Primary health care for people with an ID: an exploration of consultations, problems identified, and their management in Australia

Source: Primary health care for people with an intellectual disability: an exploration of consultations, problems identified, and their management in Australia

Abstract

Background

People with an intellectual disability (ID) have more complex and different patterns of health care needs than the general population. They experience a greater burden of multi-morbidity, high levels of undetected and unmanaged health issues, and premature mortality than the general population. Primary care has a key role in the health care of people with an ID. Currently, very little is known about the consultation type and length, problems managed, and how general practitioners (GPs) manage these problems for people with an ID compared with the general population. This information would provide valuable insights into how GPs are achieving the health guidelines and facilitating people with an ID to achieve the highest attainable standard of health.

Methods

A secondary analysis of data was collected from January 2003 to December 2012 from the Bettering the Evaluation and Care of Health (BEACH) programme. Consultation type, consultation length in minutes, problem(s) managed during the consultation, medications, treatments provided, and referrals made, pre and post age–sex standardisation, at all GP encounters with people identified in the encounter record as having an ID (‘ID’ encounters, n = 690) were compared with those at ‘non-ID’ encounters (n = 970 641). Statistical significance was tested with 95% confidence intervals.

Results

This study identified significant differences in consultation types, consultation length, problem(s) managed during the consultation, medications, treatments provided, and referrals made at ‘ID’ encounters compared with ‘non-ID’ encounters. ‘ID’ encounters had more indirect encounters, longer consultations, more problems managed, but an under management of common health conditions in people with an ID. Administrative rather than medically related actions dominated clinical treatments for people at ‘ID’ encounters, and they received fewer procedural treatments, referrals to specialists, and medications compared with those at ‘non-ID’ encounters.

Conclusion

The significant differences in consultations, problems identified and managed suggest that GPs may require additional support to (1) identify and manage common medical conditions experienced by people with an ID; (2) manage the increased time required for consultations; and (3) directly consult with people with an ID. Further research is required to determine why GPs managed problems in a significantly different way for people with an ID.

 

Who Gains Under Expanded Health Savings Accounts? – The Commonwealth Fund

The U.S. House of Representatives leadership’s bill to repeal and replace the Affordable Care Act (ACA) would have significantly expanded the use of health savings accounts (HSAs), which people can use to save tax-free money to pay for certain medical expenses. This effort isn’t new and it’s not likely to go away just because a vote on the House bill, the American Health Care Act (AHCA), has been tabled. Amendments to the tax code to encourage HSAs have been a staple of Republican health care proposals, and the HSA provisions in the House legislation were introduced as a standalone bill last year.

Source: Who Gains Under Expanded Health Savings Accounts? – The Commonwealth Fund

The U.S. House of Representatives leadership’s bill to repeal and replace the Affordable Care Act (ACA) would have significantly expanded the use of health savings accounts (HSAs), which people can use to save tax-free money to pay for certain medical expenses. This effort isn’t new and it’s not likely to go away just because a vote on the House bill, the American Health Care Act (AHCA), has been tabled. Amendments to the tax code to encourage HSAs have been a staple of Republican health care proposals, and the HSA provisions in the House legislation were introduced as a standalone bill last year.

Why all the interest? HSA proponents suggest the accounts offer cost savings and give consumers freedom to spend their money how they see fit. An HSA must be paired with a high-deductible health plan (HDHP), and there is evidence that the combination of an HDHP and HSA does reduce health care spending—by leading consumers to skip care, both needed and unneeded. Yet there is little basis to conclude that HSAs expand access to care, or that the tax benefits these accounts promise reach most Americans. In practice, most financial advantages have accrued to the top 5 percent of earners, who can afford to contribute to the accounts during the year and reap larger gains at tax time.

HSAs: The Basics

HSAs were created in 2003 in legislation establishing a Medicare prescription drug benefit. They are tax-preferred savings accounts funded by consumers and sometimes their employers. Consumers can contribute to an HSA only if they are enrolled in an HDHP, which in 2017 is an individual or group health plan that has a deductible of at least $1,300 ($2,600 for a family plan). Unlike other savings vehicles established under federal law, HSAs provide what amounts to triple tax benefits: contributions are tax-deductible; account funds are invested and grow tax-free; and withdrawals are tax-exempt (if they are used for qualified medical expenses).

HSAs are far more attractive to higher-income individuals, who are more likely to have sufficient income to fund the accounts and gain a greater tax benefit than are lower-income individuals subject to lower tax rates. In 2013, tax filers with income above $200,000 were 10 times more likely to claim a tax deduction for HSA contributions than those with incomes below $50,000, and the tax-advantaged contributions these high earners made were, on average, more than twice as large. A study of HSA take-up in the group market from 2005 to 2012 found similar results and observed, perhaps unsurprisingly, that high-income households were substantially more likely to fund their HSAs fully (with their own dollars and contributions from employers) than were middle- and lower-income filers.

Enhanced HSAs on the Horizon?

The AHCA would have expanded use of HSAs by authorizing higher tax-free contributions (increasing the amount from $3,400 to $6,550 for an individual plan) and more tax-free uses for funds. The AHCA also would have cut in half the penalty for withdrawals for nonmedical expenses.

Other proposals would provide similar and sometimes greater benefits to account holders. Legislation previously authored by Health and Human Services Secretary Tom Price would increase HSA contribution limits while also making it easier to shelter those funds and other retirement savings from taxes when they are transferred to heirs. Senator Rand Paul’s (R–Ky.) ACA replacement bill would go still further, erasing the requirement that HSAs be linked to a high-deductible plan and eliminating contribution limits altogether.

There is little doubt these expansions would encourage HSA take-up. Likewise, the proposals would make HSAs even more attractive as savings and estate planning vehicles for high-income households—particularly those who earn too much to contribute to other tax-advantaged retirement accounts and those who have maxed out such contributions. At the same time, the financial services companies that manage these accounts would reap substantial benefits, too.

Looking Ahead

HSAs are already growing under current law: by 2017, nearly 21 million accounts held more than $41 billion in assets, while the cost of the program to taxpayers has steadily increased and will nearly double by 2020. The AHCA would have dramatically accelerated this trend, causing federal spending to shoot up nearly 50 percent over the first three years following enactment and by a total of more than $19 billion by 2026.

The Congressional Budget Office estimated that the AHCA would have reduced insurance coverage dramatically, especially among Americans with low incomes. Moreover, the people most likely to need assistance paying for coverage and out-of-pocket costs—those with incomes under 200 percent of poverty, or around $24,000 for a single person—are the least likely to benefit from the bill’s approach to making coverage more affordable: HSAs. Given an ACA replacement’s potential impact on federal spending and coverage, spending billions of dollars on a program that primarily helps those least likely to need assistance purchasing coverage and paying out-of-pocket costs warrants scrutiny.

High Physician Turnover May Partly Explain ACOs’ Limited Success

Substantial Physician Turnover and Beneficiary “Churn” in a Large Medicare Pioneer ACO

Source: Physician Turnover Beneficiary Churn Medicare ACO – The Commonwealth Fund

Synopsis

A study of one of the nation’s largest Medicare accountable care organizations (ACOs) found that participating physicians see a relatively small number of patients who are actually part of the ACO population: less than 5 percent of a typical patient panel consists of ACO patients. The ACO also experiences substantial physician turnover. And when physicians leave the ACO, most of their attributed beneficiaries leave as well.

The Issue

“Physicians play a central role in the delivery of medical care and, not surprisingly, also are critical players in Medicare payment reform.”

To increase provider accountability for the cost and quality of patient care, health care systems, including the Medicare and Medicaid programs, have begun to move away from fee-for-service and toward ACOs and other alternative payment models that encourage more efficient and effective care delivery. With the ongoing implementation of the Medicare Access and CHIP Reauthorization Act of 2015, the numbers of physicians and provider organizations entering alternative payment models such as ACOs is likely to accelerate rapidly. Evidence to date, however, indicates that ACOs have achieved limited success in attaining their goals. Even though physicians play a decisive role in whether ACOs are able to deliver on their promise, there has been limited research on the physicians who work in ACOs and their experiences with patients. Commonwealth Fund–supported researchers studied a large Medicare Pioneer ACO to learn about the stability of physician participation and beneficiary enrollment.

Key Findings

  • The ACO experienced substantial turnover among physicians: only 52 percent were affiliated over the entire three-year contract period.
  • Most (88%) physicians had at least some beneficiaries attributed to them, but these patients accounted for just a small part of their panels, which averaged 1,700 patients per panel. Half (50%) of physicians had just 70 or fewer attributed beneficiaries. ACO enrollees accounted for less than 5 percent of the median physician’s patient panel.
  • About half (49%) of beneficiaries who joined the ACO in contract year 2 or 3 did so because their physician had joined the ACO. When physicians left the ACO in year 2 or 3, 90 percent of their assigned beneficiaries also left.

The Big Picture

The study’s findings suggest that two factors can dampen an ACO’s potential to hit its financial targets: a relatively low number of enrollees attributed to participating physicians, and the loss of patients when physicians leave the ACO. To the extent that there is patient turnover, the ACO’s incentives also are dampened with respect to investments that require more than a few months to achieve any payoff. The authors conclude that the financial incentives provided by ACOs to provide better, more efficient care may not be sufficient to attract physicians, given the small numbers of ACO beneficiaries they tend to serve. Physicians, they say, might instead repond better to comparable incentives that are linked to having a larger number of patients on their panels. This, however, would require standardizing incentives across payers. Standardization also reduces the potential cacophony associated with having a large number of incentives. Health systems also could reconsider how they link beneficiaries to primary care physicians to concentrate care among a smaller number of physicians, creating a critical mass of patients that might encourage and facilitate practice pattern changes.

The authors also note that having the ability to select participating physicians each year creates a temptation for ACOs to improve their risk profile—and thereby increase their opportunity for shared savings—by dropping the small number of physicians whose patients have the most unfavorable risk mix (e.g., those with very high treatment costs). The Centers for Medicare and Medicaid Services could put policies in place that would reduce the incentive to game the risk pool.

About the Study

The researchers used the following data sources for their analysis: a list of beneficiaries aligned to Partners HealthCare’s ACO; a list of physicians affiliated with the ACO during that period; databases that captured the number of years a physician was affiliated with the ACO, physician specialty, and other factors; and Medicare claims data.

The Bottom Line

A low number of attributed enrollees per physician and substantial physician turnover may help explain the muted impact that accountable care organizations have had thus far.

“I’m still here”: Exploring what matters to people with intellectual disability during advance care planning – McKenzie

Source: “I’m still here”: Exploring what matters to people with intellectual disability during advance care planning – McKenzie – 2017 – Journal of Applied Research in Intellectual Disabilities – Wiley Online Library

Abstract

Background

This study sought to identify, from the perspective of people with intellectual disabilities and life limiting conditions, the factors that strengthened and inhibited their Advance Care Planning.

Methods

This in depth qualitative study explored the experiences of four people with intellectual disability and life limiting conditions, through interviews and documentation reviews.

Results

There was strong agreement across all participants about what positively influenced Advance Care Planning, namely; going at my pace; supporting me to make my own choices; adapting the process to suit me, and, most importantly; continuing to support and plan the life I’m still living. With the exception of being comfortable/skilled in end-of-life support, the skills required of facilitators were similar to those required for all forms of person-centred planning.

Conclusion

The findings are encouraging and demonstrate that Advance Care Planning is a useful tool in ensuring that people with intellectual disability have control and choice over their lives, right to the end.

Improving hospital care of patients with intellectual and developmental disabilities – Disability and Health Journal

People with intellectual disabilities and developmental disabilities (IDD) face poorer care and outcomes when hospitalized than patients without IDD. A panel discussion “Hospital care for individuals with IDD: The Issues and Challenges” was held at the Annual Conference of the American Academy of Developmental Medicine and Dentistry, held in Chicago July 8–10, 2016. Among the panelists were representatives from Rush University Medical Center in Chicago, IL and Saint Barnabas Medical Center in Livingston, NJ who discussed efforts to improve hospital care of patients with IDD at their institutions.

Source: Improving hospital care of patients with intellectual and developmental disabilities – Disability and Health Journal

Sarah H. Ailey, PhD RN, Paula J. Brown, MBA, Caitlin M. Ridge, BA, CCLS

Preparing for Life After High School: Characteristics and Experiences of Youth in Special Education

Findings from the National Longitudinal Transition Study 2012. Volume 1: Comparisons with Other Youth (Full Report)

Key Findings: Youth with an IEP are more likely than their peers to be socioeconomically disadvantaged and to face problems with health, communication, and completing typical tasks independently. The vast majority of youth with and without an IEP feel positive about school, but those with an IEP experience bullying and are suspended at higher rates, and are less engaged in school and social activities. Youth with an IEP are more likely than youth without an IEP to struggle academically, yet less likely to

Source: Preparing for Life After High School: The Characteristics and Experiences of Youth in Special Education. Findings from the National Longitudinal Transition Study 2012. Volume 1: Comparisons with Other Youth (Full Report)

Policymakers and educators have long recognized the importance of addressing the needs of youth in special education, who today account for 12 percent of all youth in the United States. Concern that this objective was not being adequately met led Congress to pass landmark legislation in 1975, now known as the Individuals with Disabilities Education Act (IDEA) (U.S. Department of Education, 2010). IDEA mandates that children and youth with disabilities have access to a free appropriate public education.

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Data-Driven, Cross-Sector, and Community-Led Transformation: Place-based Population Health

Toward Data-Driven, Cross-Sector, and Community-Led Transformation: Academy Health provides an overview of the findings including the who, the what and the how.
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The Community Health Peer Learning Program (CHP), a partnership of AcademyHealth and the Office of the National Coordinator for Health Information Technology (ONC), conducted an environmental scan of multisector initiatives driving toward population health improvement at the community level, many with a focus on capturing, sharing, integrating, and using data to support their work. The scan and ensuing report confirm the emergence and rapid expansion of such efforts, and reflect a growing recognition that local conditions often drive the environmental and social determinants of health. Many place-based population health improvement efforts, therefore, involve sectors outside of health care (e.g., housing, education, criminal justice), and this report profiles several different programs and strategies designed to build and sustain these cross-sector collaborations. The report also conveys the scale, scope, and diversity of ongoing efforts, and offers insights into common challenges, emerging strategies, and promising practices to accelerate progress.Ultimately, the scan and associated report reveal the emergence of a movement—a convergence of programs and people connecting across traditional and non-traditional boundaries, and working together to improve community health.

Download the Executive Summary above, or click here for the full report.

Source: Toward Data-Driven, Cross-Sector, and Community-Led Transformation: Executive Summary | Academy Health

How to Bounce Back – Aging with a Disability Factsheet Series

Source: How to Bounce Back | Rehabilitation Research and Training Center on Aging With Physical Disabilities

How to Bounce Back – Aging with a Disability Factsheet Series

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Living with a disability can be stressful at times. Resilience is a term that describes how we cope with stress. By building up our resilience, we can stay more engaged in life.

What Is Resilience?

Resilience describes our ability to bounce back and keep going after a stressful experience. Different people define resilience in different ways. When we asked people with disabilities to describe resilience in their own words, some descriptions included:

  • Bouncing back, or being “buoyant.”
  • “Rolling with” or “dancing with” a disability.
  • Taking things one day at a time, while also planning for the future.
  • Finding a “new normal” as life changes.
  • Making the best of life with a disability.
  • Trusting that stressful times will pass, like the weather.

No Wrong Door No Wrong Door Systems (Aging and Disability Resource Centers)

No Wrong Door

Source: No Wrong Door

This paper provides concrete examples of how seven No Wrong Door Systems—sometimes called Aging and Disability Resource Centers—are promoting person- and family-centered practice. No Wrong Door Systems involve an array of organizations including Area Agencies on Aging, Centers for Independent Living, and state agencies such as Medicaid agencies and state units on aging. Older adults, people with disabilities, and their families can access services through these agencies in a variety of ways including in person, by telephone, and online.

Individualization is at the heart of person- and family-centered practice. It is an essential component of No Wrong Door Systems, allowing people to have information about their options and facilitate decision making based on individual and family preferences, values, and financial resources. The paper includes a toolkit of resources and contacts for states to learn more and even replicate these practices. A checklist—specifically created for this project—provides a roadmap for states to ensure that No Wrong Door Systems operate in a person- and family-centered way.

This paper is the first in a series of promising practices and emerging innovations reports. This series is a new feature of the upcoming, 3rd Long-Term Services and Supports (LTSS) Scorecard. The LTSS Scorecard—written by the AARP Public Policy Institute and funded by The SCAN Foundation and The Commonwealth Fund—measures state-level performance of LTSS systems that assist older people, adults with disabilities, and their family caregivers.

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