Tuesday, August 26, 2014

Safety Net Hospitals and EHR Adoption

A new study published in Health Affairs details EHR adoption rates and meaningful use attestation in hospitals across the United States.  While adoption has increased steadily over the years, safety net hospitals continue to lag behind other hospitals in the types of EHR system implemented.


  • In 2013, Critical Access Hospitals had similar rates of basic EHR systems as other hospitals, but were much less likely to have comprehensive systems
  • A similar trend is seen among rural hospitals in general, as well as those with high DSH payments.
  • Rural, Critical Access, and high DSH payment hospitals were all more likely to not have adopted any EHR system
  • Very few hospitals met all 15 criteria for Meaningful Use Stage 2 attestation, but this was not presented by hospital type.
It is interesting, that despite the findings above, that the authors conclude:
Despite early concerns about a digital divide15 in which hospitals serving poor patients would struggle to adopt EHRs to a greater extent than better resourced hospitals, we found no evidence of such a gap. The lack of a digital divide between safety-net institutions and other hospitals is remarkable, given that safety-net hospitals usually struggle with expensive and complex changes. Policy makers were concerned about this early on and created a separate incentive structure for these institutions.
While the data demonstrate similar rates of basic EHR adoption, they clearly show higher rates of no adoption and lower rates of comprehensive adoption among rural safety net providers.  These data suggest a digital divide does indeed exist-- one of functionality that would lead to a lower rates of Meaningful Use attestation among these rural providers, not to mention the non-adopters without any EHR system at all.  The factors associated with some of the safety net hospitals--teaching status and urban location--are simply not available in these rural areas.

Thursday, August 21, 2014

Racial differences in life expectancy, rural edition

A new article in Health Affairs examines the life expectancy gap between whites and blacks in the US, over a 20 year time period.  They found positive results, namely:

Nationally, the black-white difference in life expectancy at birth shrank during the period by 2.7 years for males (from 8.1 to 5.4 years) and by 1.7 years for females (from 5.5 to 3.8 years). 

 However, they also found considerable variations by census region and state, with some areas experiencing a much smaller decrease in life expectancy gap.  The good news is that virtually all areas saw a decrease in the gap, driven by an increase in life expectancy within black populations.

These data do not tell the full story, however.  Dr. Probst published a study in Health Affairs describing mortality differences among rural populations:
In an analysis controlling only for sex and age at interview, we found that rural whites and both rural and urban blacks were at greater risk of death by 2006 than were similar urban whites. 
And further:
When personal characteristics and circumstances were held statistically equal, only urban blacks had a higher risk of death than urban whites, while urban Hispanics were at a reduced risk of death (Exhibit 2). This suggests that much of the increased risk of death among rural whites and blacks is associated with personal characteristics more prevalent in the rural population, such as low education, poorer health, and lack of private insurance. 
These results show how important it is to not lose sight of individual characteristics in regards to studies in disparities.  While Harper et al found important and good news regarding life expectancy, small populations (e.g. rural minorities) may not experience such an improvement.  State-based studies are not discrete enough to measure the experiences of these subgroups, and should not be taken as positive results for all.

Monday, August 11, 2014

Rural ACA Marketplaces

The Robert Wood Johnson Foundation recently released a report detailing the insurance plan choices and premiums available to rural residents.  Many rural advocates have feared that rural residents will face higher premiums or fewer choices in these marketplaces, and appears that these fears are valid, at least to a degree.

Some key takeaways from the report include:

  • Rural residents have, on average, 1.2 fewer providers, 2.8 fewer plan choices, and 0.4 fewer plan types than urban residents
  • Premiums were, on average, $18 more expensive (for the second most expensive silver plan) for rural residents
  • HMOs and EPOs were less available, and POS more available, to rural residents
  • States with a higher proportion of marketplace eligible residents living in rural counties were more likely to have higher premiums and fewer insurers, choices, and plan types than more urban states.
There was considerable state by state variation in premiums, with the range being $201 higher in Nevada to $72 cheaper in Mississippi.  

These results highlight the need to continue to monitor rural resident's enrollment options, and its relationship to actual enrollment proportions.  Higher premiums, particularly in more rural states, could potentially lead to a lower uptake in coverage, furthering an already existing gap in rural healthcare delivery.