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Marks VA, Hsiang WR, Nie J, Demkowicz P, Umer W, Haleem A, Galal B, Pak I, Kim D, Salazar MC, Berger ER, Boffa DJ, Leapman MS. Acceptance of Simulated Adult Patients With Medicaid Insurance Seeking Care in a Cancer Hospital for a New Cancer Diagnosis. JAMA Netw Open 2022; 5:e2222214. [PMID: 35838668 PMCID: PMC9287756 DOI: 10.1001/jamanetworkopen.2022.22214] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
IMPORTANCE Although there have been significant increases in the number of US residents insured through Medicaid, the ability of patients with Medicaid to access cancer care services is less well known. OBJECTIVE To assess facility-level acceptance of Medicaid insurance among patients diagnosed with common cancers. DESIGN, SETTING, AND PARTICIPANTS This national cross-sectional secret shopper study was conducted in 2020 in a random sample of Commission on Cancer-accredited facilities in the United States using a simulated cohort of Medicaid-insured adult patients with colorectal, breast, kidney, and melanoma skin cancer. EXPOSURES Telephone call requesting an appointment for a patient with Medicaid with a new cancer diagnosis. MAIN OUTCOMES AND MEASURES Acceptance of Medicaid insurance for cancer care. Descriptive statistics, χ2 tests, and multivariable logistic regression models were used to examine factors associated with Medicaid acceptance for colorectal, breast, kidney, and skin cancer. High access hospitals were defined as those offering care across all 4 cancer types surveyed. Explanatory measures included facility-level factors from the 2016 American Hospital Association Annual Survey and Centers for Medicare & Medicaid Services General Information database. RESULTS A nationally representative sample of 334 facilities was created, of which 226 (67.7%) provided high access to patients with Medicaid seeking cancer care. Medicaid acceptance differed by cancer site, with 319 facilities (95.5%) accepting Medicaid insurance for breast cancer care; 302 (90.4%), colorectal; 290 (86.8%), kidney; and 266 (79.6%), skin. Comprehensive community cancer programs (OR, 0.4; 95% CI, 0.2-0.7; P = .007) were significantly less likely to provide high access to care for patients with Medicaid. Facilities with nongovernment, nonprofit (vs for-profit: OR, 3.5; 95% CI, 1.1-10.8; P = .03) and government (vs for-profit: OR, 6.6; 95% CI, 1.6-27.2; P = .01) ownership, integrated salary models (OR, 2.6; 95% CI, 1.5-4.5; P = .001), and average (vs above-average: OR, 6.4; 95% CI, 1.4-29.6; P = .02) or below-average (vs above-average: OR, 8.4; 95% CI, 1.5-47.5; P = .02) effectiveness of care were associated with high access to Medicaid. State Medicaid expansion status was not significantly associated with high access. CONCLUSIONS AND RELEVANCE This study identified access disparities for patients with Medicaid insurance at centers designated for high-quality care. These findings highlight gaps in cancer care for the expanding population of patients receiving Medicaid.
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Affiliation(s)
- Victoria A. Marks
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
| | - Walter R. Hsiang
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
- University of California San Francisco
| | - James Nie
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
| | - Patrick Demkowicz
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
| | | | | | | | - Irene Pak
- Yale University, New Haven, Connecticut
| | - Dana Kim
- Yale University, New Haven, Connecticut
| | | | | | - Daniel J. Boffa
- Department of Surgery, Yale School of Medicine, New Haven, Connecticut
| | - Michael S. Leapman
- Department of Urology, Yale School of Medicine, New Haven, Connecticut
- Yale Cancer Outcomes, Public Policy, and Effectiveness Research Center, New Haven, Connecticut
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Kim KM, White JS, Max W, Chapman SA, Muench U. Evaluation of Clinical and Economic Outcomes Following Implementation of a Medicare Pay-for-Performance Program for Surgical Procedures. JAMA Netw Open 2021; 4:e2121115. [PMID: 34406402 PMCID: PMC8374611 DOI: 10.1001/jamanetworkopen.2021.21115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Surgical complications increase hospital costs by approximately $20 000 per admission and extend hospital stays by 9.7 days. Improving surgical care quality and reducing costs is needed for patients undergoing surgery, health care professionals, hospitals, and payers. OBJECTIVE To evaluate the association of the Hospital-Acquired Conditions Present on Admission (HAC-POA) program, a mandated national pay-for-performance program by the Centers for Medicare & Medicaid Services, with surgical care quality and costs. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional study of Medicare inpatient surgical care stays from October 2004 through September 2017 in the US was conducted. The National Inpatient Sample and a propensity score-weighted difference-in-differences analysis of hospital stays with associated primary surgical procedures was used to compare changes in outcomes for the intervention and control procedures before and after HAC-POA program implementation. The sample consisted of 1 317 262 inpatient surgical episodes representing 1 198 665 stays for targeted procedures and 118 597 stays for nontargeted procedures. Analyses were performed between November 1, 2020, and May 7, 2021. EXPOSURES Implementation of the HAC-POA program for the intervention procedures included in this study (fiscal year 2009). MAIN OUTCOMES AND MEASURES Incidence of surgical site infections and deep vein thrombosis, length of stay, in-hospital mortality, and hospital costs. Analyses were adjusted for patient and hospital characteristics and indicators for procedure type, hospital, and year. RESULTS In our propensity score-weighted sample, the intervention procedures group comprised 1 047 351 (88.5%) individuals who were White and 742 734 (60.6%) women; mean (SD) age was 75 (6.9) years. The control procedures group included 94 715 (88.0%) individuals who were White, and 65 436 (60.6%) women; mean (SD) age was 75 (7.1) years. After HAC-POA implementation, the incidence of surgical site infections in targeted procedures decreased by 0.3 percentage points (95% CI, -0.5 to -0.1 percentage points; P = .02) compared with nontargeted procedures. The program was associated with a reduction in length of stay by 0.5 days (95% CI, -0.6 to -0.4 days; P < .001) and hospital costs by 8.1% (95% CI, -10.2% to -6.1%; P < .001). No significant changes in deep vein thrombosis incidence and mortality were noted. CONCLUSIONS AND RELEVANCE The findings of this study suggest that the HAC-POA program is associated with small decreases in surgical site infection and length of stay and moderate decreases in hospital costs for patients enrolled in Medicare. Policy makers may consider these findings when evaluating the continuation and expansion of this program for other surgical procedures, and payers may want to consider adopting a similar policy.
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Affiliation(s)
- Kyung Mi Kim
- Clinical Excellence Research Center, Stanford University School of Medicine, Palo Alto, California
- Department of Social and Behavioral Sciences, University of California School of Nursing, San Francisco
| | - Justin S. White
- Philip R. Lee Institute for Health Policy Studies, University of California School of Medicine, San Francisco
- Department of Epidemiology & Biostatistics, University of California School of Medicine, San Francisco
| | - Wendy Max
- Department of Social and Behavioral Sciences, University of California School of Nursing, San Francisco
- Institute for Health & Aging, University of California, San Francisco
| | - Susan A. Chapman
- Department of Social and Behavioral Sciences, University of California School of Nursing, San Francisco
| | - Ulrike Muench
- Department of Social and Behavioral Sciences, University of California School of Nursing, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California School of Medicine, San Francisco
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Roots Community Birth Center: A culturally-centered care model for improving value and equity in childbirth. Healthcare (Basel) 2020; 8:100367. [DOI: 10.1016/j.hjdsi.2019.100367] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 07/22/2019] [Accepted: 07/23/2019] [Indexed: 11/21/2022] Open
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Culhane-Pera KA, Ortega LM, Thao MS, Pergament SL, Pattock AM, Ogawa LS, Scandrett M, Satin DJ. Primary care clinicians' perspectives about quality measurements in safety-net clinics and non-safety-net clinics. Int J Equity Health 2018; 17:161. [PMID: 30404635 PMCID: PMC6222992 DOI: 10.1186/s12939-018-0872-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/10/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Quality metrics, pay for performance (P4P), and value-based payments are prominent aspects of the current and future American healthcare system. However, linking clinic payment to clinic quality measures may financially disadvantage safety-net clinics and their patient population because safety-net clinics often have worse quality metric scores than non-safety net clinics. The Minnesota Safety Net Coalition's Quality Measurement Enhancement Project sought to collect data from primary care providers' (PCPs) experiences, which could assist Minnesota policymakers and state agencies as they create a new P4P system. Our research study aims are to identify PCPs' perspectives about 1) quality metrics at safety net clinics and non-safety net clinics, 2) how clinic quality measures affect patients and patient care, and 3) how payment for quality measures may influence healthcare. METHODS Qualitative interviews with 14 PCPs (4 individual interviews and 3 focus groups) who had worked at both safety net and non-safety net primary care clinics in Minneapolis-St Paul Minnesota USA metropolitan area. Qualitative analyses identified major themes. RESULTS Three themes with sub-themes emerged. Theme #1: Minnesota's current clinic quality scores are influenced more by patients and clinic systems than by clinicians. Theme #2: Collecting data for a set of specific quality measures is not the same as measuring quality healthcare. Subtheme #2.1: Current quality measures are not aligned with how patients and clinicians define quality healthcare. Theme #3: Current quality measures are a product of and embedded in social and structural inequities in the American health care system. Subtheme #3.1: The current inequitable healthcare system should not be reinforced with financial payments. Subtheme #3.2: Health equity requires new metrics and a new healthcare system. Overall, PCPs felt that the current inequitable quality metrics should be replaced by different metrics along with major changes to the healthcare system that could produce greater health equity. CONCLUSION Aligning payment with the current quality metrics could perpetuate and exacerbate social inequities and health disparities. Policymakers should consider PCPs' perspectives and create a quality-payment framework that does not disadvantage patients who are affected by social and structural inequities as well as the clinics and providers who serve them.
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Affiliation(s)
| | - Luis Martin Ortega
- West Side Community Health Services, Inc., 895 E 7th St., Saint Paul, MN 55106 USA
| | - Mai See Thao
- Family and Community Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, PO Box 26509, Milwaukee, WI 53226 USA
| | - Shannon L. Pergament
- West Side Community Health Services, Inc., 895 E 7th St., Saint Paul, MN 55106 USA
| | - Andrew M. Pattock
- Department of Family and Community Medicine, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455 USA
| | - Lynne S. Ogawa
- West Side Community Health Services, Inc., 895 E 7th St., Saint Paul, MN 55106 USA
| | - Michael Scandrett
- Minnesota Health Care Safety Net Coalition, 1113 East Franklin Ave #202B, Minneapolis, MN 55404 USA
| | - David J. Satin
- Department of Family and Community Medicine, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455 USA
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Abstract
Research on the effects of pay-for-performance (P4P) in health care indicates largely disappointing results. This central finding, however, may mask important heterogeneity in the effects of P4P. We conducted a literature review to assess whether hospital and physician performance in P4P vary by patient and catchment area factors, organizational and structural capabilities, and P4P program characteristics. Several findings emerged: organizational size, practice type, teaching status, and physician age and gender modify performance in P4P. For physician practices and hospitals, a higher proportion of poor and minority patients is consistently associated with worse performance. Other theoretically influential characteristics-including information technology and staffing levels-yield mixed results. Inconsistent and contradictory effects of bonus likelihood, bonus size, and marginal costs on performance in P4P suggest organizations have not responded strategically to financial incentives. We conclude that extant heterogeneity in the effects of P4P does not fundamentally alter current assessments about its effectiveness.
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Medicaid beneficiaries undergoing complex surgery at quality care centers: insights into the Affordable Care Act. Am J Surg 2016; 211:750-4. [PMID: 26874897 DOI: 10.1016/j.amjsurg.2015.11.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 10/07/2015] [Accepted: 11/06/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Medicaid beneficiaries do not have equal access to high-volume centers for complex surgical procedures. We hypothesize there is a large Medicaid Gap between those receiving emergency general vs complex surgery at the same hospital. METHODS Using the Nationwide Inpatient Sample, 1998 to 2010, we identified high-volume pancreatectomy hospitals. We then compared the percentage of Medicaid patients receiving appendectomies vs pancreatectomies at these hospitals. Hospital characteristics associated with increased Medicaid Gap were evaluated using generalized estimating equation models. RESULTS A total of 602 hospital-years of data from 289 high-volume pancreatectomy hospitals were included. Median percentages of Medicaid appendectomies and pancreatectomies were 12.1% (interquartile range: 5.8% to 19.8%) and 6.7% (interquartile range: 0% to 15.4%), respectively. Hospitals that performed greater than or equal to 40 pancreatic resections per year had higher odds of having significant Medicaid Gap (odds ratio 2.3, 95% confidence interval 1.1 to 5.0). CONCLUSIONS Gaps exist between the percentages of Medicaid patients receiving emergency general surgery vs more complex surgical care at the same hospital and may be exaggerated in hospitals with very high volume of complex elective surgeries.
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Sealy-Jefferson S, Vickers J, Elam A, Wilson MR. Racial and Ethnic Health Disparities and the Affordable Care Act: a Status Update. J Racial Ethn Health Disparities 2015; 2:583-8. [PMID: 26668787 PMCID: PMC4676760 DOI: 10.1007/s40615-015-0113-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Persistent racial and ethnic health disparities exist in the USA, despite decades of research and public health initiatives. Several factors contribute to health disparities, including (but not limited to) implicit provider bias, access to health care, social determinants, and biological factors. Disparities in health by race/ethnicity are unacceptable and correctable. The Patient Protection and Affordable Care Act is a comprehensive legislation that is focused on improving health care access, quality, and cost control. This health care reform includes specific provisions which focus on preventive care, the standardized collection of data on race, ethnicity, primary language and disability status, and health information technology. Although some provisions of the Patient Protection and Affordable Care Act have not been implemented, such as funding for the U.S. Public Health Sciences track, which would have addressed the shortage of medical professionals in the USA who are trained to use patient-centered, interdisciplinary, and care coordination approaches, this legislation is still poised to make great strides toward eliminating health disparities. The purpose of this manuscript is to highlight the unprecedented opportunities that exist for the Patient Protection and Affordable Care Act to reduce racial and ethnic disparities in health in the USA.
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Affiliation(s)
- Shawnita Sealy-Jefferson
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, 3939 Woodward Avenue, Detroit, MI 48201, USA
| | - Jasmine Vickers
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, 3939 Woodward Avenue, Detroit, MI 48201, USA
| | - Angela Elam
- Department of Ophthalmology and Visual Sciences, W. K. Kellogg Eye Center, University of Michigan, 1000 Wall Street, Ann Arbor, MI 48105, USA
| | - M. Roy Wilson
- Office of the President, Wayne State University, 656 W. Kirby, 4200 Faculty/Administration Building, Detroit, MI 48202, USA
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Leaders’ experiences and perceptions implementing activity-based funding and pay-for-performance hospital funding models: A systematic review. Health Policy 2015; 119:1096-110. [DOI: 10.1016/j.healthpol.2015.05.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/10/2015] [Accepted: 05/04/2015] [Indexed: 12/19/2022]
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Alberti PM, Bonham AC, Kirch DG. Making equity a value in value-based health care. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2013; 88:1619-1623. [PMID: 24072123 DOI: 10.1097/acm.0b013e3182a7f76f] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Equity in health and health care in America continues to be a goal unmet. Certain demographic groups in the United States-including racial and ethnic minorities and individuals with lower socioeconomic status-have poorer health outcomes across a wide array of diseases, and have higher all-cause mortality. Yet despite growing understanding of how social-, structural-, and individual-level factors maintain and create inequities, solutions to reduce or eliminate them have been elusive. In this article, the authors envision how disparities-related provisions in the Affordable Care Act and other recent legislation could be linked with new value-based health care requirements and payment models to create incentives for narrowing health care disparities and move the nation toward equity.Specifically, the authors explore how recent legislative actions regarding payment reform, health information technology, community health needs assessments, and expanding health equity research could be woven together to build an evidence base for solutions to health care inequities. Although policy interventions at the clinical and payer levels alone will not eliminate disparities, given the significant role the social determinants of health play in the etiology and maintenance of inequity, such policies can allow the health care system to better identify and leverage community assets; provide high-quality, more equitable care; and demonstrate that equity is a value in health.
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Affiliation(s)
- Philip M Alberti
- Dr. Alberti is senior director, Health Equity Research and Policy, Association of American Medical Colleges, Washington, DC. Dr. Bonham is chief scientific officer, Association of American Medical Colleges, Washington, DC. Dr. Kirch is president and CEO, Association of American Medical Colleges, Washington, DC
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Impact of a pay for performance program to improve diabetes care in the safety net. Prev Med 2012; 55 Suppl:S80-5. [PMID: 23046985 DOI: 10.1016/j.ypmed.2012.05.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 03/06/2012] [Accepted: 05/03/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the impact of a "piece-rate" pay for performance (P4P) program aimed at improving diabetes care processes, outcomes and related healthcare utilization for patients enrolled in a not-for-profit Medicaid-focused managed care plan. METHODS To evaluate Hudson Health Plan's P4P program in New York (2003-2007), we conducted: (1) a case-comparison difference-in-difference study using plan-level administrative data; (2) a patient-level claims data analysis; and (3) a cross-sectional survey. RESULTS The case-comparison study found that diabetes care processes (e.g., HbA1c, lipid, and dilated eye exam rates) and outcomes (e.g., LDL-C<100mg/dL) did not improve significantly over the study period. Claims analysis showed that younger adults had significantly increased odds (OR 3.50-3.56, p<0.001) of using emergency and hospital-based services and similarly decreased odds of receiving recommended care process (OR 0.22-0.36, p<0.01-0.001). Survey study indicated that practices lack fundamental quality improvement infrastructures and training. CONCLUSIONS Recent health legislation mandates the use of P4P incentives in government programs that disproportionately care for patients with lower socioeconomic or minority backgrounds (e.g., Medicaid, Veterans Health Administration, and Tricare). More research is needed in order to understand how to tailor P4P programs for vulnerable care settings.
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Bradley CJ, Dahman B, Shickle LM, Lee W. Surgery wait times and specialty services for insured and uninsured breast cancer patients: does hospital safety net status matter? Health Serv Res 2012; 47:677-97. [PMID: 22092155 PMCID: PMC3419883 DOI: 10.1111/j.1475-6773.2011.01328.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE To determine whether safety net and non-safety net hospitals influence inpatient breast cancer care in insured and uninsured women and in white and African American women. DATA SOURCES Six years of Virginia Cancer Registry and Virginia Health Information discharge data were linked and supplemented with American Hospital Association data. STUDY DESIGN Hierarchical generalized linear models and linear probability regression models were used to estimate the relationship between hospital safety net status, the explanatory variables, and the days from diagnosis to mastectomy and the likelihood of breast reconstruction. PRINCIPAL FINDINGS The time between diagnosis and surgery was longer in safety net hospitals for all patients, regardless of insurance source. Medicaid insured and uninsured women were approximately 20 percent less likely to receive reconstruction than privately insured women. African American women were less likely to receive reconstruction than white women. CONCLUSIONS Following the implementation of health reform, disparities may potentially worsen if safety net hospitals' burden of care increases without commensurate increases in reimbursement and staffing levels. This study also suggests that Medicaid expansions may not improve outcomes in inpatient breast cancer care within the safety net system.
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Affiliation(s)
- Cathy J Bradley
- Department of Healthcare Policy and Research, Massey Cancer Center, Virginia Commonwealth University, PO Box 980430, Richmond, VA 23298-0430, USA.
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Weinick RM, Hasnain-Wynia R. Quality Improvement Efforts Under Health Reform: How To Ensure That They Help Reduce Disparities—Not Increase Them. Health Aff (Millwood) 2011; 30:1837-43. [DOI: 10.1377/hlthaff.2011.0617] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Robin M. Weinick
- Robin M. Weinick ( ) is an associate director of RAND Health in Washington, D.C
| | - Romana Hasnain-Wynia
- Romana Hasnain-Wynia is director of the Center for Healthcare Equity in the Institute for Healthcare Studies at the Feinberg School of Medicine, Northwestern University, in Chicago, Illinois
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