Dual impacts of Medicare payment reform and the COVID-19 pandemic on therapy staffing in skilled nursing facilities.

BACKGROUND: Implementation of new skilled nursing facility (SNF) Medicare payment policy, the Patient Driven Payment Model (PDPM), resulted in immediate declines in physical and occupational therapy staffing. This study characterizes continuing impacts of PDPM in conjunction with COVID-19 on SNF therapy staffing and examines variability in staffing changes based on SNF organizational characteristics. METHODS: We analyzed Medicare administrative data from a national cohort of SNFs between January 2019 and March 2022. Interrupted time series mixed effects regression examined changes in level and trend of total therapy staffing minutes/patient-day during PDPM and COVID-19 and by type of staff (therapists, assistants, contractors, and in-house staff). Secondary analyses examined the variability in staffing by organizational characteristics. RESULTS: PDPM resulted in a -6.54% level change in total therapy staffing, with larger declines for assistants and contractors. Per-patient staffing fluctuated during COVID-19 as the census changed. PDPM-related staffing declines were larger in SNFs that were: Rural, for-profit, chain-affiliated, provided more intensive therapy, employed more therapy assistants, and admitted more Medicare patients before PDPM. COVID-19 resulted in larger staffing declines in rural SNFs but smaller early declines in SNFs that were hospital-based, for-profit, or received more relief funding. CONCLUSIONS: SNFs that historically engaged in profit-maximizing behaviors (e.g., providing more therapy via lower-paid assistants) had larger staffing declines during PDPM compared to other SNFs. Therapy staffing fluctuated during COVID-19, but PDPM-related reductions persisted 2 years into the pandemic, especially in rural SNFs. Results suggest specific organizational characteristics that should be targeted for staffing and quality improvement initiatives.

Estimating the spatial correlation and convergence of China's healthcare resources allocation: evidence from the Yangtze River Delta Region.

BACKGROUND: China's imbalanced allocation of healthcare resources mainly arises from urban-rural and intercity differences, the solution of which has been the goal of reforms during the past decades. Estimating the spatial correlation and convergence could help to understand the impact of China's fast-evolving medical market and the latest healthcare reforms. METHODS: The entropy weight method was used to construct a healthcare resource supply index (HRS) by using data of 41cities in a cluster in the Yangtze River Delta (YRD) from 2007 to 2019. The Dagum Gini coefficient, kernel density estimation, Moran's I, and LISA cluster map were used to characterize the spatiotemporal evolution and agglomeration of healthcare resources, and then a spatial panel model was used to perform ß convergence estimation by incorporating the spatial effect, city heterogeneity, and healthcare reforms. RESULTS: Healthcare resources supply in the YRD region increases significantly and converges rapidly. There is a significant spatial correlation and agglomeration between provinces and cities, and a significant spatial spillover effect is also found in ß convergence. No evidence is found that the latest healthcare reforms have an impact on the balanced allocation and convergence of healthcare resources. CONCLUSION: China's long-term investment in past decades has yielded a more balanced allocation and intercity convergence of healthcare resources. However, the latest healthcare reforms do not contribute to the balanced allocation of healthcare resources from the supply-side, and demand-side analysis is needed in the future studies.

Public policy changes in public funding of family doctors in Slovenia

In Slovenia, patients report difficulties registering with a family doctor (FD), even in dense urban areas, since the patient-to-FD ratio is well below the EU average and not improving. Moreover, public primary healthcare providers (PCP) report difficulties with the financial liquidity that endangers the regular payment of employed FDs' salaries and constantly call for additional budget funding in the healthcare sector, especially after the COVID-19 pandemic crisis. It is therefore questionable, whether or not the PCP, which perform economic activity under the EU standards, respect human rights of all the stakeholders in the healthcare sector. Therefore, in this paper, I analyse the existing regulations on the public financing of FDs in Slovenia that seems to pose significant problems to patients' timely access to health care and does not facilitate the FDs' goal of delivering the patients' constitutional right to healthcare services. I discuss some better alternative solutions that would promote the patients' right to effective primary healthcare, attract more medical students to specialise in family medicine and consolidate the fiscal sustainability of the primary healthcare sector, which is at grave risk of collapse due to a dysfunctional healthcare payment and delivery system. Copyright © 2022 Inderscience Enterprises Ltd.

Exploring Public Perceptions of Dental Care Affordability in the United States: Mixed Method Analysis via Twitter.

BACKGROUND: Dental care expenses are reported to present higher financial barriers than any other type of health care service in the United States. Social media platforms such as Twitter have become a source of public health communication and surveillance. Previous studies have demonstrated the usefulness of Twitter in exploring public opinion on aspects of dental care. To date, no studies have leveraged Twitter to examine public sentiments regarding dental care affordability in the United States. OBJECTIVE: The aim of this study is to understand public perceptions of dental care affordability in the United States on the social media site, Twitter. METHODS: Tweets posted between September 1, 2017, and September 30, 2021, were collected using the Snscrape application. Query terms were selected a priori to represent dentistry and financial aspects associated with dental treatment. Data were analyzed qualitatively using both deductive and inductive approaches. In total, 8% (440/5500) of all included tweets were coded to identify prominent themes and subthemes. The entire sample of included tweets were then independently coded into thematic categories. Quantitative data analyses included geographic distribution of tweets by state, volume analysis of tweets over time, and distribution of tweets by content theme. RESULTS: A final sample of 5314 tweets were included in the study. Thematic analysis identified the following prominent themes: (1) general sentiments (1614 tweets, 30.4%); (2) delaying or forgoing dental care (1190 tweets, 22.4%); (3) payment strategies (1019 tweets, 19.2%); (4) insurance (767 tweets, 14.4%); and (5) policy statements (724 tweets, 13.6%). Geographic distributions of the tweets established California, Texas, Florida, and New York as the states with the most tweets. Qualitative analysis revealed barriers faced by individuals to accessing dental care, strategies taken to cope with dental pain, and public perceptions on aspects of dental care policy. The volume and thematic trends of the tweets corresponded to relevant societal events, including the COVID-19 pandemic and debates on health care policy resulting from the election of President Joseph R. Biden. CONCLUSIONS: The findings illustrate the real-time sentiment of social media users toward the cost of dental treatment and suggest shortcomings in funding that may be representative of greater systemic failures in the provision of dental care. Thus, this study provides insights for policy makers and dental professionals who strive to increase access to dental care.

COMMUNICATING ABOUT HEALTHCARE REFORM AS PART OF GOOD GOVERNANCE DURING THE COVID-19 PANDEMIC. EXPERIENCES FROM FINLAND AND POLAND

The right to information, understood as a citizen's right of access to data used in the process of making and enforcing laws, is a natural component of democratic systems. In the rich societies of Western Europe, which for years have been supporting civic education, society consciously uses the right to information. It is the interaction of citizens with decision-makers among others in the process of public information flow that changes ordinary public governance into good governance. The authors refer to the contextual understanding of good governance within the framework of multi-level interactions at the level of central and local government. Good governance should be understood as the achievement of 'public value' - i.e., the shared needs of many citizens but within the context of innovation and the economic development of societies. Informing means strengthening trust in public authorities, which in democratic states should have nothing to hide (even in a crisis).

Changes in the Proportion of Gastrointestinal Emergency Endoscopy and Peptic Ulcer Disease During the COVID-19 Pandemic: A Local Retrospective Observational Study From Vietnam.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has disrupted the practice of gastrointestinal (GI) endoscopy units and may increase the risk of digestive disorders. We described the situational changes in GI endoscopy and peptic ulcer disease (PUD) proportion during COVID-19 in Vietnam and examined the associated factors. METHODS: A retrospective ecological study was conducted on data of Hanoi Medical University Hospital, Vietnam. The number of upper GI endoscopy and the proportion of GI emergency endoscopy and PUD were compared between 2019 and 2020 by month (January to June). Log-binomial regression was used to explore associated factors of GI emergency endoscopy and PUD. RESULTS: The number of endoscopies decreased remarkably during the nationwide social distancing in April 2020. Compared to April 2019, the proportion in April 2020 of both GI emergency endoscopy [4.1 vs. 9.8%, proportion ratio (PR) 2.39, 95% CI 2, 2.87], and PUD [13.9 vs. 15.8%; PR, 1.14; 95% CI, 1.01, 1.29] was significantly higher. In log-binomial models, the proportion of GI emergency endoscopy was higher in April 2020 compared to April 2019 (adjusted PR, 2.41; 95% CI, 2.01, 2.88). Male sex and age of ≥50 years were associated with an increased PUD and GI emergency conditions. CONCLUSION: The proportion of both GI emergency endoscopy and PUD was significantly higher during the time of the state of emergency due to the ongoing COVID-19 pandemic in 2020 when compared to 2019 at the same health facility in Vietnam. The findings suggest that healthcare delivery reforms during the era of an emerging pandemic are required to reduce digestive disorders, in particular, and chronic diseases in general.

Strengthening the WHO in the pandemic era by removing a persistent structural defect in financing.

BACKGROUND: The WHO's success in its vital role is constrained by inadequate financial support from member states and overreliance on earmarked voluntary contributions, which erodes autonomy. The agency's broad functions, including coordination among 194 members, cannot be performed by any other entity. However, despite experts' well-articulated concerns that the agency's legitimacy and authority in global health matters have been undermined, a decades-long freeze on member assessments means that WHO priorities are disproportionately influenced by a few powerful donors. A STRUCTURAL DEFECT: To overcome inertia in addressing well-known limitations, it may be helpful to consider the weaknesses in WHO's financing mechanism as a persistent structural defect. This perspective strengthens the focus on corrections needed to remove the defect. In our view, the main features of the structural defect are the self-imposed constraints that foster the perception-if not the reality-that the agency's legitimacy is compromised. These constraints include WHO's inadequate level of financing; lack of direct control over 80% of its funds; and unbalanced participation, such that over 60% of financing originates from only 9 donors. With renewed commitment, however, member countries can remove these constraints. REMOVING THE STRUCTURAL DEFECT: To meaningfully strengthen structural integrity of the financing mechanism, restore WHO's autonomy, and minimize concerns about wealthy-donor supremacy, it will be necessary to define specific requirements and implement restrictions on financial contributions. We make five recommendations, including tripling total financing; ensuring that 70% or more of financial support derives from member assessments; limiting contributions from individual members to a maximum of 4% of total WHO financing; and limiting donations from individual partners to a maximum of 3% of total WHO financing (1% for earmarked donations). Although some might consider these measures impractical, they are justified by the magnitude of the crises the world faces, by member states' increased economic strength in recent decades, and by the importance of shielding the WHO's financing structure from perceived neocolonialism. This necessary step calls for an adjustment of priorities: the higher level of assessed contribution-from nearly all members regardless of wealth-required to reach the proposed targets would still represent only a small fraction of most members' annual military expenditures. CONCLUSION: The COVID-19 pandemic, with its devastating toll on human life and global economic stability, presents an opportunity for reflection and refocusing. Realigning WHO's financial structure to its founders' vision, as proposed here, would likely safeguard both the agency's autonomy and member states' trust, while alleviating concerns about undue influence from powerful donors. Removing the persistent structural defect in financing would empower WHO to lead and coordinate global response to meet the inevitable challenges of the coming decades.

Adapting an emergency general surgery service in response to the COVID-19 pandemic.

INTRODUCTION: In response to the COVID-19 pandemic, our emergency general surgery (EGS) service underwent significant restructuring, including establishing an enhanced ambulatory service and undertaking nonoperative management of selected pathologies. The aim of this study was to compare the activity of our EGS service before and after these changes. METHODS: Patients referred by the emergency department were identified prospectively over a 4-week period beginning from the date our EGS service was reconfigured (COVID) and compared with patients identified retrospectively from the same period the previous year (Pre-COVID), and followed up for 30 days. Data were extracted from handover documents and electronic care records. The primary outcomes were the rate of admission, ambulation and discharge. RESULTS: There were 281 and 283 patients during the Pre-COVID and COVID periods respectively. Admission rate decreased from 78.7% to 41.7%, while there were increased rates of ambulation from 7.1% to 17.3% and discharge from 6% to 22.6% (all p<0.001). For inpatients, mean duration of admission decreased (6.9 to 4.8 days), and there were fewer operative or endoscopic interventions (78 to 40). There were increased ambulatory investigations (11 to 39) and telephone reviews (0 to 39), while early computed tomography scan was increasingly used to facilitate discharge (5% vs 34.7%). There were no differences in 30-day readmission or mortality. CONCLUSIONS: Restructuring of our EGS service in response to COVID-19 facilitated an increased use of ambulatory services and imaging, achieving a decrease of 952 inpatient bed days in this critical period, while maintaining patient safety.

Building eConsult (Electronic Consults) Capability at an Academic Medical Center to Improve Efficiencies in Delivering Specialty Care.

As the COVID-19 health crisis continues to reshape healthcare, systems across the country face increasing pressure to adapt their models of care to expand access to care, while also improving efficiency and quality in the face of limited resources. Consequently, many have shown a growing interest and receptivity to the expansion of telehealth models to help meet these demands. Electronic consultations (eConsults) are a telehealth modality that allow for a non-face-to-face asynchronous consultation between a primary care provider (PCP) and a specialist aimed at facilitating specialist input without the need for a patient visit. The aim of this case study is to describe eConsults, how they differ from traditional in person models of care and other models of telemedicine and to review the evidence related to the effectiveness of eConsults by PCPs and clinicians from multiple specialties at the University of Colorado School of Medicine. We have worked to develop an infrastructure, delivery system integration, and care model adaptations that aim to improve delivery system performance by ensuring proper care in appropriate settings and lowering costs through reduced utilization. Lastly, we have increased care coordination, improved collaboration and better care transitions through strengthening of relationships between community-based PCPs and academic medical center-based specialists. This work has resulted in cost savings to patients and positive provider satisfaction.

Another Brick in the Wall: Healthcare Access Difficulties and Their Implications for Undocumented Latino/a Immigrants.

The mounting evidence highlighting the disproportionate impact of the COVID-19 pandemic in ethnic minority communities underscores the need to understand how distress and healthcare access impacts the well-being of undocumented Latino/a immigrants (ULIs), one of the most marginalized and vulnerable ethnic minority communities in the U.S. We used existing data from a cross sectional study (Proyecto Voces) of 252 ULIs to conduct path analyses that explored the relations among distress due to immigration legal status, healthcare access difficulties, and the health of ULIs. Results demonstrated that distress due to immigration legal status is related to the physical and mental health of ULIs, and that difficulties in accessing healthcare explained these relations. These data support the importance of immediate, targeted efforts for increasing access to healthcare among undocumented immigrants and highlight the long-term importance of a much-needed healthcare reform for improving access to marginalized populations.

COVID-19: A Window of Opportunity for Positive Healthcare Reforms.

The current coronavirus disease 2019 (COVID-19) pandemic is testing healthcare systems like never before and all efforts are now being put into controlling the COVID-19 crisis. We witness increasing morbidity, delivery systems that sometimes are on the brink of collapse, and some shameless rent seeking. However, besides all the challenges, there are also possibilities that are opening up. In this perspective, we focus on lessons from COVID-19 to increase the sustainability of health systems. If we catch the opportunities, the crisis might very well be a policy window for positive reforms. We describe the positive opportunities that the COVID-19 crisis has opened to reduce the sources of waste for our health systems: failures of care delivery, failures of care coordination, overtreatment or low-value care, administrative complexity, pricing failures and fraud and abuse. We argue that current events can canalize some very needy reforms to make our systems more sustainable. As always, political policy windows are temporarily open, and so swift action is needed, otherwise the opportunity will pass and the vested interests will come back to pursue their own agendas. Professionals can play a key role in this as well.

Post-COVID healthcare reform in India: What to expect?

COVID-19 has exposed the fault lines of India's public health system. The pandemic can be a useful window of opportunity to undertake public healthcare reforms that are long due. Such reforms are, however, constrained by the path-dependent characteristics of private healthcare in India. Measures taken to expand healthcare during the pandemic appear unlikely to sow the seeds of successful path transformation, and may rather reinforce the private sector dominated trajectory. Policymakers must introduce a bold set of pro-public healthcare reforms during the pandemic, which can then be incrementally built upon through securing legitimacy and support.