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Learning from Pandemic Responses Across Indian Country

In Focus: Learning from Pandemic Responses Across Indian Country

We look at what’s worked to slow the spread of the coronavirus and mitigate its impacts in the  Navajo Nation and other American Indian communities — from communitywide testing “blitzes” and mobile health services to improvised shelters for quarantining and outreach to meet people’s basic needs. These examples offer lessons for the rest of the country as we respond to the health and social shocks of COVID-19 and point to policies that could strengthen American Indian and Alaska Native communities for the long run.  

 

Earlier this year, mainstream media chronicled the alarming progression of the coronavirus pandemic in the Navajo Nation, an American Indian territory with 173,000 tribal members that in May had one of the highest rates of infection in the country. Less noticed was the outbreak among the smaller Mississippi Band of Choctaw Indians (MBCI), a tribe of some 11,000 whose members from mid-May to mid-June had a coronavirus positivity rate approaching 40 percent. “That’s worse than what we saw in New York City or elsewhere in the U.S.,” says the MBCI Tribal Chief Cyrus Ben, who battled the virus himself.

The rapid spread of the coronavirus among the Navajos, Mississippi Choctaw, and some other American Indian communities can be attributed to a variety of factors, not the least of which is the federal government’s centuries-long failure to honor treaty agreements with American Indian and Alaska Native tribes, which has led to underfunding of medical services on reservations and an underinvestment in basic utilities, such as water and electricity, as well as in housing, telecommunications, and roadways. In addition, many Navajo and Mississippi Choctaw families live in multigenerational homes, making it easy for infection to spread among young and old. And in the Navajo Nation, one-third of households lack running water, and tribal members often rely on one another for transportation, increasing the challenges surrounding social distancing. American Indians and Alaska Natives also have higher rates of diabetes and obesity than other groups, which may place them at greater risk of becoming seriously ill from COVID-19.

In recent months, the Navajos, Mississippi Choctaw, and other American Indian communities have managed to slow the spread of the coronavirus while meeting the medical and social needs of community members. In this issue of Transforming Care, we look at what’s worked to contain the virus and mitigate its impacts, focusing on the efforts of providers in Indian Health Service (IHS) medical facilities, facilities run by tribes, and in Urban Indian Health Programs. The solutions range from communitywide testing “blitzes” and mobile health services to improvised shelters for quarantining and outreach to meet people’s basic needs. These examples offer lessons for the rest of the country as we respond to the health and social shocks of COVID-19 and point to policies that could strengthen American Indian communities for the long run.

A Long History of Pandemics

COVID-19 is only the latest in a string of deadly infectious diseases, including tuberculosis and the Spanish flu of 1918, that have disproportionately killed and sickened American Indians and Alaska Natives. During the 1918 flu pandemic, more than 80 percent of deaths in Alaska were among Native people; American Indians died at four to five times the rate of other Americans during the H1N1 flu epidemic of 2009.

Spero Manson

These pandemics caused massive social and cultural upheaval. “Entire families, even tribal communities were decimated and many survivors experienced major, lasting disruptions,” says Spero Manson, Ph.D., director of the Center for American Indian and Alaska Native Health at the Colorado School of Public Health and professor of public health and psychiatry at the University of Colorado’s medical school.

A Range of Funding Streams Attempt to Fill Service Gaps

In 1975, after decades of effort by the federal government to force the assimilation of American Indian and Alaska Native tribes and withdraw from treaty agreements, Congress passed the Indian Self-Determination and Education Assistance Act. The law formalized the right of tribes to assume responsibility for managing medical care on reservations, either on their own or in partnership with the IHS.

By the time the law was passed, the migration of American Indians and Alaska Natives to cities like Seattle, Minneapolis, and Phoenix was well underway — driven by the forced relocations of children to “assimilation” boarding schools from the mid-19th century well into the 20th and the federal government’s Indian termination policy of the 1950s and early 1960s, which shut down health care and other services on some reservations.

By 2017, 60 percent of the IHS budget had been routed to tribes that had chosen to assume control over most or all health care services, including management of many of the hospitals and clinics on reservations along the East and West coasts. Some, like the Southcentral Foundation in Alaska, have used this flexibility to offer a wider array of services than many IHS-run facilities, which tend to concentrate on primary and emergency care and refer patients to specialists only when their budgets permit. In some instances, they do so only when life and limb are threatened, says W. Craig Vanderwagen, M.D., who spent 25 years working for the IHS.

 

On some reservations, tribes have supplemented federal dollars and expanded health services by leveraging tourism and gaming revenue and by billing Medicaid and other third-party payers directly (some American Indians and Alaska Natives have gained health coverage through their employers or through Medicare, Medicaid, or the military). The 41 Urban Indian Health Programs, which were created in the 1970s to serve American Indians and Alaska Natives who lacked access to health care in cities, also receive funding from the IHS but can become federally qualified health centers and tap into grants from federal and state agencies to offer a broad range of health care services and social supports. Today, most (78%) of American Indians and Alaska Natives do not live on reservations.

 

Tribal Public Health: Wabanaki Public Health Department

In Maine, the Wabanaki Public Health Department offers an example of how tribes have leveraged new funding streams to improve tribal members’ health. As a consortium of five tribal nations from across the state, it is the only public health entity in Maine to take responsibility for a population rather than a region. It has won federal contracts to oversee physical activity, nutrition, and tobacco and substance abuse prevention programs, enabling it to expand its staff from three in 2011 to 45 this year. It plans to open a substance use disorder treatment and recovery center where Indigenous people can receive services and reconnect to their culture. 

Since the pandemic began and some reservations were closed to outsiders, the health department has been spearheading efforts to help tribal members secure food. Leaders directed funds to purchase freezers so food pantries could stock up, partnered with farmers who typically supplied schools to deliver unused produce to tribes, and enlisted partners such as Walmart in delivering water to reservations, two of which don’t have reliable sources for clean drinking water.

The public health department also launched what leaders dubbed the colored paper project to monitor the needs of isolated elders. Adapting a model used by First Nations tribes in Canada, they asked elders to place paper in their windows to indicate if they needed medical help (red), supplies like toilet paper or soap (yellow), or a friendly ear (blue). Staff drove by the houses twice a day and responded to immediate needs. Green paper was used to signal everything was fine and has been most frequently displayed, says Lisa Sockabasin, Wabanaki’s director of programs and external affairs.

In Maine, the Wabanaki Public Health Department has asked isolated elders to place colored paper in their windows to indicate how they’re faring and signal the need for supplies.

In Maine, the Wabanaki Public Health Department has asked isolated elders to place colored paper in their windows to indicate how they’re faring and signal the need for supplies.

The health department has also sponsored virtual events — from Indigenous language classes to smudging ceremonies — to help those who feel isolated. The department has been gratified by the number of philanthropies that have reached out to ask how they can help. “There seems to be more of an appreciation of what public health is and concern about the disparate impact of COVID-19 in our communities,” says Sockabasin. “People are asking, ‘How do we help?’”

 

Urban Indian Health Programs: Seattle Indian Health Board

The Seattle Indian Health Board has been able to sustain operations during the pandemic by leveraging different funding streams. It is both a federally qualified health center and an Urban Indian Health Program and has secured CARES Act funding that has helped make up for drops in service volume in the early days of the pandemic. The clinic typically serves 6,000 patients a year, two-thirds of whom are American Indians or Alaska Natives from some 250 different tribes, offering a robust set of primary care services including traditional healing consultations and drum circles as well as case management and social supports for people experiencing homelessness or gender-based violence.

When Seattle emerged as one of the early coronavirus hotspots, the health center’s leaders moved quickly to protect patients, shifting 80 percent of services to virtual visits and assigning dental staff, who at the time were only performing urgent care, to act as scribes during in-person visits. Because many clinic patients don’t own smartphones or computers, a telemedicine kiosk (sanitized between visits) was placed outside the clinic to support virtual visits. The health center also shifted pediatric visits to Saturdays to enable a deep cleaning of offices beforehand, a move that clinic leaders hoped would encourage families to come in for vaccinations and other services that could not be done online. 

 

Tribally Run Facilities: Tuba City Regional Health Care

Tuba City Regional Health Care is a tribally run facility in northern Arizona that offers primary, specialty, and acute care in a 73-bed hospital, three satellite clinics, and a mobile services van that brings preventive and dental services to people in schools, chapter houses, and senior centers. Most patients and its governing board are members of the Navajo or Hopi tribes. Just 30 percent of its funding comes from the I.H.S; the rest comes from third-party payers and grants.

As the pandemic began, leaders moved quickly to reassign staff, establishing a nurse hotline that patients with mild COVID-19 symptoms could call for advice. Primary care physicians reached out to high-risk patients to set up virtual visits and offered a drive-through clinic for pediatric vaccinations. Leaders also held Facebook Live events to offer information about the coronavirus and answer questions.

Tuba City Regional Health Care has tailored its public health messages to show how to safely hold ceremonies, take part in sweat lodges, and access mental health services during the pandemic.

Tuba City Regional Health Care has tailored its public health messages to show how to safely hold ceremonies, take part in sweat lodges, and access mental health services during the pandemic. Source: Tuba City Regional Health Care.

Public health nurses and others from Tuba City’s Division of Community Health, who typically offer disease education and supports to elders, new mothers, and those with chronic conditions, have been working with physicians from Tuba City and elsewhere to begin contact tracing within 24 hours of receiving a positive test result. They’ve also delivered food, masks, and other supplies to people’s homes. “We feel that’s been part our success in getting our numbers down in our service area,” says Lynette Bonar, CEO of Tuba City. “We’re not calling to make people do things they don’t want to do. We’re trying to be helpful and keep their family safe.” They’ve seen the positivity rate fall from 40 percent in late spring to just 4 percent in late September.

When the Federal Emergency Management Agency (FEMA), the Veterans Health Administration, Arizona Department of Health, and the University of California, San Francisco (UCSF) sent volunteer clinicians to Tuba City late this spring, the hospital was able to quickly integrate the new staff and execute other changes, says Bonar: “As an independent facility, we didn’t have to go through bureaucracy. We got our onboarding program down to two days rather having people sit in orientation for a week.”

 

Widespread Testing, Contact Tracing, and Quarantines

Relative to cities and states in the U.S., some tribal communities have been much more aggressive in coronavirus testing, contact tracing, and enforcing quarantines — leveraging a strong collective spirit and past experiences with infectious disease outbreaks to encourage participation.

The Navajo Nation has conducted nearly 96,000 tests as of mid-September, reaching more than half of the population. This puts the Navajo Nation near the top of U.S. states on the basis of per capita testing. The reservation continues to have evening and weekend curfews and the number of new cases has been declining since early June.

As of July, half of the members of the Northern Cheyenne tribe in Montana had been tested (2,000 of 4,000 people) through two large events; the tribe quickly quarantined the handful who tested positive, creating shelters for those who couldn’t do so in their homes. “We’re a very tight-knit community,” says Desi Rodriguez-Lonebear, Ph.D., professor of sociology at the University of California Los Angeles and a member of the Northern Cheyenne Tribe. “We’re used to relying on each other for survival.” At one of the testing events, the tribes offered gift cards as incentives to participate.

When Seattle’s King County health department, which partnered with FEMA to oversee coronavirus testing, offered to give test kits to the Seattle Indian Health Board in March but insisted per FEMA's instructions that a national call center would be in charge of notifying patients of the results, health center leaders refused. “We said no. We have a responsibility to our patients to maintain continuity of care and to do contact tracing,” says Esther Lucero, M.P.P., Seattle Indian Health Board’s CEO. “And no one in the American Indian and Alaska Native population is going to take a call from the federal government.” Eventually, Lucero says FEMA and King County public health leaders relented. In addition to offering coronavirus tests in a tent outside its main facility, the health center is offering tests at a day center for people experiencing homelessness. Since March, they’ve performed some 1,000 tests.

Seattle Indian Health Board staff are providing coronavirus testing at the Chief Seattle Club, which also offers meals, housing assistance, a legal clinic, Native art job training, and other services to American Indians and Alaska Natives experiencing homelessness.

Seattle Indian Health Board staff are providing coronavirus testing at the Chief Seattle Club, which also offers meals, housing assistance, a legal clinic, Native art job training, and other services to American Indians and Alaska Natives experiencing homelessness. Source: Seattle Indian Health Board

Over the first six months of the pandemic, the Mississippi Band of Choctaw has tested about 45 percent of the roughly 10,000 patients at the Choctaw Health Center, a tribally run facility.

One of 10 has tested positive. The tribe has also kept in place some social distancing policies; while the state’s casinos began to reopen in late May, the tribe kept its casinos closed, waiting until early August to begin a phased reopening. Relying on a past strategy used to battle tuberculosis outbreaks, Tribal Chief Ben issued a state of emergency and the Choctaw Tribal Council passed new laws for tribal citizens who had tested positive for COVID-19 or were awaiting test results to quarantine or risk a fine. Leaders used an anonymous tip line so people could report those who violate quarantine orders.

 

Filling Gaps Through Partnerships

In some places, the pandemic has deepened partnerships that predated the coronavirus. Beverly Cotton, D.N.P., director of the Nashville Area of the IHS, says the agency, in partnership with FEMA, the Centers for Disease Control and Prevention, and the Health and Human Services’ Assistant Secretary for Preparedness and Response, has helped tribes that manage their own health care secure personal protective equipment, procure test kits and supplies, and prepare response plans.

In June, Cotton accepted an invitation from the Mississippi Choctaw’s Tribal Chief Ben to send a critical care response team to the health center. Along with Cotton, the IHS team included nurses, a critical care physician, and a respiratory therapist with experience working in COVID-19 hot zones. In addition to providing direct care, team members worked with hospital leaders to revamp protocols on how to evaluate people with symptoms suggestive of COVID-19. The critical care response team stayed in Mississippi for 25 days.

In Gallup, N.M., which borders the Navajo Nation, health care providers at the Gallup Indian Medical Center, the largest hospital run by the IHS, partnered with another local hospital, Rehoboth McKinley Christian Health Services, and the state health department to convert four Gallup hotels into temporary “respiratory shelters.” In recent months, the shelters have been used to quarantine people who don’t have another place to safely shelter on their own, including those who were exposed to the coronavirus and awaiting test results and those recovering from COVID-19. Many of those in the shelters are homeless; the poverty rate in Gallup’s McKinley County is nearly 38 percent — three times higher than the national average — and several hundred people routinely sleep on the streets or in shelters.

Staff and volunteers from a local nonprofit, Community Outreach and Patient Empowerment, deliver meals, medications, and other supplies to the respiratory shelter residents while providing on-call support and translation services and coordinating with physicians at the hospitals. Physicians and nurses from UCSF’s medical school offer treatment to COVID-19 patients in the shelters. With the need decreasing, only one shelter remains open as of mid-September.

 

LESSONS

The pandemic has affected different American Indian communities in different parts of the country in different ways. And as in other parts of the nation and the world, initial successes have in some places given way to setbacks as the crisis wears on. For instance, despite the success of Montana’s Northern Cheyenne in testing half of the tribe, the virus is spreading there due to extensive household overcrowding and a growing sense of weariness, says Rodriguez-Lonebear: “We’ve lost nearly 20 tribal members, which is a lot for a small tribe because we are all related somehow and so each loss cuts deep.”

Lessons that are emerging from providers’ creative responses could be used to strengthen American Indian health care services for the long term. 

To have the most impact, federal, state, and tribal pandemic responses should be aligned.  While tribes operate as sovereign nations, and some are geographically isolated enough to seal their borders, they are of course affected by what happens in the communities around them. Public health policies that are not aligned across tribes and their home states can sow confusion and work at cross purposes. For example while North Dakota — which in early September had the nation’s highest rates of coronavirus infection — has no official masking policy, North Dakota’s Turtle Mountain Band of Chippewa has a masking mandate on its reservation. Many members of the tribe must travel to work or shop off the reservation.

Funding for the Indian Health Service should be enhanced to reflect actual needs. The IHS has received $2.4 billion in additional funds to support COVID-19 responses, including the deployment of critical care response teams, creation of alternate care sites, and transition to telehealth platforms. Moving forward, IHS funding should be increased to improve the health of a population that is disproportionately ill and vulnerable to infectious disease. “Funding levels for the IHS are not based on actuarial analysis but just on historical spending,” says Donald Warne, M.D., M.P.H., professor of family and community medicine at the University of North Dakota. “Medicare has cost reports from hospitals to assist in determining funding levels, for example. The IHS does not have an equivalent process.”

Given that many American Indians live in poverty, expanding Medicaid could make a substantial difference in expanding their access to care. While Americans Indians generally have access to primary care and preventive health care services at IHS facilities without any financial obligation, they cannot always access specialty care if they lack Medicaid coverage or other insurance due to the limitations of IHS budgets. Warne, a member of the Oglala Lakota tribe of Pine Ridge, South Dakota, says a natural experiment has been playing out in the Dakotas since North Dakota has expanded eligibility for its Medicaid program while South Dakota has not. This has meant that tribal members are able to use their Medicaid coverage to access a wide range of specialty services in North Dakota while in South Dakota, according to Warne, there are “still areas where the referral bills are not even getting paid because there's not enough money in that budget.”  

Filling workforce gaps among American Indian health care providers will require a multifaceted approach. Widespread vacancies in clinical and leadership positions impede efforts to ensure American Indians have access to high-quality care. And given evidence that patients may benefit from having clinicians who share their racial/ethnic background and/or are familiar with their culture and traditional healing practices, it will be important to fill positions with Indigenous clinicians. In an effort to train more American Indian physicians, the Oklahoma State University Center for Health Sciences partnered with the Cherokee Nation this year to open the nation’s first medical school on tribal land. UCSF’s HEAL Initiative sends physicians and nurses from the U.S. and low- and middle-income countries for fellowships in the Navajo Nation to encourage more people to work there; a third of fellows who’ve come from elsewhere have decided to stay. The initiative also offers fellowships for Navajo physicians and other health care professionals in an effort to build the local workforce. Ultimately, the goal is to overcome the need to import talent, says Sriram Shamasunder, M.D., one of the initiative’s founders.


 

Q&A: Toward Indigenous Data Sovereignty

Desi Rodriguez-Lonebear, Ph.D.

Desi Rodriguez-Lonebear, Ph.D., a citizen of the Northern Cheyenne Tribe, is a sociology professor at the University of California Los Angeles and cofounder of the U.S. Indigenous Data Sovereignty Network, a group of researchers, policymakers, and tribal leaders who are working to safeguard the rights of Indigenous peoples to govern the collection, ownership, and use of their data according to the laws of their sovereign nations. Transforming Care spoke to Rodriguez-Lonebear about her research and the Data Sovereignty Network’s mission.  

 

Transforming Care: You’ve spoken about the difficulty of assessing the impact of the coronavirus pandemic on American Indian and Alaska Native communities because of the way data are collected and shared — and not. What are some of the biggest challenges?

Rodriguez-Lonebear: American Indians and Alaska Natives are among the most surveilled populations in this country, but more often than not, the data collected are linked to provision of federal services and remain in the control of federal and state governments and not tribes. This can make tribes dependent on external sources whose methods are inconsistent, inaccurate, or irrelevant to tribal goals. As an example, we may be able to identify American Indians and Alaska Natives in many of these administrative datasets, but we often can’t identify which tribes they are from because tribal identifiers are not being collected. We’re also a very mobile population, with people moving back and forth from reservations to urban communities and between households. We’ve seen this especially during the COVID-19 pandemic as people relocate to help care for loved ones or support their communities. It’s common for American Indians and Alaska Natives to receive services on and off reservations — from the Indian Health Service and from private hospitals and clinics via Medicare, Medicaid, or commercial insurance. So there are many opportunities for miscounting and misclassifying. Ultimately, we need to ensure that data are being collected and shared in such a way that tribes can accurately track their citizens wherever they are.

Transforming Care: Are there other ways that data collection fails to capture nuances of American Indians and Alaska Natives’ lives that have a direct bearing on health?

Rodriguez-Lonebear: Homelessness is a good example. It doesn’t look the same in Indigenous communities because there’s often someone willing to take you in. People are staying on someone’s couch or in someone’s shed or they’re sleeping somewhere. This also relates to household overcrowding. It’s more common than not to have multiple generations and multiple families living in one household. Sometimes this is by choice and sometimes it’s because they don’t have anywhere else to go, but I think few would self-identify as being homeless by a standard Western metric. One solution is to expand the definition of “homeless” so that it is more inclusive of diverse living arrangements perhaps with a question like, “Are you living with someone else because you cannot afford a place of your own?”

Transforming Care: You and your colleagues recently published a study that found the rate of COVID-19 cases was higher on reservations where indoor plumbing was lacking. Cases were also higher on reservations where more households speak languages other than English. Why is this important?

Rodriguez-Lonebear: Our findings are not novel, but by linking different data sources we were able to show the significance of basic public health risks for American Indians and Alaska Natives on reservations and COVID-19 prevalence. We know lack of household plumbing and sanitation results in poorer health outcomes, especially with contagious diseases.  We also know that not being able to have information communicated to you in a language you understand is going to result in poorer health outcomes. Tribes need critical public health infrastructure, which is a treaty right; policymakers want to see the data, which is why it is so important to have it. For the study, we linked American Community Survey data with the count of COVID-19 cases collected by Indian Country Today, a newspaper. Theirs is the only database currently collecting data on cases and deaths across Indian Country. They are doing Web searches and pooling publicly available data and cross checking it with tribes and communities, which shows you the challenges we have with tracking. 

Transforming Care: What do you hope to accomplish with the U.S. Indigenous Data Sovereignty Network?

Rodriguez-Lonebear: Dr. Stephanie Carroll, assistant professor of public health at the University of Arizona, and I started the U.S. Indigenous Data Sovereignty Network in 2015 after seeing what colleagues were doing in Aotearoa, the Maori name for New Zealand, to actively secure the data rights of other Indigenous populations. We wanted to form a network of people who were committed to ensuring that people and nations retain the rights to their data regardless of where their citizens live and can use it to govern as they see fit. There need to be stronger data-sharing agreements between tribal nations and county, state, and federal agents who are collecting data. 

Transforming Care: Where are the biggest blind spots in terms of our knowledge of American Indians’ health and health care? What would you really like to know? 
 
Rodriguez-Lonebear: There are many blind spots such that you can pick any aspect of American Indian health and health care and find the need for more research, more resources, and better policies. What I would really like to know and the question to which our future generations demand an answer: “Despite all the odds, why do Indigenous Peoples thrive?”

Transforming Care: Do you have concerns about the equitable distribution of eventual vaccines for COVID-19 given tribes’ past and present experiences with the federal government? How can we make sure American Indian and Alaska Native communities are included in research and have governance over vaccine distribution?

Rodriguez-Lonebear: I often say that Indigenous Peoples are born skeptics. It’s a survival mechanism. I absolutely do not trust that vaccine distribution will be equitable. To ensure it is, we should be more concerned with tribal sovereignty. Tribes must be directly involved in the governance of vaccine distribution on a nation-to-nation level with the federal government.


 

Publications of Note

ICU Beds Scarce to Non-Existent in Low-Income Communities

Researchers found nearly half of the lowest-income communities in the U.S. (49%) had no ICU beds in contrast to just 3 percent of the highest-income communities. They also found the disparities in the availability of ICU beds based on community incomes were more acute in rural areas than urban ones. The authors say policies that facilitate coordination among hospitals are needed to mitigate the effects of the COVID-19 pandemic on mortality rates in low-income communities. Genevieve P. Kanter, Andrea G. Segal, and Peter W. Groeneveld, “Income Disparities in Access to Critical Care Services,” Health Affairs 39, no. 8 (August 2020):1362–7.

 

Support from Clinical Pharmacists Improves Outcomes for Black Patients with Diabetes

A study of UCMYRx, a program that places clinical pharmacists into primary care practices to offer education and promote medication adherence among patients with chronic conditions, found that having at least one visit with the pharmacist was associated with a significant reduction in hemoglobin A1c (-0.4%) levels among Black patients with type 2 diabetes. The study, conducted at a large health care system, found no significant impact on systolic blood pressure among patients in this group. The pharmacists review patients’ lab test results and vital signs, perform medication reconciliation, use a standardized survey to assess barriers to medication adherence, and develop tailored interventions to encourage medication adherence. Kimberly Danae et al., “An Effectiveness Evaluation of a Primary Care-Embedded Clinical Pharmacist-Led Intervention Among Blacks with Diabetes,Journal of General Internal Medicine 35, no. 9 (Sept. 2020):2569–75.

 

Neighborhood Social Conditions Linked to Health Care Utilization and Costs

Researchers found after controlling for demographic, medical, and other patient characteristics, disadvantaged neighborhood conditions are associated with lower total annual Medicare costs but higher potentially preventable costs. Neighborhood social conditions were measured by the Area Deprivation Index at the census block group level. Patients in the most disadvantaged communities had similar total Medicare costs (-$22) but higher potentially preventable costs ($53) relative to patients living in communities with intermediate-level social conditions. In contrast, patients living in neighborhoods with the least disadvantaged social conditions had higher annual Medicare costs ($427) and similar potentially preventable costs (-$23) as compared with patients with intermediate-level social conditions. They conclude that socioeconomic barriers may limit access and use of primary care and disease management services, resulting in a higher proportion of health care costs going to potentially preventable care. Youngkang Zhang et al., “Association Between Residential Neighborhood Social Conditions and Health Care Utilization and Costs,” Medical Care 58, no. 7 (July 2020):586–93.

 

New Funding, Regulation, and Strategy Needed for Long-Term Care

The authors of this commentary in the New England Journal of Medicine recommend transforming the way we pay for and organize long-term care to ensure the nation’s aging population has safe, affordable options in a wide variety of settings. Among their recommendations: Medicaid programs should invest considerably more in long-term care and ensure home-based care providers are paid, whether they are family members or professionals; supporting the development of community-based alternatives to nursing homes (e.g., family-style homes with small numbers of residents); and more comprehensive funding of long-term care services through existing programs or the creation of universal, standalone long-term care insurance. Rachel M. Werner, Allison K. Hoffman, and Norma B. Coe, “Long-Term Care Policy After COVID-19 — Solving the Nursing Home Crisis,” New England Journal of Medicine 383, no. 10 (Sept. 3, 2020):903–5.

 

National Survey Finds Large Integrated Systems No More Invested in Quality and Payment Reforms Than Independent Hospitals and Practices

To determine whether the potential harms of hospital and physician practice consolidation are offset by improvements in quality, researchers analyzed survey responses from a nationally representative sample of hospitals, physician practices, and health systems with various ownership structures. They assessed the extent to which each adopted quality-focused care delivery and payment reforms and found while scores varied widely across hospitals and practices, little of the variation was explained by ownership status. They concluded financial integration was generally not associated with better quality. The survey included questions about the care of complex, high-need patients; participation in quality-focused payment programs; screening for clinical conditions and social needs; and use of registries and evidence-based guidelines. Elliott S. Fisher et al., “Financial Integration’s Impact on Care Delivery and Payment Reforms: A Survey of Hospitals and Physician Practices,” Health Affairs 39, no. 8 (August 2020):1302–11.

 

Addressing the Structural Drivers of Health

A commentary in the Journal of General Internal Medicine makes recommendations for shifting the U.S. health care system from a transactional system focused on paying and providing discrete services to one focused on measurably improving health. Recommendations include addressing patients’ social needs; investing more in primary care, mental health, and substance use disorder services; using the purchasing power and employment policies of health care institutions to increase the financial security of employees and surrounding communities; and encouraging trade groups such as the American Medical Association and American Hospital Association to use their lobbying clout to support public health. Alice Hm Chen and Marshall H. Chin, “What If the Role of Healthcare Was to Maximize Health,” Journal of General Internal Medicine 35, no. 6 (June 2020):1884–6.

 

New Quality Measurement Systems Needed for Pandemics and Beyond

The authors of a commentary in the Journal of the American Medical Association point to significant deficits in the nation’s approach to quality and safety measurement, including lags in data reporting, a lack of standardization across institutions, and an overreliance on abstraction and human intervention for assessment. To ensure the health care system can learn quickly what’s effective and not during crises and at other times, they make several recommendations. Among them: developing data capture systems that collect information without requiring extra effort on the part of hospitals and providers; focusing measures on information that can be generated by electronic health records rather than medical claims; and establishing national measurement committees or task forces to quickly define measures and make recommendations for changing medical record systems to accommodate new measures. J. Matthew Austin and Allen Kachalia, “The State of Health Care Quality Measurement in the Era of COVID-19: The Importance of Doing Better,” Journal of the American Medical Association 324, no. 4 (July 28, 2020):333–4.

 

Improving the Quality of U.S. Health Care

In a commentary in the New England Journal of Medicine, Elizabeth A. McGlynn, Ph.D., who found in 2003 that U.S. adults receive about 55 percent of recommended care for the leading causes of death and disease, says the U.S. health care professionals and policymakers must reconsider their approaches to measurement, financing, and organizational structures — and place more emphasis on addressing social needs — if they want to improve health care quality. “Measuring discrete events, as we have generally done, reinforces fragmentation and may not lead to overall quality improvement,” she says. Elizabeth A. McGlynn, “Improving the Quality of U.S. Health Care — What Will It Take?New England Journal of Medicine 383, no. 9 (Aug. 27, 2020):801–3.

 

Home-Based Care for Patients with Opioid Use Disorder

A commentary in the Journal of the American Medical Association describes the benefits and potential pitfalls of delivering opioid use disorder treatment to patients in their homes, a practice enabled by recent changes in regulation and payment for telehealth services. They say more research is needed to determine whether these services are comparable to in-person care on key metrics such as retention in treatment, effectiveness of long-term treatment, and cost effectiveness. In addition to identifying which patients are appropriate for these services, they say it will be important to assess the extent to which the innovation reaches underserved communities. Lori Uscher-Pines, Haiden A. Huskamp, and Ateev Mehrotra, “Treating Patients with Opioid Use Disorder in Their Homes: An Emerging Treatment Model,” Journal of the American Medical Association 324, no. 1 (July 7, 2020):39–40.

 

A Looming Crisis for State Medicaid Programs

With millions of Americans filing for unemployment, states are likely to see a surge of new enrollees in their Medicaid programs, putting states that have lost revenue in financial jeopardy. The authors of a commentary in the Journal of the American Medical Association suggest several ways the federal government can help, including increasing the Medicaid match rate and incentivizing Medicaid expansions in states that elected not to do so. Without support, “some states could make significant cuts in Medicaid to balance their budgets at a time when the program is most critical,” they say. Heidi L. Allen and Benjamin D. Sommers, “Medicaid and COVID-19: At the Center of Both Health and Economic Crises,” Journal of the American Medical Association 324, no. 2 (July 14, 2020):135–6.

 

Providing Outpatient Services in the Home During and After COVID-19

In April, the Centers for Medicare and Medicaid Services (CMS) issued waivers enabling hospitals to move some health care services to off-campus sites and into patients’ homes for the duration of the pandemic. The authors of a commentary in the Journal of the American Medical Association say that to encourage hospitals to make investments in equipment and personnel for home-based care, CMS should signal its willingness to extend the waivers a year beyond the end of the pandemic. They also recommend the agency provide technical assistance to accelerate implementation of outpatient care at home and create alignment between these waivers and its existing value-based payment model strategies. Finally, to protect Medicare beneficiaries from higher out-of-pocket spending, they suggest CMS harmonize benefits offered through Medicare Part D and Part B. “By promoting site of care innovation without financial downside, CMS is opening a historic opportunity for hospitals to test new care delivery models to provide safe and effective outpatient services at home to all Medicare beneficiaries,” they say. Justin E. Bekelman, Ezekiel J. Emanuel, and Amol S. Navathe, “Outpatient Treatment at Home for Medicare Beneficiaries During and After the COVID-19 Pandemic,” Journal of the American Medical Association 324, no. 1 (July 7, 2020):21–2.

 

Building a Structurally Competent Health Care System

The authors of a commentary in the Journal of the American Medical Association say clinicians and health systems must move further upstream to address the structural drivers that promote poverty and other aspects of social disadvantage, which contribute to disparities in COVID-19 outcomes. They recommend: the U.S. health care system form commissions to identify the policies that contributed to poor outcomes (from supply chain problems for personal protective equipment to lack of Medicaid expansion); build public–private partnerships and engage with communities to address social needs; improve communication with affected communities and leverage their firsthand experience to inform preparedness plans and health messaging strategies; and educate physicians about social inequality. Jonathan M. Metzl, Aletha Maybank, and Fernando De Maio, “Responding to the COVID-19 Pandemic: The Need for a Structurally Competent Health Care System,” Journal of the American Medical Association 324, no. 3 (July 21, 2020):231–2.


 

Editorial Advisory Board

Special thanks to Editorial Advisory Board member Laura Gottlieb for her help with this issue.

Jean Accius, Ph.D., senior vice president, AARP

Anne-Marie J. Audet, M.D., M.Sc., senior medical officer, The Quality Institute, United Hospital Fund

Eric Coleman, M.D., M.P.H., professor of medicine, University of Colorado

Marshall Chin, M.D., M.P.H., professor of healthcare ethics, University of Chicago

Timothy Ferris, M.D., M.P.H., CEO of Massachusetts General Physician Organization and professor of medicine at Harvard Medical School

Don Goldmann, M.D., chief medical and scientific officer, Institute for Healthcare Improvement

Laura Gottlieb, M.D., M.P.H., assistant professor of family and community medicine, University of California, San Francisco, School of Medicine

Carole Roan Gresenz, Ph.D., senior economist, RAND Corp.

Allison Hamblin, M.S.P.H., vice president for strategic planning, Center for Health Care Strategies

Thomas Hartman, vice president, IPRO

Clemens Hong, M.D., M.P.H., medical director of community health improvement, Los Angeles County Department of Health Services

Lauren Murray, director of consumer engagement and community outreach, National Partnership for Women & Families

Kathleen Nolan, M.P.H., regional vice president, Health Management Associates

J. Nwando Olayiwola, M.D., M.P.H., chair and professor, Department of Family and Community Medicine at The Ohio State University

Harold Pincus, M.D., professor of psychiatry, Columbia University

Chris Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality

Sara Rosenbaum, J.D., professor of health policy, George Washington University

Michael Rothman, Dr.P.H., executive director, Center for Care Innovations

Mark A. Zezza, Ph.D., director of policy and research, New York State Health Foundation

Publication Details

Publication Date: September 30, 2020

Experts

Martha Hostetter
Consulting Writer and Editor, Pear Tree Communications
Consulting Writer and Editor