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

项目摘要/摘要 在过去的15年里，美国各地的健康状况出现了令人担忧的鸿沟。这个 一些人口--特别是劳动年龄的白人成年人--的死亡率上升了0.5%。 一年，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段的人口继续下降。 长期以来，健康差距一直困扰着少数民族和社会经济上处于不利地位的人口。 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 在很大程度上受教育程度较低的白人人口的困扰表明，按经济阶层划分的健康差距正在扩大。使用一个 用于医疗项目的国内生产总值的份额越来越大，这一进展的逆转 任何亚群的死亡率都特别令人担忧。 为什么会发生这种事？虽然有证据表明，某些健康相关行为的负担增加 或者疾病(如药物滥用)可能起到关键作用，不断增加的疾病负担本身并不能解释 各亚群之间进展中的分歧。此外，社会决定因素的因果路径 在不同种族/民族或经济阶层的人群中，健康对死亡率和健康的影响不同 人们对此仍然知之甚少。例如，美国宏观层面的宏观经济政策(如贸易)可能会影响 工作年龄成年人的经济机会和前景；然而，它们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--奖励提高的质量 人口层面的护理和健康结果--这种改革可能会促使医生和医院将重点放在 关于改善对弱势患者的护理，他们往往有最大的改善空间，但这些 改革还可能通过避免弱势患者而加剧质量和结果的差异。 因此，了解今天的改革是否会以公平的方式实现其目标是一项至关重要的任务。 我提出了一个有两个关键目标的研究议程。首先，我试图确定新的因果关系背后的机制 在健康结果方面新出现的差距。利用宏观经济变化作为对社会经济的外生冲击 关于健康的决定因素，我将研究它们对不同种族、收入和地域的结果的影响。在这个范围内 分析，我会检查相关疾病负担的变化，以了解其临床表现 在这些更广泛的经济冲击中。第二，我试图检查今天对交付系统的改革是否， 旨在改变医生和医院提供护理的方式，可能会影响健康方面的差异 按种族、收入和地理位置排列。我将分析奖励质量和结果的计划的影响 医生级别，如《医疗保险准入和芯片再授权法案》(MACRA)以及计划 以提供者组织级别的激励为中心，特别是责任关怀组织(ACO)模式 在医疗保险和65岁以下的私人保险人口中，对质量和结果的差异。

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.