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Inequities in Health Outcomes in the Twenty-First Century: Understanding New Causes and the Impact of Delivery System Reforms on Health Care Disparities

二十一世纪卫生结果的不平等：了解医疗保健不平等的新原因和交付系统改革的影响

基本信息

批准号：
10247671
负责人：
Zirui Song
金额：
$ 42.38万
依托单位：
HARVARD MEDICAL SCHOOL
依托单位国家：
美国
项目类别：
财政年份：
2017
资助国家：
美国
起止时间：
2017-09-01 至 2023-08-31
项目状态：
已结题

项目摘要

Project Summary/Abstract Over the last 15 years, an alarming chasm in health outcomes has emerged across the United States. The mortality rate of some populations—in particular working-age white adults—has increased by as much as 0.5% a year, reversing a 20-year trend of declining mortality, while mortality rates among other demographic groups in the United States and similar age populations in other developed countries have continued to decline. Disparities in health have long afflicted racial minorities and socioeconomically disadvantaged populations. Although this has motivated efforts by government and communities to reduce them, the new mortality chasm afflicting largely less-educated white populations suggests a widening gap in health by economic class. With a growing share of the nation's gross domestic product spent on health programs, this reversal of progress on mortality for any subgroup is particularly troubling. Why is this happening? While evidence suggests that elevated burdens of certain health-related behaviors or diseases (e.g. substance abuse) may play a key role, the increasing disease burden by itself cannot explain the divergence in progress between subgroups. Moreover, the causal pathways by which social determinants of health impact mortality and health differently across populations of different race/ethnicity or economic class remain poorly understood. For example, broad macro-level economic policies in the U.S. (e.g. trade) can affect economic opportunities and outlook for working-age adults; yet their impacts on health are largely unknown. And as the nation moves forward with ambitious reforms of its delivery system—rewarding improved quality of care and health outcomes at the population level—such reforms may push physicians and hospitals to focus on improving the care of disadvantaged patients the most, who often have the most room to improve, but these reforms might also exacerbate disparities in quality and outcomes via the avoidance of disadvantaged patients. Thus, understanding whether today's reforms will achieve their goals in an equitable way is a crucial task. I propose a research agenda with 2 key goals. First, I seek to identify new causal mechanisms behind the emerging disparities in health outcomes. Using macro-level economic changes as exogenous shocks to social determinants of health, I will study their impact on outcomes across race, income, and geography. Within this analysis, I will examine the associated changes in burden of disease to understand the clinical manifestations of those broader economic shocks. Second, I seek to examine whether today's reforms to the delivery system, which are designed to change the ways physicians and hospitals deliver care, can impact disparities in health by race, income, and geography. I will analyze the impact of programs that reward quality and outcomes at the physician level, such as the Medicare Access and CHIP Reauthorization Act (MACRA), as well as programs centered on incentives at the provider organization level, notably accountable care organization (ACO) models in Medicare and in privately-insured populations under age 65, on disparities in quality and outcomes.

项目总结/摘要在过去的15年里，美国各地出现了令人震惊的健康结果鸿沟。的一些人口的死亡率--特别是工作年龄的白色成年人--上升了0.5% 这扭转了20年来死亡率下降的趋势，而其他人口群体的死亡率在美国和其他发达国家的类似年龄人口继续下降。健康方面的差异长期困扰着少数民族和社会经济弱势群体。尽管这促使政府和社区努力减少死亡率，但新的死亡率鸿沟受教育程度较低的白色人口的患病率表明，经济阶层的健康差距正在扩大。与越来越多的国家的国内生产总值的份额用于医疗计划，这种逆转的进展，任何亚组的死亡率都特别令人担忧。为什么会这样？虽然有证据表明，某些健康相关行为的负担增加，或疾病（如药物滥用）可能起关键作用，但疾病负担的增加本身不能解释分组之间的进展差异。此外，社会决定因素不同种族/民族或经济阶层的人群对死亡率和健康的影响不同仍然知之甚少。例如，美国宏观经济政策（如贸易）可能会影响经济机会和工作年龄成年人的前景;但其对健康的影响在很大程度上是未知的。随着国家推进其交付系统的雄心勃勃的改革-奖励提高质量在人口水平上的护理和健康结果-这样的改革可能会推动医生和医院关注对改善弱势患者的护理最多，他们往往有最大的改善空间，但这些改革还可能因回避处境不利的病人而加剧质量和结果方面的差距。因此，了解今天的改革能否以公平的方式实现其目标是一项至关重要的任务。我提出了一个研究议程，有两个关键目标。首先，我试图找出新的因果机制背后的健康成果方面出现的差距。利用宏观经济变化作为社会经济的外生冲击健康的决定因素，我将研究他们对种族，收入和地理结果的影响。在这分析，我将检查疾病负担的相关变化，了解临床表现这些更广泛的经济冲击。第二，我试图研究今天对交付系统的改革，旨在改变医生和医院提供医疗服务的方式，种族，收入，和地理我将分析奖励质量和成果的计划的影响，医生水平，如医疗保险访问和芯片再授权法案（MACRA），以及计划以提供者组织层面的激励为中心，特别是责任护理组织（ACO）模式在医疗保险和65岁以下的私人保险人群中，质量和结果的差异。