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  • Scholarly Articles

  • Starting on the Path to a High Performance Health System: Analysis of the Payment and System Reform Provisions in the Patient protection and Affordable Care Act of 2010

    This report, originally published in December 2009 and since updated to reflect the March 2010 passage of the Patient Protection and Affordable Care Act, analyzes the provisions in the new law that will affect providers’ financial incentives, the organization and delivery of health care services, investment in prevention and population health, and the capacit to achieve the best health care and health outcomes for all. Major initiatives include establishment of health insurance exchanges and new market rules, creation of an Independent Payment Advisory Board and Center for Medicare and Medicaid Innovation, and introduction of payment policies designed to reward hospitals and physicians for value rather than volume. Download File

    Keeping It Simple: Health Plan Benefit Standardization and Regulatory Choice under the Affordable Care Act

    The recently enacted Patient Protection and Affordable Care Act (―Affordable Care Act‖ or ―ACA‖)1 provides federal and state regulators with an opportunity to address inefficiencies in the health insurance market. Health insurance markets in many areas of the country have a confusing array of benefit choices that make it difficult for consumers to effectively comparison-shop. This lack of transparency contributes to inefficiency in the market. Download File

    Patient Protection and Affordable Care Act of 2010: Reforming the Health Care Reform for the New Decade

    The Patient Protection and Affordable Care Act (the ACA, for short) became law with President Obama’s signature on March 23, 2010. It represents the most significant transformation of the American health care system since Medicare and Medicaid. It is argued that it will fundamentally change nearly every aspect of health care, from insurance to the final delivery of care. The length and complexity of the legislation and divisive and heated debates have led to massive confusion about the impact of ACA. It also became one of the centerpieces of 2010 congressional campaigns. Download File

    The Impact of Comparative Effectiveness Research on Interventional Pain Management: Evolution from Medicare Modernization Act to Patient Protection and Affordable Care Act and the Patient-Centered Outcomes Research Institute

    The Patient-Centered Outcomes Research Institute (PCORI) was established by the Affordable Care Act of 2010 to promote comparative effectiveness research (CER) to assist patients, clinicians, purchasers and policy-makers in making informed health decisions by advancing the quality and relevance of evidence concerning the manner in which diseases, disorders, and other  health conditions can effectively and appropriately be prevented, diagnosed, treated, monitored, and managed through
    research and evidence synthesis. Download File

    Care Integration in the Patient Protection and Affordable Care Act: Implications for Behavioral Health

    Individuals with co-occurring serious mental illness and substance use disorders experience a highly
    fragmented system of care, contributing to poor health outcomes and elevated levels of unmet treatment needs. Several elements in the health care reform law may address these issues by enhancing the integration of physical and
    behavioral health care systems. The purpose of this paper is to analyze these elements, which fall into three domains:
    increasing access, restructuring financing and reimbursement mechanisms, and enhancing infrastructure. We conclude
    with a consideration of the implementation challenges that lie ahead. Download File

    America Under the Affordable Care Act

    With the enactment of the Health Care and Education Reconciliation Act of 2010 on March 30, 2010, the
    Patient Protection and Affordable Care Act (ACA) became law, fundamentally changing health insurance and
    access to health care in the United States. Using the Urban Institute’s Health Insurance Policy Simulation Model (HIPSM),
    we estimate how the ACA would affect the types of health insurance coverage Americans have, the number of those without insurance, and America’s overall spending on healthcare. For ease of comparison, we simulate the ACA as if fully
    implemented in 2010 and contrast the results with HIPSM’s pre-reform baseline results for 2010. Download File

    The Affordable Care Act:Leading America to socialism?

    The new health care bill, called the “Affordable Care Act,” signed into law recently by President Obama, has led to a renewed debate as to whether the United States is gradually heading towards socialism. Some contend that it will lead to socialized medicine while others disagree. This paper reviews the new law and its provisions. It examines the argument for and against the new law and takes a comparative approach (the new health care provisions in the U.S. and socialized medicine in Canada), to ascertain whether we are heading towards socialized medicine here in this country. Download File

    Affordable Care Act: Frequently asked questions

    1. Does the Employer Mandate apply to public agencies?

    Yes. The term “employer” expressly includes government entities in the definition of
    employer for Section 4980H (Employer Shared Responsibility). (78 F.R. 217, 221.)

    2. How do we know if our agency is required to comply with the Employer
    Mandate or pay a penalty (i.e. are we a small or large employer)?

    The Employer Mandate provision of the Affordable Care Act (“ACA”) applies to large
    employers. Under the ACA large employers are those employers who employ at least
    50 full-time employees, or a combination of full-time and part-time employees that
    equals at least 50, during the preceding calendar year. (78 F.R. 217, 221.) Among
    other things, in determining whether an agency meets the large employer threshold, the
    proposed regulations require employers to average their number of employees across
    the months in the preceding calendar year. Employers that do not meet the 50
    employee threshold will not be considered a large employer, and as such will not liable
    for a Section 4980H assessable payment. (78 F.R. 217, 221.) Download File

    Implementing the Affordable Care Act: Key design decisions for state-based exchanges

    The Affordable Care Act requires the establishment of new health insurance marketplaces—known as exchanges—in every state by October 1, 2013. This report examines key design decisions made by the 17 states and the District of Columbia that chose to establish a state-based exchange. The analysis finds that states made significant progress in structuring their exchanges, with states varying in their design decisions. Many states expect to exceed some federal requirements—to collect and display quality data, for instance—for 2014.These findings suggest that states capitalized on the flexibility provided by the Affordable Care Act to tailor their exchanges to their unique needs and made decisions with an eye towards outcomes, such as enrollment, consumer experience, and sustainability. These findings also suggest that states’ initial decisions will inform future exchange implementation and that states will adjust their decisions while continuing to adopt innovative approaches to accomplish policy goals. Download File

    Health insurance exchanges

    Health insurance exchanges are the centerpiece of the private health insurance reforms of the Patient Protection and Affordable Care Act of 2010 (ACA). If they function a planned, these exchanges will expand health insurance coverage, improve the quality of such coverage and perhaps of health care itself, and reduce costs. Previous attempts at creating health insurance exchanges, however, produced only mixed results. This report identifies the earlie attempts’ problems, enumerates the key issues that are critical for overcoming those problems analyzes in detail the ACA’s provisions addressing these issues, and discusses further policy options. Download File

    U.S. health-care reform: The Patient Protection and Affordable Care Act

    This short article provides an overview of the Patient Protection and Affordable Care Act, whichwas approved by the U.S. Congress and signed by President Barack Obama in March 2010, with an emphasis on provisions relate to the expansion of health insurance. It highlights key provisions concerning coverage expansion, insurance market reforms, and the projected costs and financing of the legislation. Download File

    The Affordable Care Act and Competition Policy: Antidote or placebo?

    In the run-up to its enactment, the Patient Protection and Affordabl Care Act (ACA)1 elicited howls of protest from opponents who claimed the federal government was taking over the American healthcare system, micromanaging medicine, and generally exposing the nation to the bête noire of socialized medicine.2 Hyperbole misrepresentation, and chauvinism aside,3 these sound bites suffer from a deeper flaw: they mischaracterize the fundamental thrust of the
    new law. Though the ACA establishes significant new regulator authority, this is not a new development (indeed it can be faulted for preserving pre-existing regulatory regimes), nor does it impair market competition. To the contrary, much of the law aims at improving conditions conducive to effective competition. Download File

    Challenging supremacy: Virginia’s response to the Patient Protection and Affordable Care Act

    Health care reform has been a primary goal of presidential candidates for the past half-century. At least since the adoption of the Universal Declaration of Human Rights in 19481 and the inception of the Medicare system in 1965, the primacy of achieving extensive and efficient health care in American policymaking cannot be seriously disputed.Currently, health care costs seem uncontrollable, and nearly fifty million Americans remain uninsured.4 Continuing into modern times, a cornerstone of President Bill Clinton‘s first term in office was to provide health care for all Americans.5 And although Democrats held a majority of seats in both chambers of Congress at the time, Clinton‘s attempt to re-vamp the health care system failed remarkably. Download File

    Out-of-network involuntary medical care: An analysis of emergency care provisions of the Patient Protection and Affordable Care Act

    The Patient Protection and Affordable Care Act (PACA) was enacted in March, 2010.2 Include among the many provisions of this sweeping healthcare reform bill are new requirements that healt plans offering benefits for emergency services must meet.3 As described in more detail herein, th new requirements prohibit the use of preauthorization requirements, regulate cost-sharing provisions for out-of-network emergency care, and establish minimum health plan reimbursement levels t providers for out-of-network emergency care. While PACA specifies the new requirements, the Act does not specify how plans must meet those conditions. On June 28, 2010, the Secretary of Health and Human Services (HHS) published Interim Final Rules (IFR) that describe how HHS will implement the out-of-network emergency service provisions. Download File

    Left out: Immigrants’ access to health care and insurance

    Recent policy changes have limited immigrants’ access to insurance and to health care. Fewer noncitizen immigrants and their children (even U.S.-born) have Medicaid or job-based insurance, and many more are uninsured than is the case with native citizens or children of citizens. Noncitizens and their children also have worse access to both regular ambulatory and emergenc care, even when insured. Immigration status is an important component o racial and ethnic disparities in insurance coverage and access to care. Download File

    "Tomorrow" may finally have arrived-The Patient Protection and Affordable Care Act: A necessary first step toward health care equity in the United States

    On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act ("PPACA") 4-the conclusion of a year-long legislative process aimed at addressing the well-documented deficiencies in access to and the delivery of health care services in the United States.5 This legislation signaled that the "tomorrow" that promised significant reform of the health insurance and health care delivery system may have arrived. In 2010, the Congress, or at least most Democrats in Congress, and the President moved beyond arguments that the legislation was not perfect and that some of its implications and impacts were unclear, including the cost of expanding insurance coverage to the uninsured and the extent to which reform would produce federal budget savings.Download File

    The Affordable Care Act and the future of clinical medicine: The opportunities and challenges

    The Affordable Care Act is a once-in-a-generation change to the U.S. health system. It guarantees access to health care for all
    Americans, creates new incentives to change clinical practice to foster better coordination and quality, gives physicians more information to make them better clinicians and patients more information to make them more value-conscious consumers, and changes the payment system to reward value. The Act and the health information technology provisions in the American Recovery and Reinvestment Act remove many barriers to delivering high-quality care, such as unnecessary administrative complexity, inaccessible clinical data, and insufficient access to primary care and allied health providers. Download File

    New physicians, the Affordable Care Act, and the changing practice of medicine

    THE PASSAGE OF THE AFFORDABLE CARE ACT (ACA) in March 2010 signaled a dramatic moment for the
    US health care system. Featuring expanded health coverage for millions of individuals, insurance reforms,
    and a commitment to testing numerous approaches to improving the delivery of medical care, the ACA affect nearly every aspect of the practice of medicine. These changes raise the question: how do physicians in general and the next generation of physicians in particular—young physicians, residents, and medical students—view the ACA? Download File

    Veterans and the Affordable Care Act

    ARMED CONFLICT HAS BEEN A FREQUENT OCCURrence throughout US history. During the last century, the United States has fought 8 wars that together span more than 35 years, not counting numerous conflicts that are not officially considered wars. In view of the many health consequences of war, the potential effect of the Affordable Care Act (ACA) on healthcare for veterans warrants careful consideration In 2011, there were 22.2 million veterans of service in the US Armed Forces. Veterans are a highly diverse population but can be grouped into 3 categories from a health insurance perspective. Approximately 37% are enrolled in the Department of Veterans Affairs (VA) health care system in accordance with a congressionally mandated eligibility system based on having a service-connected disability, low income and net worth, or other prescribed circumstances. Download File

    Health insurance exchanges and the Affordable Care Act: Eight difficult issues

    The state-level health insurance exchanges to be created under the Affordable Care Act (ACA) are expected to play a major role in the purchase and sale of health insurance when they become fully operational in 2014. This report focuses on eight of the most difficult issues that the states and the federal government face in implementing the exchanges: governance of the
    exchanges; avoidance of adverse selection; making self-funded plans compatible with exchanges making exchanges attractive to employers; exchanges’ use of their regulatory authority determining the information that exchanges must make available to consumers and employers; the exchanges’ role in making eligibility determinations for premium tax credits and cost-sharing
    reduction payments and their relationship with public insurance programs; and reducing administrative costs. The report also examines how the ACA handles those issues, and make concrete recommendations as to how those issues should be addressed. Download File

    The Patient Protection and Affordable Care Act: implications for public health policy and practice

    The Affordable Care Act is a watershed in U.S. public health policy. Through a series of extensions of, and revisions to, the multiple laws that together comprise the federal legal framework for the U.S. health-care system, the Act establishes the basic legal protections that until now have been absent: a near-universal guarantee of access to affordable health insurance coverage, from birth through retirement. When fully implemented, the Act will cut the number of uninsured Americans by more than half. The law will result in health insurance coverage for about 94% of the American population, reducing the uninsured by 31 million people, and increasing Medicaid enrollment by 15 million beneficiaries. Approximately 24 million people are expected
    to remain without coverage. Download File

    Net effects of the Affordable Care Act on state budgets

    The Patient Protection and Affordable Care Act (Affordable Care Act or ACA) will affect state budgets in many ways. State Medicaid spending on low-income adults will rise, for two reasons. First, the Affordable Care Act is expected to increase enrollment among individuals who currently qualify but have not yet signed up for Medicaid, enrollment for which states must pay their standard share of Medicaid expenses. Second, the legislation requires Medicaid to cover all adults with incomes at or below 133 percent of the federal poverty level (FPL). While the federal government will pay 100 percent of all health care costs for newly eligible adults during 2014- 2016, states will begin paying some of these costs in 2017, with the state share gradually rising to 10 percent in 2020 and thereafter. Taking into account both of these factors, prior analyses by the Urban Institute have concluded that, depending on whether participation levels resemble historical averages, as anticipated by the Congressional Budget Office, or significantly exceed those levels, state costs for Medicaid adults with incomes at or below 133 percent of FPL will rise by between $21.1 billion and $43.2 billion during 2014-2019. Download File

    Health status, risk factors, and medical conditions among persons enrolled in Medicaid vs uninsured low-income adults potentially eligible for Medicaid under the Affordable Care Act

    THE SUPREME COURT RULING ON the Affordable Care Act (ACA), the Patient Protection and Affordable
    Care Act of 2010 (Pub L No. 111-148)1 as amended by the Health Care and Education Reconciliation Act of 2010 (Pub L No. 111-152), determined that states have the option to expand Medicaid coverage to most low-income adults, an option that
    could add millions of new Medicaid enrollees. In states choosing to implement the expansion, with full federal financing from 2014 through 2016, this would expand Medicaid’s traditional focus away from low-income pregnant women and children, very–low-income parents, and the severely disabled to new population groups.These include childless adults and parents whose incomes are too high to qualify for Medicaid under current state eligibility criteria.This is likely to affect the type of Medicaid patients seen by physicians in states choosing to expand Medicaid. Download File

    Democratic constitutionalism and the Affordable Care Act

    During the congressional debate over the 2010 Patient Protection and Affordable Care Act (ACA),1 opponents of the Act mounted dramatic demonstrations against it. Tea Party activists attacked the ACA as an unconstitutional infringement on states’ rights and individual liberty.2 The Tea Party’s well-publicized engagement in popular constitutionalism constitutional interpretation outside of the courts3—has been celebrated by conservative politicians and scholars of constitutional law4 and has caused other constitutional scholars to think twice about their own interest in popular constitutionalism.5 Often lost in this story is the fact that the ACA itself was the product of popular constitutionalism, a victory for political advocates who argued that the right to health care was a fundamental human right that warranted protection by the federal government. Download File

    Realigning the social order: The Patient Protection and Affordable Care Act and the U.S. health insurance system

    The Patient Protection and Affordable Care Act (―Affordable Care Act‖)1 is a testament to this proposition. Signed into law in the wake of what surely was one of the most dramatic legislative battles in the history of United States social welfare legislation, the Affordable Care Act fundamentally alters the key legal relationships that undergird the American health insurance system in order to achieve greater equity in health care itself.

    What makes a piece of legislation controversial? In a sense, virtually all outcomes of the legislative process stir some controversy, since the process generates results through political conflict. But even a cursory examination of the history of national health reform in the U.S. drives home the magnitude of the drama that historically has surrounded virtually every effort to achieve a major shift in public policy.2 Part of the problem is Americans’ moral ambivalence over using governmental interventions to aid others, a key aspect of redistributive legislation such as the Affordable Care Act. Download File

    The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act

    Public substance abuse treatment services have largely operated as an independent part of the overall health care system, with unique methods of administration, funding, and service delivery. The Affordable Care Act of 2010 and other recent health care reforms, coupled with declines in state general revenue spending, will change this. Overall funding for these substance abuse services should increase, and they should be better integrated into the mainstream of general health care. Reform provisions are also likely to expand the variety of substance abuse treatment providers and shift services away from residential and standalone programs toward outpatient programs and more integrated programs or care systems. As a result, patients should have better access to care that is more medically based and person-centered. Download File

    Health insurance, risk, and responsibility after the Patient Protection and Affordable Care Act

    The Affordable Care Act embodies a new social contract of health care solidarity through private ownership, markets, choice, and individual responsibility, with government as the insurer for the elderly and the poor. The new health care social contract reflects a “fair share” approach to health care financing. This approach largely rejects the actuarial fairness vision of what constitutes a fair share while pointing toward a new responsibility to be as healthy as you can. This new responsibility reflects the influence of health economics and health ethics. There are challenges to achieving the solidarity through individual responsibility envisioned in the Act—most significantly ”risk classification by design” and non-compliance with the mandates—but the Act contains regulatory tools that the states, the new Exchanges, and the Department of Health and Human Services can use to address these challenges. Download File

    Affordable Care Act expands dental benefits for children but does not address critical access to dental care issues

    Approximately 8.7 million children are expected to gain some form of dental benefits by 2018 as a result of the Affordable Care Act (ACA), an increase of 15% relative to 2010. This will reduce the number of children without dental benefits by about 55%.

    Although 17.7 million adults are expected to gain some level of dental benefits as a result of the ACA, almost all of this increase is in Medicaid which varies significantly state to state on adult dental benefits policy. As a result, only 4.5 million of adults are expected to gain ‘extensive’ dental benefits through Medicaid. An additional 800,000 will gain private dental benefits through health insurance exchanges. Combined, this will reduce the number of adults without dental benefits by about 5%. 

    There is likely to be significant pressure on Medicaid providers within the dental care delivery system. The ACA is expected to generate an additional 10.4 million dental visits per year through Medicaid by 2018. Download File

    Hospital readmissions and the Affordable Care Act: Paying for coordinated quality care

    HOSPITAL READMISSIONS HAVE BEEN THE SUBJECT OF ever-increasing scrutiny. Indeed, they are an important
    focus of the US Patient Protection and Affordable Care Act (ACA). Identified by the Medicare Payment Advisory Commission as a major action item for some time, hospital readmissions remain prevalent, costly, and largely preventable. The recently updated Hospital Compare Web site reveals that the national 30-day readmission rates for acute myocardial infarction (AMI), heart failure, and pneumonia have had limited if any improvement from 2007 through 2010.2 “Payment incentives to avoid readmissions” have been cited in the Department of Health and Human Services’ strategic plan for 2010 through 2015 as an example of quality of care improvement.3 Hospital readmissions also have been singled out for improvement by the Centers for Medicare&Medicaid Services’ (CMS’s) National Strategy for Quality Improvement in Health Care. Download File

    The Affordable Care Act: Why Medicaid expansion is bad medicine for South Carolina

    President Obama and his allies inside and outside of Congress who led the fight for the Affordable Care Ac (ACA) cited the reduction in the number of uninsured Americas as a major goal of the law. A key strategy in the ACA for reducing the uninsured
    population was to expand Medicaid, government sponsored insurance for the poor. In the form the law passed Congress on March 23, 2010, the ACA required that “individuals under 65 years of age with income below 133 percent of the federal poverty
    level (FPL) … be eligible for Medicaid” beginning in January of 2014. Download File

    The Patient Protection and Affordable Care Act effects on dental care

    Health care reform has been a subject of debate long before the presidential campaign of 2008, through the presidential signing of the Patient Protection and Affordable Care Act (PPACA) on March 23, 2010, and is likely to continue as a topic of discussion well into the future. The effects of this historic reform on the delivery of healthcare and on the economy are subject to speculation. While most people are at least generally aware that access to medical care will be improved in many ways, few people, including many in the dental profession, are aware that this legislation also addresses oral health disparities and access to dental care. It is the purpose of this paper to review how dental care is currently accessed in the United States and where oral health care disparities exist, to suggest approaches to alleviating these disparities and to delineate how the changes in dental policies found in the PPACA hope to address these concerns. The main arguments of organized dentistry, both those in support of and in opposition to the PPACA, are summarized. Download File

    The road ahead for the Affordable Care Act

    The Affordable Care Act (ACA), the U.S. health care reform law enacted in 2010 and upheld as constitutional by the U.S. Supreme Court on June 28, 2012, has survived a series of life-threatening obstacles since its congressional consideration began in mid-2009. The most dramatic threat involved the surprise election of Massachusetts Republican Scott Brown to the U.S. Senate on January 19, 2010, which deprived Democrats of their 60-vote Senate majority and left most observers convinced that continued hopes for comprehensive health care reform were delusional. Until the oral arguments before the Supreme Court this March, few analysts believed that the Court’s decision would be another life-threatening episode. Download File

    The effects of the Affordable Care Act on workers’ health insurance coverage

    Uwe Reinhardt, a leading authority on health care economics, as asserting that “If we had to do it over again, no policy analyst would recommend this model.”1 Nonetheless, the Patient Protection and Affordable Care Act of 2010 (the ACA) builds on, rather than eliminates, employer-sponsored insurance. However, because the ACA makes substantial changes to the employer-based system, some wonder whether the employers’ role in providing insurance will diminish or disappear over time. The ACA builds on the employer-based health insurance system by developing exchanges through which small employers can offer coverage and by penalizing large employers that do not offer coverage. Download File

    Health care coverage under the Affordable Care Act — A progress report

    With politicians and pundits clamoring in the background, the first open-enrollment period — created by the Affordable Care Act (ACA) for Americans seeking insurance coverage in the new individual marketplaces — came to a close on March 31. There were last-minute extensions by the Department of Health and Human Services and by certain states, but for most insurance seekers, March 31 was the last chance to enroll through the individual marketplaces until the next open-enrollment period launches in November. Americans who did not have qualified health insurance when open enrollment ended and who do not qualify for an exemption will incur a penalty of $95 or 1% of their income over the tax-filing limit (whichever is greater) when they file income taxes on April 15, 2015. Download File

    The perception of stress and its impact on health in poor communities

    With the increased understanding of the relationship between stress and disease, the role of stress in explaining persistent disparities in health outcomes has received growing attention. One body of research has focused on allostatic load—the ‘‘wear and tear’’ that results from chronic or excessive activation of the stress response. Other research has looked at the link between stress and health behaviors. In this study, we conducted 7 focus groups with a total of 56 people to understand how people living in Highbridge, South Bronx, New York, a low income community with poor health outcomes, perceive stress and its relationship to health. Focus group participants described a direct causal pathway between stress and poor health as well as an indirect pathway through health behaviors, including uncontrolled eating, sleep deprivation, substance abuse, smoking, violence and aggression, and withdrawal and inactivity. Participants articulated a number of theories about why stress leads to these unhealthy behaviors, including self-medication, adaptive behavior, discounting the future, depletion of willpower, and competing priorities. Their nuanced understanding of the link between stress and health elucidates the mechanisms and pathways by which stress may result in disparities in health outcomes and create challenges in changing health behaviors in poor communities like the South Bronx. Download File

    Silent killer “expo”sed in the South Bronx

    The statistics are staggering. The American Diabetes Association estimates that there are 20.8 million people in the United States, or 7% of the population, who have diabetes. While an estimated 14.6 million have been diagnosed with diabetes, unfortunately, 6.2 million people (or nearly one third) are unaware that they have the disease. Although it is believed that diabetes is underreported as a condition leading to or causing death, each year, more than 200,000 deaths are reported as being caused by diabetes or its complications. Morbidity and mortality due to diabetes has made this disease a significant public health problem and led the Centers for Disease Control and Prevention to declare the disease an epidemic in the United States.

    Diabetes is the sixth leading cause of death among Americans and the fifth leading cause of death in New York City. Approximately 18 percent of all people living in the South Bronx are diabetic. The incidence of serious chronic disease in the South Bronx is the highest in New York City. In Hunts Point and Mott Haven, two South Bronx neighborhoods within Urban Health Plan’s service area, the incidence of diabetes has doubled in the past decade and its mortality rate is two times higher than that of the rest of the city. Given the severity of the problem and the disproportionately high incidence rates of diabetes prevalent in residents of the South Bronx, Urban Health Plan, Inc. will hold its third annual Diabetes Expo; an open forum to discuss effective ways to cope with diabetes and its complications. Download File

    Expanding smokefree communities - Community profiles: South Bronx, New York

    The American Lung Association in New York in partnership with community housing groups and other key community partners have formed the South Bronx Smokefree Housing Project – a collaborative dedicated to reducing tobacco-related health disparities by eliminating harmful exposure to secondhand smoke for 187,000 South Bronx residents living in multi-unit housing.

    Health Equity Focus

    Facing considerable barriers to improving the health outcomes of its residents, the South Bronx has been rated one of the nation’s unhealthiest and most poverty stricken areas. In its annual County Health Rankings, the Robert Wood Johnson Foundation found that the Bronx ranked last, 62nd out of 62 counties in New York State in health outcomes. This project aims to protect low-income multi-unit housing residents from exposure to harmful secondhand smoke by implementing comprehensive smokefree multi-unit housing voluntarily in all of the South Bronx Overall Economic Development Corporation and Nos Que Damos’ low-income serving properties in the South Bronx. Download File

    The role of faith-based institutions in addressing health disparities: A case study of an initiative

    Although many public health initiatives have been implemented through collaborations with faith-based institutions, little is known about best practices for developing such programs. Using a community-based participatory approach, this case study examines the implementation of an initiative in the Bronx, New York, that is designed to educate community members about health promotion and disease management and to mobilize church members to seek equal access to health care services. The study used qualitative methods, including the collaborative development of a logic model for the initiative, focus groups, interviews, analysis of program reports, and participant observation. The paper examines three key aspects of the initiative’s implementation: (1) the engagement of the church leadership; (2) the use of church structures as venues for education and intervention; and (3) changes in church policies. Key findings include the importance of pre-existing relationships within the community and the prominent agenda-setting role played by key pastors, and the strength of the Coalition’s dual focus on health behaviors and health disparities. Given the churches’ demonstrated ability to pull people together, to motivate and to inspire, there is great potential for faith-based interventions, and models developed through such interventions, to address health disparities. Download File 

    South Bronx environmental health and policy study

    South Bronx has heavy vehicle traffic passing through it along major highways, creating pollution that can affect local residents - under any wind direction. Local community groups were concerned that the truck activity, and diesel emissions generated by them, were contributing to high incidences of asthma. Download File

    Impact of LEED-Certified Affordable Housing on Asthma in the South Bronx


    • To evaluate the impact of environmentally-friendly, affordable housing on asthma symptoms.

    • Tenants moving into Melrose Commons V (MCV), a Leadership in Energy and Environmental Design (LEED)-certified, affordable housing complex in the South Bronx, were followed for 18 months to determine the health impact of their new “green” environment, built on energy efficient and environmentally-conscious principles.

    • MCV was built using features with the potential to improve health outcomes, including construction materials with low or minimal levels of environmental pollutants, and specialized ventilation systems. Residents were not allowed to keep pets in the building and smoking was prohibited within twenty-five feet of the complex.

    • Participants were surveyed periodically to determine changes in the frequency of asthma-related symptoms and utilization of urgent health care. Tenants received a home-based asthma education session and were evaluated to determine its impact on their knowledge of asthma and environmental triggers of asthma symptoms. Behavioral changes implemented by tenants were also assessed. Download File

    The Healthy Bronx initiative

    In 2011, the CIR members of the Bronx created the Healthy Bronx Initiative (HBI) with the goal of going beyond the hospital walls to understand the context in which our patients lived. By identifying and tackling the root causes of health problems in our community, we broadened our role as service-oriented providers but found that we were ill-prepared to address the environmental and behavioral factors that not only influence health but prevent diseases. To address this problem, we incorporated one of CIR’s four core values, service, to implement a model that would improve the quality of care we provide to our community. Through service, we hoped to gain a better understanding of the conditions our patients face in our community and be better informed when advising and treating them. Since then, CIR has developed other service-oriented programs, including the Family Health Challenge, which is tackling one of the most serious health concerns – child obesity. By educating and encouraging healthy behavior changes in the classrooms of school-age children, residents that have participated in the Family Health Challenge are making strides to halt the progression of obesity in the Bronx and finding that they are in fact learning along the way. Download File

    Not enough time, not enough experience, not aware of risk: Why healthcare providers don’t routinely test youth for HIV

    The U.S. Centers for Disease Control and Prevention (CDC) estimates that at least half of all new HIV infections occur in young people between the ages of 13 and 24—as many as 20,000 new HIV-positive youth each year, and the majority of them are infected sexually.  

    The HIV epidemic continues to disproportionately impact teens and adolescents in urban communities of color. Youth in the Bronx are highly vulnerable to HIV infection, as the Bronx has the second-highest cumulative AIDS rate of all boroughs in New York City. The Bronx, with 16% of New York City’s population, accounts for 17% of all AIDS cases among men, 27% of cases among women and 28% of cases among children.

    In the Bronx, 1,567 new AIDS cases were reported in 1999 (26% of the New York City total) and 1,228 new cases in 2000 (21%). Data for 2001 are incomplete. The Bronx has some of the highest cumulative levels of people living with AIDS in New York City, with Fordham/Bronx Park and Crotona/Tremont among eight New York City neighborhoods with the highest incidence of AIDS. Download File

    Two projects to promote healthy lifestyles and eliminate obesity: The Bronx health behaviors survey project the Bronx health-smart church program

        Who answered the survey questions?

    •  A total of 674 adults between 18 and 83 years old (67% of whom earned less than $40,000 per year) completed the survey.
    • Of the 674 adults, 314 were Hispanic/Latino, 207 were non-Hispanic Black, and 153 were non-Hispanic White.

        Who conducted the survey?

    • Researchers from the University of Florida and Fordham University conducted the survey

      What did the researchers learn from these adults in the Bronx? 
    • Many of these adults are more likely to drink water and other healthy drinks (such as drinks with little or no sugar) if a doctor tells them to do so. Download File

    Asthma prevention and management in Bronx, New York and New York State at large

    Asthma has been and remains a prevalent problem for many residents of the Bronx, New York City and the state as a whole. Asthma imposes, proportionally, a large burden on New York’s healthcare system and affects numerous Bronx residents, especially its children. The prevalence rate in New York was the eighth highest among all states for annual average percentage of current asthma among children 0-17 years of age from 2001 to 2005 and nineteenth highest for self-reported current asthma conditions among adults.  New York State consistently ranked near or as one of the top states in prevalence of hospitalization rates among children and ER/urgent care use among adults. This higher than average health care service utilization rate is one of the factors that puts New York within the bottom quartile in the indicator of “potentially avoidable use of hospitals and costs of [c]are”. Thus the importance of asthma prevention and management cannot be stressed enough. Mere treatment of acute asthma events and its symptoms, while important for those necessary times when asthma puts lives at risk, is not taking the proper holistic approach to the issue. Therefore prevention and management are better tools to curtail the adverse effects of asthma as prevention leads to a better overall quality of life and also leads to improvements in other areas of health such as preventing obesity. Download File

    The multidimensional effects of poverty on childhood Asthma

    The South Bronx, one of New York City’s most impoverished regions, is home to daily gang violence, dozens of garbage, sewage, medical waste incinerators, and the nation’s highest asthma rates.  It is also home to Isiah, a garrulous, optimistic eight year old boy. Isiah and his mother live alone in a substandard public housing complex. His positive disposition hides that he has endured far more trials that eight year old -children in affluent Riverdale, a Bronx town only miles away. He watched his mother struggle with a cocaine addiction and hid father was forced to move upstate, fleeing debts to heroin dealers. He copes well with his disadvantaged environment, but suffers almost daily with attacks of wheezing brought on by fits of asthma. Download File

    Obesity in the South Bronx: A look across generations

    Obesity is a major health concern in New York City. It is a problem that crosses generations, affecting children, parents, and grandparents. Being overweight or obese increases the risk for many health problems, including diabetes, high blood pressure, high cholesterol, cancer, and heart disease. Maintaining a healthy weight involves getting regular physical activity and eating well – choosing sensible portions of healthy foods. This report examines rates of obesity and overweight among people of all ages living in the South Bronx, compared with rates in the Bronx overall and in New York City.

    Exercise and diet among South Bronx adolescents and adults are also examined. Download File

    Asthma facts second edition

    The New York City Department of Health and Mental Hygiene’s Childhood Asthma Initiative (NYCCAI) is a public health effort to reduce asthma morbidity among children 0 -18 years of age. Expected outcomes of the NYCCAI include reductions in hospitalizations, emergency department visits and school absences due to asthma, and, relatedly, improvements in management of childhood asthma among families. The NYCCAI is building on existing research, educational and clinical efforts, resulting in a coordinated and comprehensive effort to understand, treat and prevent asthma in New York City. Download File

    Asthma and air pollution in the Bronx: Methodological and data considerations in using GIS for environmental justice and health research

    This paper examines methods of environmental justice assessment with Geographic Information Systems, using research on the spatial correspondence between asthma and air pollution in the Bronx, New York City as a case study. Issues of spatial extent and resolution, the selection of environmental burdens to analyze, data and methodological limitations, and different approaches to delineating exposure are discussed in the context of the asthma study, which, through proximity analysis, found that people living near (within specified distance buffers) noxious land uses were up to 66 percent more likely to be hospitalized for asthma, and were 30 percent more likely to be poor and 13 percent more likely to be a minority than those outside the buffers. Download File

    Separate and unequal: Medical apartheid in New York City

    Widespread racial and ethnic disparities in health care and health outcomes in our communities and across the nation prompted Bronx Health REACH, a coalition of 40 community and faith-based organizations, to examine the causes of these disparities and develop strategies to eliminate them. What we found includes pervasivesegregation of care, based on the link between race, ethnicity and insurancestatus, resulting in the systematic separation of whites and people of color intodifferent systems of care. We call it Medical Apartheid.

    In this report, we outline specific findings of system-wide policies and practices contributing to the segregation of care, as well as a set of recommendations to address these issues. Download File

    New York: Burden of chronic diseases

     Chronic diseases – such as heart disease, stroke, cancer, and diabetes – are among the most prevalent, costly, and preventable of all health problems. Leading a healthy lifestyle (avoiding tobacco use, being physically active, and eating well) greatly reduces a person’s risk for developing chronic disease. Access to high-quality and affordable prevention measures (including screening and appropriate follow-up) are essential steps in saving lives, reducing disability and lowering costs for medical care. Download File

    1950-1969 from infectious to chronic diseases

     In November 1954, Mayor Robert Wagner appointed Dr. Leona Baumgartner as the first female Health Commissioner in New York history.Through her dynamism, Baumgartner attracted a talented staff and secured training and higher salaries to retain skilled personnel. When Dr. Jonas Salk announced he had developed a new vaccine for polio that year, Dr. Baumgartner arranged for the vaccine to be tested in New York City, which suffered polio outbreaks nearly every summer. More than 40,000 New York City schoolchildren received the vaccine as part of a nationwide field trial. Tests having proven the vaccine effective, by 1955 Dr. Baumgartner made polio vaccination a regular part of the school health program and initiated aggressive polio vaccination campaigns among adults. By 1960, New York had become virtually polio-free. Download File

    Promoting evidence-based interventions to prevent or manage chronic diseases

    Approximately 6.2 million adult New Yorkers (41.1%) suffer from a chronic disease such as arthritis, asthma, stroke, heart disease, diabetes, or cancer and New Yorkers with chronic diseases are more likely to report poor health status and activity limitations than those without a chronic disease. The risks of adverse outcomes, including mortality, hospitalizations, and poor functional status, increase as the number of chronic conditions in an individual increases. Estimates indicate that there are between 3.7 and 4.2 million (25-30%) adult New Yorkers with prediabetes.  A diagnosis of prediabetes increases the risk of developing type 2 diabetes and without lifestyle interventions to improve health, 15% to 30% of people with prediabetes will develop type 2 diabetes within five years. Download File

    Childhood obesity at New York City public hospitals

    Childhood obesity is a large and growing health problem in the US and in many other parts of the world. Latest CDC estimates are of 17% prevalence of obesity among US adolescents.8 Childhood obesity is associated with health complications for the affected child, notably diabetes. Type II (“Adult Onset”, or “Insulin Dependent”) diabetes was rarely observed in children until the current epidemic of childhood obesity. Childhood obesity is a major risk factor of adult obesity, with its associated morbidity and mortality. New York City and State have made efforts to combat this epidemic. Some recent efforts include requiring restaurants to post calorie counts along with prices and a proposal for a special tax on sugary drinks. Estimates of the prevalence and cost of obesity are considerations in the New York debate. Our office was asked to estimate the prevalence of obesity among the children cared for, largely at public expense, by the public hospital system in New York City. Download File

    Reversing obesity in New York City

    Increasing rates of obesity threaten New York City’s future. Recent surveys show that 56% of NYC adults and more than 40% of elementary school children are overweight or obese. Obesity worsens a variety of New York’s most serious health problems including heart disease, stroke, asthma, depression, and diabetes. Current patterns of obesity and diabetes place a higher and unfair burden on the poor and on Blacks and Latinos, widening the gaps in health among these groups. If these trends continue, our children and grandchildren may have shorter life spans than we do, reversing more than 100 years of public health progress. Changing this future requires action to make it easier for New Yorkers to find healthy affordable food, to move more and find safe and affordable places to exercise, and to reduce the promotion and convenience of unhealthy food. Download File

    Childhood obesity in New York City elementary school students

    Childhood obesity is a rapidly worsening epidemic in the United States. Findings from the most recent National Health and Nutrition Examination Survey (NHANES) indicate that in 1999–2000, the prevalence of obesity among children aged 6 through 11 years was 15%. This was a dramatic increase from earlier NHANES surveys, which documented prevalence at 5% in 1960 and 11% in 1988–1994. Increases were particularly marked in Mexican American and Black children. In both groups, prevalence increased more than 10 percentage points between 1988–1994 and 1999–2000, compared with an increase of less than 5 percentage points in White children. Findings from the National Longitudinal Survey of Youth on children aged 4 through 12 years found similar trends and disparities in obesity prevalence. Obesity during childhood has important short-term medical consequences, including adverse effects on growth, blood pressure, blood lipids, and glucose metabolism. Other complications include respiratory conditions, such as asthma and obstructive sleep apnea. The long-term medical consequences of childhood obesity are also substantial and include a greater risk of hypertension, diabetes, cardiovascular disease, gall bladder disease, and osteoarthritis in adulthood. Download File

    A tale of two obescities: Comparing responses to childhood obesity in London and New York City

    In the last 25 years, childhood obesity rates in London and New York City have more than doubled, creating epidemics that now threaten the well-being of current and future residents, widen existing socioeconomic and racial/ethnic inequities in health, and impose a growing economic burden. Each city has initiated a variety of policies and programs to reduce childhood obesity, but few policy makers or researchers believe that the current responses are adequate to reverse the increases in obesity. Both the US and England have recently seen a modest slowdown in the rate of increase of childhood obesity. While it is too soon to know if these declines will be sustained, the two cities now have an opportunity to accelerate and amplify efforts to reverse the trend of the past 25 years. Download File

    Preventing and reducing childhood obesity in New York

    New York State has a childhood obesity crisis. The New York State Department of Health estimates that one in four New Yorkers under the age of 18, or approximately 1.1 million young people, is obese. This childhood obesity crisis, in turn, is fueling a health care cost crisis, with an estimated annual $242 million in medical costs attributed to these children, which is putting even greater strain on the New York State budget.

    According to the Centers for Disease Control and Prevention (CDC), the terms overweight and obesity refer to ranges of weight that are greater than what is generally considered as healthy for a certain height. A calculation, known as the body mass index, uses a person’s weight and height to link the amount of body fat, and whether the person is overweight or obese. Download File

    Neighborhood food environment and walkability predict obesity in New York City

     Differences in the neighborhood food environment may contribute to disparities in obesity. The purpose of this study was to examine the association of neighborhood food envi­ronments with body mass index (BMI) and obesity after control for neighborhood walkability. This study employed a cross-sectional, multilevel analysis of BMI and obesity among 13,102 adult residents of New York City. We constructed measures of the food environment and walk­ability for the neighborhood, defined as a half-mile buffer around the study subject’s home address. Density of BMI-healthy food outlets (supermarkets, fruit and vegetable markets, and natural food stores) was inversely associated with BMI. Mean adjusted BMI was similar in the first two quintiles of healthy food density (0 and 1.13 stores/km2, respectively), but declined across the three higher quintiles and was 0.80 units lower [95% confidence interval (CI), 0.27–1.32] in the fifth quintile (10.98 stores/km2) than in the first. The prevalence ratio for obesity comparing the fifth quintile of healthy food density with the lowest two quintiles combined was 0.87 (95% CI, 0.78–0.97). These associations remained after control for two neighborhood walkability measures, population density and land-use mix. The prevalence ratio for obesity for the fourth versus first quartile of population density was 0.84 (95% CI, 0.73–0.96) and for land-use mix was 0.91 (95% CI, 0.86–0.97). Increasing density of food outlets categorized as BMI-unhealthy was not significantly associated with BMI or obesity. Download File

    Growing obesity in America: New York City’s plan to curb obesity

    Supply and demand normally regulates which products are sold, but when a major epidemic is negatively affecting the population, legislative implementations should be put into effect to intervene. Obesity has been is a growing concern among Americans and that concern has increased substantially. As of 2010, the Center for Disease Control and Prevention estimated that roughly forty percent of adults, age twenty years and over were obese, and that thirty-three percent of those in that same age bracket, were considered overweight. During the same time period eighteen percent of adolescents, age twelve to nineteen, and seventeen percent of children age six to eleven, were found to be obese. These staggering statistics pushed New York City’s Department of Health and Mental Hygiene to adopt Amendment § 81.53 to the New York City Health Code. The purpose of the amendment is to limit the size of sugary drinks that customers can purchase at restaurants, entertainment venues and street carts. This ban becomes effective in March of 2013 and is the first of its kind to pass in the United States. As with any controversial piece of legislation, there are always arguments drawn for and against it. Download File

    Community interventions to address obesity – The Interface of evidence and public policy in New York City

    NYC serves over 225 million meals and snacks per year

    • Originally sought only to reduce hunger

    • NYC healthier procurement rules to reduce obesity and prevent chronic disease:

    – School Food: 2003

    – Daycares: 2005

    – All publicly funded foods:



    – ≤ 25 calories per 8 oz for beverages other then 100% juice or milk. Download File

    Childhood overweight in a New York City WIC population

    Overweight and obesity among both children and adults are increasing and, as a result, receiving greater attention. The recent release by the US Department of Health and Human Services of The Surgeon General’sCall to Action to Prevent and Decrease Overweightand Obesity is one indication of the recognition of obesity as a serious public health issue. National survey data from the Behavioral Risk Factor Surveillance System show that the prevalence of obesity among adults increased from 12% in 1991 to 17.9% in 1998.2 Data from the Third National Health and Nutrition Examination Survey (NHANES) suggest that prevalence is actually closer to 23%, and preliminary results from the most recent NHANES show a further increase, to 31%. NHANES data also show an increase in overweight among children aged 6 to 11 from 4% of the population in 1971 through 1974 to 15% in 1999 through 2000, and a corresponding increase among children aged 2 to 5 years from 5% to 10%. Download File

    Diabetes in New York City: Public health burden and disparities

    Despite advances in knowledge of diabetes care and control, diabetes was the 4th leading cause of death in New York City (NYC) in 2003, directly causing more than 1,800 deaths and contributing to thousands more. In the past decade, the prevalence of diagnosed diabetes has more than doubled among adults in NYC (Figure 1). More than 200,000 additional adult New Yorkers have diabetes but have not yet been diagnosed. This means that approximately 1 in 8 adults has diabetes. More than half of adult New Yorkers are overweight or obese, which increases the risk of diabetes.

     • Uncontrolled diabetes is the leading cause of blindness, end-stage renal disease and non-traumatic lower extremity amputations in adults.

    • Each year in NYC there are more than 20,000 hospitalizations with a principal diagnosis of diabetes.

    • Although the hospitalization rate for diabetes has been stable in recent years, the increase in prevalence reflects a growing number of newly diagnosed, not yet hospitalized people.

    • It is likely that diabetes-related hospitalizations will increase in the coming years. Download File

    Reversing the diabetes and obesity epidemics in New York City

    In the last 10 years, the number of New Yorkers who have been diagnosed with diabetes has increased by 250% and the death rate has nearly doubled1. If these trends continue, medical researchers warn, our children and grand­children will have shorter life spans than we do2. In this report, we describe the alarming rise in diabetes in New York City and assess its causes, consequences, and costs. We examine the relationship between the rise in obesity and diabetes and we consider the moral and social dimensions of the diabetes epidemic. Our goal is to encourage New York policy makers, health professionals and residents to respond to diabetes more forcefully and effectively. 

    Fortunately, much of the medical knowledge needed to control diabetes is already known3,4. Unfortunately, too often individuals, institutions and our society as a whole fail to act on the knowledge we have. Sometimes, this failure is a result of lack of knowledge or interest, but often it is a result of individuals who sincerely want to affect change but are trapped in a system in which obstacles thwart best intentions. Download File

    Diabetes in New York City

    In 29 years the diabetes death rate has doubled in New York City. During this period the death rates from many other diseases declined. The Department of Health records for the entire city, without distinction as to age or sex, show the average diabetes death rate per 100,000 people. These general averages for 29 years, according to sex, indicate that the death rate increased in both sexes, but it increased more rapidly in females among whom the rate was consistently higher. When did diabetes begin to take its toll of human life? Out of a total of 24,850 deaths from this cause in 29 years, only 126 deaths took place among children under 5 years of age. Among boys and girls from 5 to 15 years of age, 422 deaths took place in this same period. In this age group, too, diabetes was not an important cause of death. Diabetes is clearly not to be classed among the diseases of childhood, as are diphtheria, measles and whooping cough. Download File

    Facing the Diabetes epidemic — Mandatory reporting of Glycosylated Hemoglobin values in New York City

    In 29 years the diabetes death rate has doubled in New York City. During this period the death rates from many other diseases declined. The Department of Health records for the entire city, without distinction as to age or sex, show the average diabetes death rate per 100,000 people. These general averages for 29 years, according to sex, indicate that the death rate increased in both sexes, but it increased more rapidly in females among whom the rate was consistently higher. When did diabetes begin to take its toll of human life? Out of a total of 24,850 deaths from this cause in 29 years, only 126 deaths took place among children under 5 years of age. Among boys and girls from 5 to 15 years of age, 422 deaths took place in this same period. In this age group, too, diabetes was not an important cause of death. Diabetes is clearly not to be classed among the diseases of childhood, as are diphtheria, measles and whooping cough. Download File

    Barriers to buying healthy foods for people with Diabetes: Evidence of environmental disparities

    At least 16 million Americans have diabetes, and its prevalence is increasing, especially among Latinos.1 African American and Latino adults are 1.3 to 1.9 times more likely to have diabetes than are White adults.1–3 Among adults 40 to 74 years of age, 26% of Puerto Ricans, 24% of Mexican Americans, and 19% of African Americans have diabetes, compared with 12% to 13% of Whites. In New York City, Latinos 18 to 39 years of age are 4 times more likely than Whites to have diabetes, and African Americans in this age group are 2 times more likely than Whites to have diabetes.4 In the United States, Latinos and African Americans also are less likely than Whites to be in control of their blood sugar levels; they have 2 to 4 times Whites’ rate of diabetes complications, such as renal disease and blindness, and they have higher diabetes-specific mortality rates. Download File

    Impact of the increasing burden of diabetes on Acute Myocardial Infarction in New York City

    Worldwide increases in obesity and diabetes have aroused concern that increased morbidity and mortality will follow. The objective here is to determine the trend of diabetes related morbidity and mortality in New York, New York. Using New York death certificate data for 1989–1991 and 1999–2001 and hospital discharge data for 1988–2002, we measured all-cause and cause-specific mortality in 1990 and 2000, as well as annual hospitalization rates for diabetes and its complications among patients hospitalized with acute myocardial infarction and/or diabetes. During this decade, all-cause and cause-specific mortality rates declined, with the striking exception of diabetes, which increased 61 and 52% for men and women, respectively, as did hospitalization rates for diabetes and its complications. The percentage of all acute myocardial infractions occurring in patients with diabetes increased from 21 to 36%, and the absolute number doubled from 2,951 to 6,048. Although hospital days due to acute myocardial infarction fell overall, for those with diabetes, they increased 51% (from 34,188 to 51,566). Download File

    Diabetes prevalence among Puerto Rican adults in New York City, NY, 2000

    Diabetes is a leading cause of mortality, morbidity, and disability that disproportionately affects US Hispanic persons. Reported diabetes prevalence among the US Hispanic population is approximately twice that of non- Hispanic Whites. Because the US Hispanic population is heterogeneous, diabetes risk is likely to vary according to the diverse ethnic origins. Puerto Rican persons are the largest Hispanic group in New York City, NY, and they are among the most assimilated Hispanic persons to the US culture. However, recent information about diabetes in this population is lacking. This study assessed the prevalence of diagnosed diabetes and associated characteristics among Puerto Rican adults in New York City. Download File

    Population-based assessment of Diabetes care and self-management among Puerto Rican Adults in New York City

    New York State has the third largest Hispanic population in the United States, after California and Texas. The largest segment of the New York State Hispanic population is Puerto Rican, totaling more than million and being highly concentrated in New York City (NYC).1 Diabetes has been recognized as a major health problem in this population. The Hispanic Health and Nutrition Examination Survey (Hispanic HANES), conducted in 1982 through 1984, and a telephone survey from 1999 to 20004 reported that diabetes prevalence among Puerto Ricans in NYC was approximately twice that of non-Hispanic whites. Similar high prevalence of diabetes was reported by studies conducted in the Commonwealth of Puerto Rico, where about a half of adult NYC Puerto Ricans were born. Difficulties in meeting recommended diabetes. Download File

    A socioeconomic analysis of obesity and Diabetes in New York City

    Surging obesity rates throughout the United States have rapidly changed the face of diabetes mellitus, spawning a type 2 diabetes epidemic. Whereas in the past the most prevalent form of the disease was type 1, today more than 90% of cases are type 2. From 1991 to 2001, obesity grew nationwide by 74%; correspondingly, the prevalence of type 2 diabetes increased 61% during the same period. Researchers have calculated that each kilogram increase in body mass increases the risk for developing diabetes by 4.5%. Indeed, because of the increasing number of children developing the disease, type 2 is no longer referred to as “adult onset.” Because of the obesity epidemic, more than 7.8% of adult Americans have diabetes today. The problem is particularly severe in New York City, despite its reputation as a city of fit pedestrians; the prevalence of diabetes among New Yorkers has doubled during the past decade to 12.5%, mirroring surging obesity rates citywide. Indeed, uncontrolled diabetes is the leading cause of blindness, end-stage renal disease, and nontraumatic lower-extremity amputations for adult New Yorkers. Download File

    Overreporting of deaths from Coronary Heart Disease in New York City hospitals, 2003

    Coronary heart disease (CHD) is the leading cause of death for adults in the United States, and stroke ranks third. In New York City, an unusual pattern of high CHD death rates and low stroke death rates has been observed; the age-adjusted CHD death rate in 2003 was 1.7 times the national rate, and the age-adjusted stroke death rate was half the national rate. This pattern is unexpected, given that risk factors for CHD and stroke are similar and that the prevalence in New York City of most common CHD risk factors, such as hypertension, hyperlipidemia, obesity, and smoking, is similar to or lower than that in the rest of the country. New York City CHD death rates have been consistently higher than national CHD death rates for more than 3 decades despite steady CHD death rate declines nationally and in New York City. Misreporting cause of death on death certificates may be contributing to New York City’s observed high CHD death rate. Studies have suggested that such misreporting may be common. Download File

    Primary prevention of Coronary Heart Disease by diet

    The subject of diet, atherosclerosis, and coronary heart disease was covered by Ancel Keys" at the Conference on Atherosclerosis and Coronary Heart Disease held on January 15, I97, and sponsored by the New York Heart Association. Among the major conclusions from Dr. Keys' epidemiologic studies of more than a decade ago were the following:

    1) There were very great differences between populations in the incidence of atherosclerosis and the mortality of coronary heart disease at given ages.

    2) These differences were not explained by race, nationality, or climate or any nondietary factor studied.

    3) The differences appeared to be closely correlated with the average serum cholesterol concentration in samples of the population. Download File

    Fine particulate matter constituents associated with cardiovascular hospitalizations and mortality in New York City

    Recent time-series studies have indicated that both cardiovascular disease (CVD) mortality and hospitalizations are associated with particulate matter (PM). However, seasonal patterns of PM associations with these outcomes are not consistent, and PM components responsible for these associations have not been determined. We investigated this issue in New York City (NYC), where PM originates from regional and local combustion sources. In this study, we examined the role of particulate matter with aerodynamic diameter ≤ 2.5 μm (PM2.5) and its key chemical components on both CVD hospitalizations and on mortality in NYC. We analyzed daily deaths and emergency hospitalizations for CVDs among persons ≥ 40 years of age for associations with PM2.5, its chemical components, nitrogen dioxide (NO2), carbon monoxide, and sulfur dioxide for the years 2000–2006 using a Poisson time-series model adjusting for temporal and seasonal trends, temperature effects, and day of the week. We estimated excess risks per interquartile-range increases at lags 0 through 3 days for warm (April through September) and cold (October through March) seasons. Download File

    The association between birthplace and mortality from cardiovascular causes among Black and White residents of New York City

    Life expectancy is shorter and mortality from cardiovascular disease higher among blacks than among whites in the United States. We studied whether place of birth was associated with mortality from cardiovascular causes among non-Hispanic black and white residents of New York City. We linked mortality records from 1988 through 1992 with 1990 U.S. Census data for New York City. Mortality data for blacks born in the U.S. South and Northeast and in the Caribbean were compared with those for whites born in the Northeast. Among blacks, the rates of overall mortality and mortality from cardiovascular causes exceeded those among whites. Among persons born in the Northeast, the rates of death from cardiovascular disease for white men (285 per 100,000), as compared with black men (299), and for white women (155), as compared with black women (165), were similar. However, Southern-born black men and women both had mortality from cardiovascular disease that was substantially higher than that of their counterparts born in the Northeast, and Caribbean-born blacks had rates substantially lower than their Northeastern- born counterparts. Download File

    Best bets for reducing Medicare costs for dual eligible beneficiaries: Assessing the evidence

    In response to concerns about the federal deficit and the national debt, some policymakers and researchers have put forward strategies to reduce the growth in Medicare and Medicaid spending by improving the coordination of care for those who are dually eligible for Medicare and Medicaid (known as “dual eligible beneficiaries). More specifically, some have suggested that large savings can be achieved by improving the coordination of care either by enrolling dual eligible beneficiaries into managed care plans or by paying care coordination programs to integrate and coordinate Medicare and Medicaid services from providers who are reimbursed by Medicare and Medicaid on a fee-for-service (FFS) basis, with estimated savings of up to $20
    billion per year. Download File

    Can Medicare be preserved while reducing the deficit?

    The politically polarized debate over the role of Medicare in deficit and debt reduction often ignores the accumulating evidence that the program can achieve significant spending reductions without sacrificing Medicare’s essential protections. The caricature of Medicare as a program out of control and in need of fundamental restructuring is wrong. Equally wrong are views that any significant changes to Medicare’s current benefit design and payment policies would compromise beneficiary access and quality. Instead of joining this nonproductive clash of ideological and political positions, we identify policies that correct long-standing gaps in financial protections that Medicare beneficiaries face, promote greater efficiency within payment systems, and recognize the need for additional revenues to pay for the impending surge in the number of beneficiaries in the program. Download File

    Affordable care act update: implementing Medicare cost savings

    The Affordable Care Act includes a series of Medicare reforms that will generate billions of dollars in savings for Medicare and strengthen the care Medicare beneficiaries receive. The new law protects guaranteed benefits for all Medicare beneficiaries, and provides new benefits and services to seniors on Medicare that will help keep seniors healthy. The law also includes provisions that will improve the quality of care, develop and promote new models of care delivery, appropriately price services, modernize our health system, and fight waste, fraud, and abuse. Implementing these changes extends the life of the Medicare Hospital Insurance Trust Fund by 12 years from 2017 to 2029, more than doubling the time before the exhaustion of the Trust Fund. Download File

    The accuracy of Medicare’s hospital claims data: progress has been made, but problems remain

    Administrative health care databases provide an increasingly accessible and widely used source of data for health care
    research.1-10 However, the accuracy of hospital discharge data remains uncertain. Studies conducted in the 1970s found that
    the coding of nonclinical data, such as age,gender, and dates of admission and discharge, was highly accurate but that diagnoses and procedures were less reliably coded. Recent studies continue to raise questions about the accuracy of diagnostic coding.The National Diagnosis Related Group (DRG) Validation Study, which provided the most comprehensive recent assessment of the accuracy of hospital discharge data, found an overall error rate of 20.8% in DRG assignment.DRGs include diverse clinical conditions, the findings could not be generalized to the coding of specific diagnose or procedures. Also, the published results could not be directly compared with those of the Institute of Medicine (IOM) studies of 1977 and 1980, even though both the National DRG Validation Study and the IOM studies used similar methods. We reanalyzed the data from the National DRG Validation Study to address these issues. Download File

    Cost shifting or cost cutting?: The incidence of reductions in Medicare payments

    This paper examines how reductions in hospital payments by Medicare affect hospital operations. I look at two episodes of payment reductions: the late 1980s and the early 1990s. I find a large difference in the impact of payment reductions in these two time periods. In the 1980s, reduced Medicare payments were offset dollar for dollar by increased prices to private insurers. In the 1990s, however, payment reductions result in lower hospital profits, which must ultimately reduce hospital costs. Hospitals
    have responded to the payment reductions by reducing the number of beds and nurses, and sometimes by closing entirely, but not by reduced acquisition of high-tech equipment. Download File

    Medicare hospital readmissions reduction program: To improve care and lower costs, Medicare imposes a financial penalty on hospitals with excess readmissions

    This brief describes the Medicare Hospital Readmissions Reduction Program (HRR) established in the Affordable Care Act (ACA) that provides a financial incentive to hospitals to lower readmission rates. Although the program has been in operation for only a few years, initial results show potential. A number of technical issues in the program design have been identified and are being addressed by the Centers for Medicare and Medicaid Services (CMS) through the administrative process.
    However, there are also concerns about potential flaws in the program’s methodological approach Others fear unintended consequences for safety-net hospitals that may threaten care for vulnerable populations. Download File

    Adverse events in hospitals: national incidence among Medicare beneficiaries

    The term “adverse event” describes harm to a patient as a result of medical care, such as infection associated with use of a catheter. The term “never events” refers to a specific list of serious events, such as surgery on the wrong patient, that the National Quality Forum (NQF) deemed “should never occur in a health care setting.” The Tax Relief and Health Care Act of 2006 mandates that the Office of Inspector General report to Congress regarding the incidence of never events among Medicare beneficiaries, the payment for services in connection with such events, and the Centers for Medicare & Medicaid Services (CMS) processes to identify events and deny payment.We selected a nationally representative random sample of 780 Medicare beneficiaries from all beneficiaries discharged during October 2008. Physician reviewers determined (1) whether an adverse event occurred, (2) whether the event was on the NQF list of Serious Reportable Events or the Medicare list of hospital-acquired conditions (HAC), (3) what the level of harm was to the patient, and (4) whether the event was preventable. Download File

    Out-of-pocket health spending by poor and near-poor elderly Medicare beneficiaries

    Objective. To estimate out-of-pocket health care spending by lower-income Medicare beneficiaries, and to examine spending variations between those who receiv Medicaid assistance and those who do not receive such aid.
    Data Sources and Collecion. 1993 Medicare Current Beneficiary Survey (MCBS) Cost and Use files, supplemented with data from the Bureau of the Census (Current Population Survey); the Congressional Budget Office; the Health Care Financing
    Administration, Office of the Actuary (National Health Accounts); and the Social Security Administration.                               Study Design. We analyzed out-of-pocket spending through a Medicare Benefit Simulation model, which projects out-of-pocket health care spending from the 1993 MCBS to 1997. Out-of-pocket health care spending is defined to include Medicare
    deductibles and coinsurance; premiums for private insurance, Medicare Part B, and Medicare HMOs; payments for non-covered goods and services; and balance billing by physicians. It excludes the costs of home care and nursing facility services, as well
    as indirect tax payments toward health care financing.
    Principal Findings. Almost 60 percent of beneficiaries with incomes below the poverty level did not receive Medicaid assistance in 1997. We estimate that these beneficiaries spent, on average, about half their income out-of-pocket for health care, whether they were enrolled in a Medicare HMO or in the traditional fee-for-service program. Download File

    Medicare’s bending cost curve

    The rate of national health care spending growth per person has been on a downward trajectory in recent years (see Figure 1). This downward trend has been especially significant for the Medicare program since 2009. In fact, the most recent data show that the average per enrollee annual spending growth rate for the Medicare program (including both Traditional Medicare and the Medicare Advantage (MA) program) for 2009-2012 was one-third of the average growth rate from 2000-2008: 2.3 percent versus 6.3 percent (data not shown in table).The preliminary estimate of the per enrollee expenditure growth rate for Medicare in 2013 is only 0.1 percent. In other words, there was essentially no growth in Medicare expenditures on a per capita basis last year. The number of beneficiaries covered by the program is rising by about 3 percent per year, and the aggregate (across all beneficiaries) estimated Medicare expenditure growth rate for 2013 is 3 percent. Early claims data as well as Treasury data on Medicare payments from the first half of 2014 indicate that very slow per capita growth has continued so far this year, although final spending growth estimates will not be available for some time. Download File

    Shared decision making to improve care and reduce costs

    A sleeper provision of the Affordable Care Act (ACA) encourages
    greater use of shared decision making in health care. For many health situations in which there’s not one clearly superior
    course of treatment, shared decision making can ensure that medical care better aligns with
    patients’ preferences and values. One way to implement this approach is by using patient decision aids — written materials,
    videos, or interactive electronic presentations designed to inform patients and their families about care options; each option’s outcomes,including benefits and possible side effects; the health care team’s skills; and costs. Shared decision making has the potential to provide numerous benefits for patients, clinicians,and the health care system, including increased patient knowledge, less anxiety over the care process, improved health outcomes,reductions in unwarranted variation in care and costs,
    and greater alignment of care with patients’ values. Download File

    What works in care coordination?: Activities to reduce spending in Medicare fee-for-service

    The rapid increase in health care spending in the United States over the past two decades and its anticipated growth in the coming years can be tied inextricably to the increasing number of people with multiple chronic conditions. Medicare beneficiaries are especially likely to have numerous conditions, with two-thirds of Medicare spending attributed to patients with five or more chronic conditions.1 Medicare Fee-For-Service (FFS) spending, in particular, accounts for over three quarters of the total Medicare spending.2 Gaps in the coordination of care for these chronically ill patients, including inadequate transitional care from hospital to home and insufficient management of multiple medications, often result in poor care quality, increased hospital admissions, and growing health care expenditures in Medicare. Download File

    Assessing the impact of potential cuts in Medicare doctor-training subsidies

    The federal Medicare program provided about $9.5 billion in graduate medical-education subsidies to the hospital industry in 2010. These funds provide direct and indirect financial support to help offset the costs incurred by hospitals sponsoring residency programs for future doctors. The justification for these subsidies have come under renewed scrutiny in Congress and the Obama administration, where policy makers are increasingly preoccupied with cutting the budget and reducing the federal deficit. The so-called sequestration process that may subject Medicare provider payments to across-the-board cutbacks next year and for the following nine years is leading policy makers to identify specific ways to cut Medicare payments without causing undue harm to the health-care system. Download File

    Medicare, Medicaid fraud a billion-dollar art form in the US

    Medicare and Medicaid fraud costs billions of dollars each year in the US. Investigators have shown that fraud is found in all segments of the health care system. Even though the Canadian system has stricter regulations and tighter controls, can regulators here afford to be complacent about believing that such abuse would not happen here? One province has established an antifraud unit to monitor its health insurance scheme; it already has one prosecution under its belt. Download File

    New York Medicaid fraud may reach into billions

    It was created 40 years ago to provide health care for the poorest New Yorkers, offering a lifeline to those who could not afford to have a baby or a heart attack. But in the decades since, New York State's Medicaid program has also become a $44.5 billion target for the unscrupulous and the opportunistic.

    It has drawn dentists like Dr. Dolly Rosen, who within 12 months somehow built the state's biggest Medicaid dental practice out of a Brooklyn storefront, where she claimed to have performed as many as 991 procedures a day in 2003. After The New York Times discovered her extraordinary billings through a computer analysis and questioned the state about them, Dr. Rosen and two associates were indicted on charges of stealing more than $1 million from the program. Download File

    Electronic fraud detection in the U.S. Medicaid healthcare program: Lessons learned from other industries

    It is estimated that between $600 and $850 billion annually is lost to fraud, waste, and abuse in the US healthcare system, with $125 to $175 billion of this due to fraudulent activity (Kelley 2009). Medicaid, a state-run, federally-matched government program which accounts for roughly one-quarter of all healthcare expenses in the US, has been particularly susceptible targets for fraud in recent years. With escalating overall healthcare costs, payers, especially government-run programs, must seek savings throughout the system to maintain reasonable quality of care standards. As such, the need for effective fraud detection and prevention is critical. Electronic fraud detection systems are widely used in the insurance, telecommunications, and financial sectors. What lessons can be learned from these efforts and applied to improve fraud detection in the Medicaid health care program? In this paper, we conduct a systematic literature study to analyze the applicability of existing electronic fraud detection techniques in similar industries to the US Medicaid program. Download File

    Patient confidentiality statutes in Medicare and Medicaid fraud investigations

    The Medicare and Medicaid programs have been burdened with healthcare providers' fraudulent and abusive practices since their implementation in 1965. To help states discover and prevent medicare and Medicaid fraud, Congress has enacted statutes permitting acees to patients' medical records in investigations of fraud. The majority of states have enacted physician-patient and psychotherapist- patient privilege statutes to protect confidential information from disclosure. This the state's need for patient information conflicts with the patient's right of privacy. Download File

    Attorneys caught in the web of Medicare/Medicaid fraud: an overview of an attorney’s ethical duties and criminal liability in the wake

    Attempting to recoup some of the billions of dollars lost each year to Medicare and Medicaid fraud, the government has prosecuted physicians and hospitals whose actions appeared questionable.  Until recently, attorneys could be fairly confident that they would not face criminal or even civil litigation if they wrote Medicare referral contracts for physicians. However, with losses from fraud in the health care industry estimated between $80 and $90 billion per year, federal prosecutors have begun to target their investigations toward attorneys working in the health care field. In 1998, the government indicted two attorneys, along with several former hospital officials and physicians, “for an alleged scheme to solicit, receive, and pay $2.2million in bribes” in connection with Medicare fraud. Download File

    Fraud & abuse: DOJ and Medicare and Medicaid model compliance programs

    Medicaid and Medicare fraud and abuse has commanded the attention of the federal government in recent years due to its impact on escalating health care costs.' Combating health care fraud is now one of the Department of Justice's (DOJ) highest priorities, as evidenced by the extensive resources dedicated to investigating possible fraudulent activity.^ In this environment of active government enforcement, strict statutes proscribing health care fraud and abuse, and substantial penalties for violations, organizations are seeking to reduce their liability for acts of fraud and abuse by establishing compliance programs, requesting advisory opinions, and engaging in voluntary self-disclosure. Download File

    A patient-centered approach to health care fraud recovery

    This Article begins with a simple premise: Health care fraud hurts patients. From that premise flows a simple corollary: efforts to combat health care fraud should, if possible, remedy this patient harm. Despite its intuitive appeal, this syllogism does not represent current practice. Funds recovered through health care fraud enforcement are distributed to the Medicare Tmst Fund, to the federal agencies that investigate and prosecute health care fraud, and to private parties who initiate suits on the government's behalf under the civil False Claims Act'—^but rarely to patients who may have been harmed by the conduct. While focusing enforcement efforts on returning funds to the Federal Treasury clearly helps to assure that the federal health care programs^ remain solvent and continue to provide care to beneficiaries in the aggregate, it offers little solace to injured individuals. Download File

    Calling All Con Artists: The president’s new entitlement will prove a fount of fraud

    Oklahoma senator and medical doctor Tom Coburn often tells the story of Guillermo Denis Gonzalez, a convicted killer who, while out of prison between murders, posed as a supplier of medical products and submitted more than half a million dollars in false Medicare claims. But Gonzalez was just one of the thousands who bilk taxpayers for billions of dollars annually. While statistics hard to come by, the available numbers are truly frightening. A 2009 Government Accountability office study found that 10.5 percent of Medicaid payments in fiscal year 2008 were improper. And a Thompson Reuters study in October of 2009 found there to be somewhere between $600 and $850 billion annually in health-care waste, which includes fraud but also inefficiency and medical errors. Nationwide estimates of fraud alone tend to place it in the $60–100 billion range. Download File

    States, safety net providers recover millions from Medicaid fraud schemes

    In late December and early January, states started receiving millions of dollars in reimbursements owed to them after Bayer Corp. and GlaxoSmithKline (GSK) agreed last April to pay more than $344 million to settle Medicaid fraud charges.

    California received the largest settlement—$ 14.4 million from Bayer.

    The largest settlement check that GSK paid to a state was $5.7 million to New York.

    More than $2.3 million from the nearly $5 million that North Carolina recovered from Bayer and GSK will fund public schools in the state, said Noelle Talley, spokesperson for the North Carolina Attorney General’s Office. Download File

    CRC resolves Medicaid fraud allegations with $9.2 million sum

    The Department of Justice announced on April 16 that CRC Health Group has agreed to pay $9.25 million to the federal government and the state of Tennessee to settle allegations that it submitted false claims by providing substandard treatment to Medicaid patients at its facility in Burns, Tennessee. “Medicaid patients who enter residential treatment programs for alcohol and drug addiction deserve to have treatment provided by qualified personnel according to the appropriate standard of care,” said Assistant Attorney General for the Justice Department’s Civil Division Stuart F. Delery. “We will not tolerate health care providers who prioritize profit margins over the needs of their patients.” The Burns facility, called New Life Lodge, was purchased by CRC in 2006. According to the government, between 2006 and 2012, New Life Lodge billed the Tennessee Medicaid program (TennCare) for treatment that was not provided or was provided by therapists who were not licensed by Tennessee.      Download File