TAG: "Health policy"

Undocumented farmworkers use Medicaid half as often as documented farmworkers


UC Davis study finds that greatest predictor of farmworker use of Medicaid is having children.

J. Paul Leigh, UC Davis

By Karen Finney, UC Davis

Undocumented farmworkers are half as likely as those who are documented to use Medicaid, the federal health insurance program available to low-income individuals and families, according to a new study from UC Davis Health System. The research also shows that the greatest predictor of farmworker use of Medicaid, which provides coverage for prenatal, pediatric and emergency care regardless of documentation status, was having children.

“Undocumented agricultural workers are using Medicaid at about half the rate of documented immigrants and citizens, and they appear to be using it in accordance with the law,” said J. Paul Leigh, senior author of the study, professor of public health sciences and researcher with the Center for Healthcare Policy and Research. “There’s a perception that undocumented farmworkers are overusing Medicaid resources, but our findings indicate the opposite.”

In conducting the study, which is published online in the Journal of Occupational and Environmental Medicine, Leigh analyzed records from the U.S. Department of Labor’s National Agricultural Workers Survey (NAWS) on 41,324 farmworkers from 1993 through 2009, about half of whom were migrants working without residency, citizenship or visas.

Because the NAWS database is the only nationally representative sample of undocumented workers, it is a rare source of information on demographics and income at both individual and household levels for this often elusive group. Given that almost 50 percent of Medicaid recipients are children, the data on households rather than individual adults was particularly relevant to the current study.

Leigh found that undocumented farmworker heads of household were 52 percent less likely to use Medicaid than their documented counterparts: 22.6 percent of documented farmworker heads of household and only 12.2 percent of undocumented farmworker heads of household reported that one or more family members received Medicaid services over two-year intervals during the 16-year study period.

The odds of receiving Medicaid benefits for documented heads of household with one child were 6.57 times greater than that of documented heads of household with no children. One-child undocumented heads of household were 8.4 times more likely to utilize Medicaid than childless documented heads of household.

“Simply having children is the best determinant of Medicaid use,” said Leigh. “Use by undocumented, unmarried males appears to be extremely rare.”

The seemingly disproportionate effect of children on undocumented versus documented heads of household may be explained by access to non-government health insurance options, according to Leigh. Documented workers are much more likely than undocumented workers to have employer-sponsored health insurance, which families typically prefer over Medicaid. Undocumented heads of household, even those with children who are U.S. citizens, rarely have that choice.

“Undocumented workers don’t have any other place to go for health insurance,” Leigh said. “As soon as they have a child in the family, undocumented workers are much more likely to use Medicaid.”

Higher income, either for individuals or families, was associated with lower odds of Medicaid use for both documented and undocumented heads of household. There were also variations by region, with California having the highest odds of Medicaid use.

This is one in a series of studies of health care utilization prepared by Leigh, an expert in economics and occupational illnesses. Next in the pipeline is a study of those who use food stamps and the U.S. Department of Agriculture’s Special Supplemental Nutrition Program for Women, Infants and Children, which provides supplemental foods, health care referrals, and nutrition education for low-income women and young children who are deemed at nutritional risk.

“Medicaid Use by Documented and Undocumented Farm Workers” was co-authored by Yoon-Kyung Chung of the Korea Energy Economics Institute in Seoul and Ph.D. graduate of the UC Davis Department of Economics. It was supported by the National Institute for Occupational Safety and Health (grant number 2U54OH007550-11). The study is available online.

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California breast density law slow to have an impact


UC Davis research demonstrates need for more physician education.

Jonathan Hargreaves, UC Davis

By Dorsey Griffith, UC Davis

Ten months after California legislators enacted a controversial law mandating that radiologists notify women if they have dense breast tissue, UC Davis researchers have found that half of primary care physicians are still unfamiliar with the law and many don’t feel comfortable answering breast density-related questions from patients. The findings, to be published in the March print edition of Journal of the American College of Radiology, suggest that if the law is going to have any significant impact on patient care, primary care providers need more education about breast density and secondary imaging options.

“Overall, the impact of the breast density legislation probably is not significant if  primary care physicians are not educated or aware of it,” said lead author Kathleen Khong, a UC Davis radiologist and staff physician. “We should put some emphasis on educating the primary care physicians so that when they get questions from patients, they can be comfortable in addressing the issues.”

The California law, which took effect in April 2013, requires that patients whose breast density is defined as “heterogeneously dense” or “extremely dense” (about 50 percent of women), receive the following notification:

“Your mammogram shows that your breast tissue is dense. Dense breast tissue is common and is not abnormal. However, dense breast tissue can make it harder to evaluate the results of your mammogram and may also be associated with an increased risk of breast cancer. This information about the results of your mammogram is given to you to raise your awareness and to inform your conversations with your doctor. Together, you can decide which screening options are right for you. A report of your results was sent to your physician.”

The researchers point out that breast density has long been a required part of any radiological report following mammography, but unless a patient asks to see the report, the information is shared only with the patient’s providers. Led by patient advocates, the legislation is intended to increase awareness of dense breasts and encourage patients to discuss the clinical issues with their doctors. According to published research, 28 states have passed, rejected or considered dense-breast notification legislation since 2009.

But the UC Davis study demonstrated that while women and their doctors are receiving the notifications, many of those physicians are unclear about what to do with the information. As a consequence, the researchers said, it appears that relatively few patients with dense breasts are asking questions about their breast density and its implications.

The UC Davis study surveyed 77 physicians about the new law.  Roughly half (49 percent) reported no knowledge of the legislation and only 32 percent of respondents noted an increase in patient levels of concern about breast density compared to prior years. In addition, a majority of primary care physicians were only “somewhat comfortable” (55 percent) or “not comfortable” (12 percent) with breast-density questions from their patients.

Khong said their survey results were surprising, but acknowledged that many primary care physicians may not feel they have sufficient training to make a clinical recommendation for a particular type of secondary screening. In fact, the study also found that 75 percent of respondents would like more education about the breast-density law and its implications for primary care.

“They are eager to learn and want to help their patients and be part of something positive as a result of this,” Khong said.

Jonathan Hargreaves, assistant professor of clinical radiology and a study co-author, said, for example,  that if a patient has dense breasts she should have a risk assessment, which takes into account her family history of breast cancer, biopsy history and other factors to determine whether a supplemental screening is warranted. Once  complete, the physician should then discuss the potential benefits and risks of supplemental imaging in determining the most appropriate approach for the patient. The use of ancillary screening in addition to mammography is a complex subject and still the subject of considerable debate, explained Hargreaves.

Tomosynthesis, known as 3-D mammography, is one supplemental test that breast radiologists generally agree provides a slight benefit for women with dense breasts over a standard mammogram and can be scheduled for the next annual mammographic screening appointment after receiving a notification. Breast magnetic resonance imaging (MRI) is another secondary imaging option, Hargreaves said, but is generally only used for screening in women who have a very strong family history of breast cancer or have a known high-risk gene, such as BRCA.

“The law has raised a lot of awareness about breast density,” Hargreaves said. “That being said, mammography screening is the primary thing patients need to do, and beyond that, the real benefits of other screening techniques are still the subject of ongoing medical debate.”

Khong and Hargreaves hope to validate their findings by expanding their research to include primary care physicians from other major university health care systems in California.

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Kids of melanoma survivors need better protection from sun’s harmful rays


UCLA study is first to include Latinos, whom have often been left out of skin cancer prevention research.

Credit: Sean Brenner, UCLA

By Reggie Kumar, UCLA

UCLA researchers have found that children of melanoma survivors are not comprehensively adhering to sun protection recommendations, despite them being at an increased risk for developing the disease as adults.

In the study led by Beth Glenn, associate director of the UCLA Jonsson Comprehensive Cancer Center’s Healthy and At-Risk Populations Research Program, researchers asked parents about their attitudes toward melanoma prevention, how at risk for melanoma they believed their child to be, and their current use of sun protection strategies for their child. They found that about three-quarters of parents relied on sunscreen to protect their child against sun exposure, but less than a third of parents reported that their child wore a hat or sunglasses or attempted to seek shade when exposed to the sun.

Additionally, Glenn said, 43 percent of parents surveyed reported that their child experienced a sunburn in the past year. This is concerning because sunburns are a major risk factor for melanoma.

The UCLA researchers used the California Cancer Registry (which tracks all cases of cancer across the state) to identify and survey 300 melanoma survivors with children ages 17 and younger during a three-year period. The study targeted both non-Latino white melanoma survivors and for the first time Latino melanoma survivors as well.

Latinos have often been left out of skin cancer prevention research due to a common misconception that sun protection is not important for this group.

“Sunburns were common among the children in our study despite their elevated risk for skin cancer. Also, children of Latino survivors were just as likely as children of non-Latino white survivors to have experienced a recent sunburn, which highlights the importance of including this group in our work,” said Glenn, associate professor of Health Policy and Management in the UCLA Fielding School of Public Health.

The survey results will be used to apply for additional funding to develop an intervention program that combines a text message reminder system with educational materials and activities for parents and children. The intervention program is designed to help melanoma survivors more effectively monitor and properly protect their child against UV radiation.

“Protecting kids against the sun’s harmful rays at an early age is vitally important. Our goal is to develop an intervention that will help parents protect their children today and help children develop sun safe habits that will reduce their risk for skin cancer in the future,” said Glenn.

The study will be published online Jan. 13 in the journal Cancer Epidemiology, Biomarkers & Prevention.

The research was supported in part by the National Cancer Institute.

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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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Higher-earning docs make more money by ordering more procedures per patient


UCLA findings suggest that the practice may not be in patients’ best interest.

By Kim Irwin, UCLA

In results they characterized as “very surprising,” UCLA researchers found for the first time that higher-earning clinicians make more money by ordering more procedures and services per patient rather than by seeing more patients, which may not be in patients’ best interest.

The researchers, from UCLA’s Department of Urology and the Veterans Health Administration, examined the amount Medicare was billed and the amount paid to clinicians. They reviewed data from Medicare Part B payments during 2012.

“Medicare spending is the biggest factor, crowding out investment in all other social priorities,” said Dr. Jonathan Bergman, the research letter’s first author and an assistant professor of urology and family medicine at the David Geffen School of Medicine at UCLA.

“With clinicians making more not by seeing more unique patients, but by providing more services per person, additional research needs to be done to determine if these additional services are contributing to improved quality of care,” Bergman said. “These findings suggest that the current health care reimbursement model — fee-for-service — may not be creating the correct incentives for clinicians to keep their patients healthy. Fee-for-service may not be the most reasonable way to reimburse physicians.”

The research letter was published in the journal JAMA Internal Medicine.

Bergman, who also is a urologist and bioethicist at the VA Greater Los Angeles Healthcare System, believes the review of Medicare data is important because of its potential impact on public policy.

“Our findings suggest a weakness in fee-for-service medicine,” he said. “Perhaps it would make more sense to reimburse clinicians for providing high-quality care, or for treating more patients. There probably shouldn’t be such wide variation in services for patients being treated for the same conditions.”

Further research will need to be done to assess if treatment outcomes differ between those who had more services ordered and those who had fewer. This may also show a clearer view of how to best target resources to maximize value for patients, Bergman said.

Going forward, Bergman and his team will look at alternative payment models, such as those used at Veterans Affairs facilities and in “safety net” hospitals, to see if they make more sense than fee-for-service plans.

The research letter reported: “The goals of payment reform are currently unrealized, as evidenced in these data. Physicians take an oath to care for patients using ‘appropriate means and appropriate ends,’ focusing on what is best for the patient, and this centuries-old oath still resonates with graduates of medical school classes. Rather than react to externalities imposed by payers, clinicians can lead the movement toward a high-value, patient-centered care. We are uniquely empowered to ensure that all individuals access the procedures they need, and are not exposed to those they don’t.”

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Social, behavioral data provide key info for electronic health records


IOM report details 12 social and behavioral factors that should be included in EHRs.

If social and behavioral data were included in electronic medial recorders if could help nurses and physicians have a better picture of the patient's health. (Photo by Cindy Chew)

By Juliana Bunim, UC San Francisco

Social and behavioral data provide crucial information about factors that influence health and effectiveness of treatment and should be incorporated into patient electronic health records (EHR), according to a new report from the Institute of Medicine (IOM).

The IOM committee, co-chaired by Nancy Adler, Ph.D., vice chair of the Department of Psychiatry at UC San Francisco and William Stead, M.D., of Vanderbilt University, was created in 2013 to conduct a two-phase study, first to identify the social and behavioral areas that most strongly determine health, and then to evaluate the measures that can most effectively be used in EHRs. Kirsten Bibbins-Domingo, M.D., of the UCSF Department of Medicine, also served on the committee.

The committee reviewed the evidence linking social conditions and health behaviors to health, which suggests that health behaviors such as alcohol use, and social conditions such as financial resource strain account for more than half of all premature deaths in the United States. They evaluated more than 70 relevant domains and subdomains, 17 of which were judged to be most valuable for inclusion in electronic health records.

“Having access to information about health-related aspects of a patient’s life in the electronic health record can enable clinicians to make more accurate diagnoses and engage more effectively with the patient in making treatment choices,” said Adler. “The information can also help health systems understand the needs of the populations they serve and design more effective services.”

The second phase of the report, published Nov. 13, details 12 social and behavioral factors that should be included in electronic health records.

The new report, Capturing Social and Behavioral Domains and Measures in Electronic Health Records: Phase 2, recommends that providers use their EHRs to capture patients’ census information including race, ethnicity and address, in addition to tracking alcohol use, tobacco use and exposure, physical activity, educational attainment, social connections, depression, stress, financial resource strain, neighborhood and community compositional characteristics, and exposure to violence.

“When analyzed along with genomic and clinical data, standardized social and behavior information in EHRs can enable new discoveries regarding the etiology and progress of disease,” said Adler. “It can also point to the effectiveness of specific treatments for patients with different psychosocial and biological profiles.”

Read phase one of the report here.

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Many seniors who fall repeatedly don’t seek medical attention


Study finds health care workers also often fail to counsel seniors on preventing future falls.

More than half a million older Californians — 12.6 percent of the state’s senior population — fall more than once a year, but nearly 60 percent of them fail to seek medical attention afterward, according to a new study by the UCLA Center for Health Policy Research.

The study also found that among those who did seek treatment, 40 percent did not receive counseling from a medical provider about how to prevent future falls.

Falls are the leading injury-related cause of death and need for medical care among Californians age 65 and older, according to the study. In 2012, more than 1,800 seniors died after falling and seniors’ fall-related injuries resulted in more than 72,000 hospitalizations.

“There is a cost in terms of both lives and resources when doctors fail to talk to seniors who have already fallen about how to prevent future falls,” said Steven Wallace, associate director of the Center for Health Policy Research and author of the study.

Using data from the 2011–12 California Health Interview Survey, the study found older seniors are twice as likely as younger seniors to have multiple falls: nearly 1 in 5 people 85 and older reported that they fell more than once a year, compared with 1 in 10 of those aged 65 to 74. Nearly a quarter of seniors who have suffered a stroke, and almost 20 percent of those with any disability, had multiple falls. Twenty-six percent of seniors with moderate mental impairment had multiple falls, as did 38 percent with severe mental impairment.

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Expanding palliative care in California could save billions of dollars


Berkeley Forum report highlights three programs that give patients greater choice of care.

Click image to view report

A report released today (Nov. 19) by the Berkeley Forum finds that California hospital spending could be reduced by billions of dollars over the next eight years if patients’ wishes about palliative care were honored.

The Berkeley Forum — a collaborative effort involving executive leadership of major health insurers, health care delivery systems and the state of California with health policy experts from the School of Public Health at UC Berkeley — previously issued a vision of increased choice and better value for patients nearing end of life.

The new report builds on that vision, highlighting three major programs that give patients in California greater choice of care outside the hospital. The programs’ interdisciplinary teams incorporate patient goals and wishes when planning treatment, resulting in patient-centered care that tends to move people out of intensive hospital settings and into care in the community.

“Our review shows that offering more choices to patients can not only increase satisfaction with care and improve outcomes, but also divert spending from expensive and unwanted services,” said Eric Kessell, policy director for the Berkeley Forum and lead author on the report.

The study also found that by expanding access to community-based palliative care to over 100,000 Californians a year through 2022, more than $5.5 billion could be moved from high-cost, unwanted hospital services while honoring patient wishes for care at home and in other community settings.

“The wishes of patients, their families and loved ones should be honored at the end of life,” said Richard Scheffler, co-chair of the Berkeley Forum. “Many of them do not want to die in a hospital. This report gives them other choices.”

In order to achieve this vision, conversations about palliative care will need to be incorporated throughout the health care delivery system, with increased use of nurse practitioners and other health care professionals, and a tripling of physicians certified in hospice and palliative medicine.

Stephen Shortell, chair of the Berkeley Forum, said, “The increased interest in palliative care is part of a larger movement toward greater patient and family engagement in all aspects of their care over the life course.”

“Expanding palliative care in California is the right thing to do on every level. It is what patients want, it improves outcomes, it lowers costs and most importantly provides compassionate relief to those suffering.”

— David Feinberg, president of the UCLA Health System, CEO of the UCLA Hospital System and UC Health’s representative on the Berkeley Forum

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Online tool provides health information by ZIP code, city, legislative district


UCLA site advances Center for Health Policy Research mission of democratizing data.

For the first time, anyone can easily access comprehensive California health statistics by ZIP code, city and legislative district thanks to a new web tool created by the UCLA Center for Health Policy Research. The easy-to-use AskCHIS Neighborhood Edition, or AskCHIS NE, enables users to customize searches, compare and “pool” small geographic areas, and map and chart their results.

AskCHIS NE covers a wide range of health topics, including rates of health insurance, chronic conditions like asthma and diabetes, and behaviors like smoking and physical activity; quality of children’s health; and access to health care and mental health care; and much more.

AskCHIS Neighborhood Edition is a service of the center’s renowned California Health Interview Survey, the nation’s largest state health survey. An existing companion web tool, AskCHIS, allows users to find health data at the county, region and state levels.

AskCHIS NE drills down even deeper than AskCHIS, allowing users to quickly find health disparities within specific cities or legislative districts. Using the system’s pooling feature, hospitals can build health profiles of their service areas, combining ZIP codes or cities. Community groups can decide which programs to offer at parks based on a neighborhood’s specific health needs. Journalists can compare obesity rates in neighborhoods they cover.

“This is the first time that Californians will be able to access neighborhood health information in just a few, simple steps,” said Ninez Ponce, the California Health Interview Survey’s principal investigator. “This information will help Californians make health decisions that are specifically targeted to the unique needs of their communities.”

Using AskCHIS NE is simple:

  • Log onto http://askchisne.ucla.edu. People who have previously used AskCHIS can use an existing logon ID and password; new users can create a free account before logging in for the first time.
  • Select a topic from the panel on the left.
  • Search for geographic areas of interest and click the “Create a table” button.
  • The search results are quickly displayed in a table, bar chart and interactive map.

The interactive map makes it easy to for users to see health disparities across the landscape. Data for one ZIP code can be loaded and displayed, but the user also can zoom out to view adjacent ZIP codes or the entire state for comparison.

As in AskCHIS, results can be easily exported into Excel spreadsheets. But AskCHIS NE also makes it easy for users to download the charts and maps for use in reports and presentations. The site also makes HTML coding available for use in online media.

“AskCHIS NE truly moves forward the center’s mission of democratizing data,” said Bogdan Rau, the project manager for AskCHIS NE. “It’s provided as a public service so that everyone who needs access to quality, authoritative health information can benefit.”

AskCHIS Neighborhood Edition is sponsored by grants from Kaiser Permanente and the California Wellness Foundation.

Heavy website traffic is expected when AskCHIS NE launches. If the site is busy, please try again later.

Visit the UCLA Center for Health Policy Research — and see a demo of AskCHIS NE — at Booth 1043 at the American Public Health Association annual meeting in New Orleans, Nov. 16 – 19. View the schedule for the meeting.

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UCSF sugar science initiative launched


Researchers highlight strong links between sugar and chronic disease.

By Kristen Bole, UC San Francisco

Researchers at UC San Francisco have launched SugarScience, a groundbreaking research and education initiative designed to highlight the most authoritative scientific findings on added sugar and its impact on health.

The national initiative is launching in partnership with outreach programs in health departments across the country, including the National Association of City and County Health Organizations and cities nationwide.

Developed by a team of UCSF health scientists in collaboration with scientists at UC Davis and Emory University School of Medicine, the initiative reflects an exhaustive review of more than 8,000 scientific papers that have been published to date on the health effects of added sugar.

The research shows strong evidence of links between the overconsumption of added sugar and chronic diseases, including Type 2 diabetes, heart disease and liver disease. It also reveals evidence linking sugar to Alzheimer’s disease and cancer, although the team assessed that more research is needed before those links can be considered conclusive.

Laura Schmidt, UC San Francisco

“The average American consumes nearly three times the recommended amount of added sugar every day, which is taking a tremendous toll on our nation’s health,” said Laura Schmidt, Ph.D., a UCSF professor in the Philip R. Lee Institute for Health Policy Studies and the lead investigator on the project. “This is the definitive science that establishes the causative link between sugar and chronic disease across the population.”

The initiative aims to bring scientific research out of medical journals and into the public domain by showcasing key findings that can help individuals and communities make informed decisions about their health. For example, SugarScience.org cites research showing that drinking just one can of soda per day can increase a person’s risk of dying from heart disease by nearly one-third, and can raise the risk of getting Type 2 diabetes by one-quarter.

More than 27 million Americans have been diagnosed with heart disease, which is the nation’s leading cause of death. Another 25.8 million Americans have Type 2 diabetes, caused by the body’s resistance to the hormone insulin coupled with the inability to produce enough insulin to regulate blood sugar levels. Of greatest concern is the rising number of children suffering from these chronic diseases.

Kristen Bibbins-Domingo, UC San Francisco

“Twenty years ago, Type 2 diabetes was unheard of among children, but now, more than 13,000 children are diagnosed with it each year,” said Kirsten Bibbins-Domingo, M.D., Ph.D., a UCSF professor of medicine, epidemiology and biostatistics, and director of the UCSF Center for Vulnerable Populations at San Francisco General Hospital and Trauma Center. “Diabetes is a devastating disease and we know that it is directly related to the added sugar we consume in food and beverages.”

Another rising concern is the impact of added sugar on Non-Alcoholic Fatty Liver Disease (NAFLD), which affects 31 percent of adults and 13 percent of children, and can lead to cirrhosis and liver failure.

“As pediatricians, we had evidence of the connection between sugar and diabetes, heart disease, and liver disease for years, but we haven’t had this level of definitive scientific evidence to back up our concerns,” said Robert Lustig, M.D., M.S.L., a pediatric endocrinologist at UCSF Benioff Children’s Hospital San Francisco and a member of the SugarScience team. “Our goal is to make that science digestible to the American public, and take the first step toward a national conversation based on the real scientific evidence.”

Robert Lustig, UC San Francisco

While there are no federal recommended daily values for added sugar, the American Heart Association recommends consuming less than 6 tsp. (25 g) for women and 9 tsp. (38 g) for men. Guidelines for children depend on caloric intake, but range between 3-6 tsp (12-25 g) per day. Americans currently consume 19.5 tsp. of added sugar, on average, every day.

Added sugar is defined as any caloric sweetener that is added in food preparation, at the table, in the kitchen or in a processing plant. It can be difficult for people to know how much sugar they are consuming, since roughly 74 percent of processed foods contain added sugar, which is listed under at least 60 different names on food labels.

The 12-member SugarScience team will continue to monitor scientific research about added sugar and will track findings at SugarScience.org. The initiative harnesses the power of UCSF’s extensive health sciences enterprise, which ranges from basic laboratory research to clinical, population and policy sciences, with an emphasis on translating science into public benefit. All four of UCSF’s graduate schools – dentistry, medicine, nursing and pharmacy – lead their fields in research funding from the National Institutes of Health, reflecting the caliber of their research. It also is aligned with the UC Global Food Initiative, which seeks to harness UC resources to address global food needs.

SugarScience is made possible by an independent grant from the Laura and John Arnold Foundation. It is supported by the Clinical and Translational Science Institute and the Philip R. Lee Institute for Health Policy Studies at UCSF.

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Laws protecting doctors vs. malpractice suits may not change how they practice


Study suggests that what has been called ‘defensive medicine,’ might just be medicine.

Changing laws to protect physicians from medical malpractice lawsuits may not yield cost savings through a reduction in “defensive medicine,” according to a new study by UCLA and RAND Corp.

Studying the behavior of emergency physicians in three states that raised the standard for malpractice in the emergency room to “gross negligence,” researchers found that strong new legal protections did not change the care that physicians ordered or reduce costs.

The results are published in the Oct. 16 edition of the New England Journal of Medicine.

“Our findings suggest that malpractice reform may have less effect on costs than people assume,” said Dr. Daniel Waxman, the study’s lead author and an emergency physician at the David Geffen School of Medicine at UCLA. “Physicians say they order unnecessary tests strictly out of fear of being sued, but our results suggest the story is more complicated.”

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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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