Healthcare Association, a nonprofit organization that promotes health care quality improvement, accountability and affordability in California.

The researchers analyzed four years of data, from 2009 to 2012, on 158 major medical groups and 4.5 million patients in California. Groups were put into three categories: owned by physicians, owned by a local hospital or hospital system, or owned by a large hospital system that spans multiple geographic markets in the state.

The measure of costs included physician visits, inpatient hospital admissions, outpatient surgery and diagnostic procedures, drugs, and all other forms of medical care except for mental health services. (The researchers did not have data on mental health services since they are paid for separately.)

After controlling for such factors as the mix of severely ill patients and geographic differences in cost, the researchers found that per patient expenditures were 19.8 percent higher for physician groups in multi-hospital systems compared with physician-owned organizations. Groups owned by local hospitals were better, but per patient costs still ran 10.3 percent higher compared with physician-owned groups.

Why would consolidation lead to increased costs? It could be that once a medical group has been acquired, physicians in those groups are expected to admit their patients to the high-priced hospital, Robinson said.

“Hospital-owned medical groups usually are expected to conduct ambulatory surgery and diagnostic procedures in the outpatient departments of their parent hospital, but hospital outpatient departments are much more costly and charge much higher prices than freestanding, non-hospital ambulatory centers,” he said.

Robinson said that public policy should not encourage mergers and acquisitions as a means of promoting collaboration. Instead, he said, policymakers should consider supporting the use of bundled payments for hospitals and physicians to improve coordination of care.

“Hospitals are an essential part of the health care system, but they should not be the center of the delivery system,” said Robinson. “Rather, physician-led organizations based in ambulatory and community settings are likely to be more efficient and provide cheaper care.”

The study authors noted that their findings are limited to California, and that further studies should be done using data from other states.

“Nevertheless, these findings are important since California is the nation’s leader in terms of having physicians participate in large medical groups that already perform the functions ascribed to ‘accountable care organizations’ by the Obama administration,” said Robinson.

The Robert Wood Johnson Foundation provided support for this research.

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Increased hospital use after Medicaid expansion is mostly temporary


UCLA study finds pent-up demand for health care will decline after first year of enrollment.

The expansion of Medicaid to millions of uninsured people should not have the catastrophic impact some predicted for state budgets because the increases in hospital and emergency room usage are only temporary, according to a new study by the UCLA Center for Health Policy Research.

“We found that the surge doesn’t last long once people get coverage,” said Nigel Lo, a research analyst at the UCLA Center for Health Policy Research and the study’s lead author. “Our findings suggest that early and significant investments in infrastructure and in improving the process of care delivery can effectively address the pent-up demand for health care services of previously uninsured people. Fears that these new enrollees will overuse health care services are just not true.”

Using two years of claims data from 182,000 low-income, uninsured people enrolled in California’s state-run health insurance programs, the UCLA researchers found that people who previously had had the least medical care used hospital emergency rooms at a high rate of 600 visits per 1,000 people. But usage declined sharply in the first quarter to 424 visits (a 29 percent drop), followed by another 25 percent decline the following quarter. Between 2011 and 2013, the overall decline was 69.5 percent (183 ER visits). The report also shows that their hospital admissions declined sharply, from 194 to 42, a decline of 78.5 percent.

“California’s success should set an example for states that are on the fence about expanding Medicaid,” said co-author Gerald Kominski, professor of health policy and management and director of the Center for Health Policy Research. “It’s an investment: Build more infrastructure and care delivery early on, and you can manage chronic care, address unmet health care needs, and keep cost increases to a manageable level.”

The Affordable Care Act has extended Medicaid eligibility in 27 states, but many other states have refused coverage in part because of predictions that state budgets would be overwhelmed by the demands of the previously uninsured, particularly once federal subsidies stop covering the full expansion cost in 2017. Three states — Indiana, Missouri and Utah — are considering expansion, and other state legislatures will soon debate the issue.

The Obama administration is pushing states to expand Medicaid, arguing that they are not only leaving millions of their residents uninsured, but are also forcing their hospitals to absorb billions of dollars in uncompensated costs for treating people without insurance.

The UCLA study looked at data from two programs in California — the Health Care Coverage Initiative, which ran from 2007 to 2010, and the Low Income Health Program, which ran from 2011 to 2013. On Jan. 1, 2014, these enrollees became part of the 1.5 million Californians who were able to transition under the Affordable Care Act into Medi-Cal, California’s Medicaid program that provides health insurance to low-income people.

The authors said that because California’s Low Income Health Program had provided preventative medical care and regular treatment for chronic diseases, the newly insured were no longer dependent on emergency room treatment and hospitalization. Improving care delivery through the use of an assigned source of primary care, care coordination and health risk assessments, as well as greater availability of specialty services and culturally competent self-care also potentially helped manage pent-up demand, they said.

The UCLA results provide new insights into previously published findings that costly emergency room visits in Oregon increased by 40 percent during the year after the state expanded Medicaid eligibility. By examining data over a longer period of time, the UCLA study was able to determine that such spikes in usage were only temporary.

The study was funded by the California Department of Health Care Services and the Blue Shield of California Foundation.

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UCLA Health System, Anthem join others to launch Vivity


Unique product created by insurer and seven health systems aligns care for SoCal members.

The UCLA Health System and six other top hospital systems in Los Angeles and Orange counties have partnered with Anthem Blue Cross to offer Anthem Blue Cross Vivity, an integrated health system. This partnership — the first in the nation between an insurer and competing hospital systems — will help the medical centers enhance the health of all Anthem Blue Cross Vivity members and enable them to share financial risk and gain.

The six other hospital systems — all of which have hospitals ranked among Los Angeles County’s top 30 by U.S. News and World Report — are Cedars-Sinai, Good Samaritan Hospital, Huntington Memorial Hospital, MemorialCare Health System, PIH Health and Torrance Memorial Medical Center.

“Vivity will create economies of scale, allowing us to provide the highest quality and affordable health care to thousands of Californians,” said Dr. David Feinberg, president of the UCLA Health System and CEO of the UCLA Hospital System. “UCLA is proud to join Anthem Blue Cross and its hospital partners at the vanguard of health care delivery in the U.S.”

Vivity continues the move away from traditional fee-for-service reimbursements that may create incentive for providers to increase the volume of medical procedures they perform, and it continues the trend toward a structure that financially rewards activities that keep patients healthy.

“This is an exciting and historic time,” said Pam Kehaly, west region president for Anthem Blue Cross. “This innovative venture will create a foundation to significantly advance the medical delivery system, simplifying the care experience and creating a structure with aligned incentives to eliminate waste and redundancy and improve overall health.”

This is just the first step in aligning the delivery system. Longer term, value will come from future improvements in efficiency and effectiveness enabled by such things as a common electronic medical records system, shared care management systems, joint wellness resources and other enhancements.

Anthem Blue Cross Vivity will provide members with more predictable costs, a simpler experience and convenient access to some of the best primary care doctors, specialists and hospitals in the region. For doctor visits, medical procedures or prescriptions, Vivity members only pay a co-pay; they don’t have to worry about meeting deductibles or deciphering complicated medical bills. The seven hospital systems and their affiliated medical groups have built a network of doctors that provides both quality care and affordable prices to Vivity members in Los Angeles and Orange counties.

CalPERS, the nation’s second largest purchaser of health benefits and an early adopter of health care system innovations, has already agreed to use Vivity network doctors and hospitals within its Select HMO network in Los Angeles and Orange counties. Large group brokers can start requesting proposals on Oct. 1, with coverage beginning on Jan. 1, 2015.

The name Vivity captures a fresh perspective on health care. Coined from vivify, meaning “to enliven or animate,” the name speaks to the energized team of providers coming together to deliver a uniquely people-centric offering.

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Coalition teams to help reduce heart attacks, strokes in San Diego County


UC San Diego part of regional project awarded $5.8M Health Care Innovation grant.

Approximately 84 million people in the United States suffer from some form of cardiovascular disease, and about 720,000 Americans have a heart attack every year, which works out to one every 44 seconds. To address these alarming statistics, the Be There San Diego Initiative has been awarded a $5.8 million Health Care Innovation grant for a coalition project to help reduce heart attacks and strokes in San Diego County.

The initiative’s program, San Diego: A Heart Attack and Stroke Free Zone, is a regional collaboration of health care organizations and stakeholders to improve health care delivery and patient outcomes.

The goal during the three year project is to enroll 4,000 high-risk patients and lower their blood pressure and cholesterol levels through evidence-based practices and a better understanding of the importance of treatment adherence. The project will also promote heart attack and stroke prevention measures, test novel, cost-effective technology solutions and provide educational opportunities both for patients and within the physician community.

Partners in the Be There Initiative include UC San Diego Health System, Arch Health Partners, Scripps Health, Sharp HealthCare, Kaiser Permanente, Palomar Medical Center, Naval Medical Center, Veterans Administration, the San Diego County Medical Society Foundation, the County of San Diego Health and Human Services Agency, community clinics and others. UC San Diego Health System serves as the fiscal agent for the project.

“Health organizations that are competitive in the market will be working together for the benefit of San Diego patients,” said Anthony DeMaria, M.D., principal investigator of the Heart Attack and Stroke Free Zone program and cardiologist at UC San Diego Health System. “This approach will decrease our community’s risk for cardiovascular disease and could result in saving millions in the county by preventing half of the heart attacks and strokes that would have otherwise occurred in the participating patient population.”

Patients will be educated about the program, consented and enrolled through their physician’s office beginning later this year. Participants will also receive blood pressure cuffs to monitor levels at home and work closely with a health care coach.

“Because it’s a silent condition, we find that many patients are unaware of having hypertension, and only about 40 percent of patients diagnosed with high blood pressure take their medication, which can directly lead to cardiovascular disease. We hope through the Heart Attack and Stroke Free Zone program, we can increase this to 80 percent,” said Katherine Bailey, executive director of the Be There Initiative.

The Health Care Innovation grant supporting the project is made possible by the Centers for Medicare and Medicaid Services (CMS) through the Affordable Care Act and is part of an ongoing effort to advance innovative solutions in delivering and improving patient care across the nation.

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Tackling tomorrow’s health challenges


Stanley Prusiner among UC participants at New York Times health conference.

New York Times correspondent Elisabeth Rosenthal and Nobel laureate Stanley Prusiner discuss developments in Alzheimer's research at the Health for Tomorrow conference at UCSF Mission Bay. (Photos by Susan Merrell, UC San Francisco)

By Alec Rosenberg

Nobel Prize winner Stanley Prusiner is not resting on his laurels.

Instead, the 72-year-old UC San Francisco neurologist has set his sights on solving one of the biggest challenges facing health care today: Alzheimer’s disease.

Prusiner made a passionate plea for tackling Alzheimer’s and other neurodegenerative diseases Thursday (May 29) at the New York Times Health for Tomorrow conference at UCSF Mission Bay Conference Center. The conference, which featured experts from the University of California and across the country, addressed the changing landscape of health care.

Alzheimer’s already has a large impact on health care: It’s the sixth-leading cause of death in the U.S. — more than breast cancer and prostate cancer combined — and nearly half of people age 85 and older have the disease, Prusiner said. Without action, it will get worse — the prevalence of the disease is projected to triple by 2050 to as many as 16 million Americans.

“This is a huge, huge problem, and we’re not doing nearly enough,” said Prusiner, a UC San Francisco professor of neurology and director of the Institute for Neurodegenerative Diseases. “This is such an important area. There is no substitute for research. That’s going to really make a difference.”

Stanley Prusiner, UC San Francisco

Filling the pipeline

The National Institutes of Health provides only $500 million in research funding for Alzheimer’s, compared with more than $5 billion for cancer research, even though each costs society about $200 billion a year, Prusiner noted.

While many drugs treat cancer and hundreds more are in the pipeline, no single drug today halts or slows neurodegenerative diseases, he said. Prusiner, who just wrote a memoir, “Madness and Memory,” about his Nobel Prize-winning discovery of prions — infectious proteins that could be at the root of neurodegenerative diseases such as Alzheimer’s and Parkinson’s — aims to change that.

In April, UCSF formed a new collaboration with Japan-based pharmaceutical company Daiichi Sankyo Co. Ltd. This joint venture, capitalizing on Prusiner’s research, is focusing on developing drugs and molecular diagnostics for multiple neurodegenerative diseases, including Alzheimer’s and Parkinson’s.

“I’m very optimistic now that we are going to get there,” Prusiner said. “This is a huge step forward. We need 10 more of these around the world.”

UC President Janet Napolitano

Making progress

UC is conducting research on health’s most pressing problems, teaching the next generation of health professionals and working to improve health care quality, access and affordability, said UC President Janet Napolitano, who delivered welcoming remarks at the conference.

“There are no quick fixes, but I think working together we can make steady progress,” Napolitano said.

Indeed, research is being conducted throughout UC on Alzheimer’s and many other health issues. Napolitano noted that UC San Francisco leads a team that was just awarded a $26 million federal grant — part of President Obama’s Brain Initiative — to create an implantable device that will retrain the brain to recover from mental illness. She also pointed to research by conference speakers David Kilgore of UC Irvine and Michael Fischbach of UC San Francisco.

David Kilgore, UC Irvine

Countering ‘diabesity’

Kilgore, a clinical professor of family medicine, talked about the problem of “diabesity”: Diabetes rates have tripled in the last 20 years, while more than two-thirds of adults are considered to be overweight or obese. Among Kilgore’s patients at a UC Irvine clinic, 70 percent have diabetes, often in combination with other chronic diseases.

“The challenge of chronic disease has completely changed what it’s like to be a primary care physician,” Kilgore said.

More prevention is needed, Kilgore said. He started group medical visits for patients with diabetes. They receive extra information about nutrition, exercise and receive a healthy cooking lesson.

“They love it,” Kilgore said.

UC San Francisco's Michael Fischbach and Stanford's Justin Sonnenburg discuss research into gut bacteria.

Going with the gut

Fischbach, a UC San Francisco assistant professor of bioengineering and therapeutic sciences, discussed his research on the gut with collaborator Justin Sonnenburg, a Stanford University microbiologist who has a bachelor’s degree from UC Davis and a doctorate from UC San Diego. They are studying gut bacteria and how it could help reveal the causes and new treatments for Crohn’s disease and obesity.

“The beauty of being in basic research is you don’t know where you’re going to end up,” Fischbach said after their panel presentation. “It’s nice to be on a journey where you don’t know where the ship lands. I hope it’s going to improve human health.”

Seeking solutions

The Health for Tomorrow conference addressed issues ranging from the impacts of the Affordable Care Act to rethinking how to deliver care in the 21st century to issues of access, affordability and applying technology. Speakers included Marilyn Tavenner, administrator of the Centers for Medicare & Medicaid Services; Diana Dooley, secretary of the California Health and Human Services Agency; New York Times correspondent Elisabeth Rosenthal; CEOs Toby Cosgrove of the Cleveland Clinic and Bernard Tyson of Kaiser Permanente; and several with UC ties.

As part of the conference, five entrepreneurs were invited to give short talks about their health-related startup companies. Three of them studied at UC:

  • Erik Douglas, CEO of CellScope, has a doctorate degree from UC Berkeley and UC San Francisco. The company’s first product, CellScope Oto, turns a smartphone into a digitally connected otoscope, enabling remote care for ear infections, the leading reason for pediatric visits.
  • Anupam Pathak, Lift Labs founder and CEO, has B.S. and M.S. degrees from UC Berkeley. Lift Labs makes active stabilization tools for people living with tremor. Its pocket-sized Liftware, which has a spoon and other attachments, is a “Swiss Army knife for people with tremors.”
  • Joanna Strober, founder and CEO of Kurbo Health, has a J.D. from UCLA. She founded Kurbo after becoming concerned about the consequences of her middle son being overweight. Kurbo has developed a mobile app designed for children and their families to help them lose weight and live healthier lives.

The Health for Tomorrow conference can be viewed on demand, broken down by panel, at www.nythealthfortomorrow.com.

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California’s public hospitals could face $1.5B funding gap


California will fare better than other states but will still feel pain.

Dylan Roby, UCLA

Public hospitals in California that serve the poorest patients could face a $1.54 billion funding shortfall in 2019, when federal funding cuts go into effect. Those cuts, along with health care cost inflation, could jeopardize the financial stability of the state’s safety-net hospital system, according to a study by the UCLA Center for Health Policy Research and Virginia Commonwealth University published in the June issue of the journal Health Affairs.

Several county hospitals — including LAC + USC Medical Center, Santa Clara Valley Medical Center, Alameda Health System, Harbor–UCLA Medical Center and Olive View–UCLA Medical Center — may be especially vulnerable because they receive the highest disproportionate-share hospital (DSH) payments in the state and are located in regions with large numbers of undocumented immigrants who are not eligible for Medi-Cal, California’s version of the Medicaid program.

“Hospitals that can least afford a cut are the most at risk,” said Dylan Roby, director of the UCLA center’s Health Economics and Evaluation Research Program. “Policymakers should ensure that the impending shift in federal funding does not destabilize institutions that are the backbone of public health in California.”

California’s safety-net hospitals rely heavily on federal DSH funding, which compensates them for treating the most vulnerable patients — those who are uninsured and those on Medicaid, primarily children, pregnant women, the disabled and the elderly. In 2010, DSH funds paid more than half of $2 billion in DSH costs ($1.1 billion) to the 21 safety-net hospitals included in the study, with county and state funds covering the rest.

But with impending DSH cuts, the study estimates payments would drop to roughly $830 million to $980 million and leave hospitals struggling to cover $1.38 billion to $1.54 billion in DSH costs in 2019. As many as 4 million Californians and 30 million Americans nationwide are still likely to be uninsured at that time. Without a strong safety-net hospital system, those patients will have few places to turn to for care.

Consequence of legislation

The cuts are a consequence of the Affordable Care Act, whose authors anticipated that as more patients gained health coverage under the ACA, they would generate more revenue for public hospitals, decreasing the need for DSH payments.

But the newly insured patients may not be revenue-generators at public hospitals, and there will be many remaining uninsured patients, according to the study, which used the California Simulation of Insurance Markets to model hospitals’ future patient payer mix. For instance, some of the newly insured patients at public hospitals may switch to private hospitals and take their insurance payments with them.

Other states may fare worse

Hospitals in other states that opted out of expanding their Medicaid programs could be much harder hit than California for two reasons: They won’t get federal funding from Medicaid expansion, and their DSH payments will be cut.

“As challenging as these cuts will be for safety-net hospitals in California, they will be much worse in other states,” said Katherine Neuhausen, lead author of the study and a clinical assistant professor at Virginia Commonwealth University who conducted the research as a Robert Wood Johnson Foundation Clinical Scholar at UCLA. “Safety-net hospitals in states that do not expand Medicaid and those in states that do not target DSH payments to the hospitals with the greatest need could be in jeopardy.”

Public hospitals on a ‘shoestring’

Still, California is not immune to the coming budgetary realignment.

California highly targets its DSH payments to 21 public hospitals (just 4 percent of the state’s hospitals), including 15 county hospitals and six University of California hospitals. Many of these public hospitals — which operate half the state’s trauma centers and a quarter of the burn centers, as well as teaching hospitals — are in low-income areas with few paying patients and are especially vulnerable to any loss of funds.

“They’re already operating on a shoestring,” Roby said.

At LAC + USC Medical Center, half the people receiving outpatient services were found to be uninsured, and more than a third were on Medicaid. At hospitals statewide, the figures were much lower: 21.3 percent and 29.3 percent, respectively.

California awards DSH payments to public hospitals based on their numbers of uninsured and Medicaid discharges and their share of uncompensated care costs. Therefore, public hospitals with greater uncompensated care costs and more low-income patients should retain more of their DSH funds, according to the authors.

The authors conclude that California and other states can take steps to close the funding gap and keep hospitals stable. Hospital leaders, they say, could work with policymakers to make sure DSH payments are targeted to the safety-net hospitals that serve the most uninsured and Medicaid patients; states that expanded Medicaid under the ACA could pay higher reimbursement rates to safety-net hospitals for people who are newly eligible for Medicaid, which is already done in California; and safety-net hospital leaders in states that opted out of Medicaid expansion could seek out additional county and state subsidies.

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Could a modest investment expand Medi-Cal to state’s undocumented residents?


A little investment could go a long way, UC Berkeley/UCLA study finds.

Approximately 690,000 to 730,000 undocumented Californians could gain access to routine and preventive health care in 2015 with just a 2 percent increase in state Medi-Cal spending – estimated at $353 million to $369 million – according to a joint study by UC Berkeley’s Center for Labor Research and Education and the UCLA Center for Health Policy Research.

The study looks at certain provisions of the proposed Health for All Act, or Senate Bill 1005, proposed by state Sen. Ricardo Lara (D-Huntington Park/Long Beach) and under consideration in the state Legislature. The proposed legislation would make all low-income Californians who are excluded from federal health reform, including undocumented immigrants, eligible for Medi-Cal. More than 1.4 million undocumented Californians – ineligible for Affordable Care Act coverage programs due to their immigration status  – are uninsured.

“California would be the first in the nation to make its health-insurance program inclusive of all low-income residents and their families, including those who are undocumented,” said Laurel Lucia, policy analyst at the UC Berkeley Labor Center.

The proposed policy would complement the state’s recent role in expanding immigrants’ rights in the absence of federal immigration reform; this includes moves to provide driver’s licenses to all residents and to extend financial aid to undocumented college students who arrived in the United States as children, said Lucia.

The proposed change would move California from a system of disjointed emergency care to more rational and comprehensive care at a relatively low cost per person, according to the study authors. According to the study, some 60 percent of health care costs for California’s low-income, undocumented adults are already paid under long-standing federal policy. Matching dollars are provided by the federal government to the state for emergency and pregnancy-related services available to all low-income Californians, regardless of immigration status. But undocumented immigrants, who make up 9 percent of California’s workforce, often lack access to health-promoting, cost-effective preventive and routine services.

“The undocumented don’t get sufficient access to preventive care and often wait as long as possible before seeking care,” said Nadereh Pourat, director of research at the UCLA Center for Health Policy Research. “Providing preventive care helps the undocumented stay healthy and allows them to continue to contribute to California’s economy.”

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Covered CA open enrollment ends, but many still will transition in and out


UC Berkeley analysis highlights fluidity of California health insurance landscape.

Ken Jacobs, UC Berkeley

Recent media reports about Covered California have focused on the crush of people trying to sign up for the program’s medical insurance programs by March 31, but analysts at UC Berkeley say not to overlook the many people who will join or leave the program after that deadline.

Researchers at UC Berkeley’s Center for Labor Research and Education are providing new data on the large numbers of people who will enter and leave the program over the coming year, outside the open enrollment period, as the program makes more people, due to various life transitions, eligible for coverage.

In a policy brief released today (April 2), the researchers said their data underscores how important it is to recognize the fluidity of California’s health insurance landscape in order to help people smoothly transition from one health plan to another and to avoid becoming uninsured.

“For many people, Covered California is a place where they will access coverage for a short time during a life transition, such as job-loss or divorce. People will enter and leave coverage on a regular basis,” said Ken Jacobs, who co-authored the report along with researchers Miranda Dietz and Dave Graham-Squire.

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