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Rutgers health care study highlights struggle for wellness in low-income communities as state prepares Medicaid ACO rollout

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Low-income New Jersey communities have higher rates of avoidable hospitals visits — ailments that could be managed in a doctor's office if caught earlier — according to a report released Wednesday by the Rutgers Center for State Health Policy.

The study points to factors outside the health care system, like homelessness and lack of fresh, healthy food, driving high hospital use in some poor communities, while for others the key issues are health care related, such as insufficient primary medical care.

The report comes as New Jersey prepares to launch later this year its new Medicaid Accountable Care Organization pilot program. The program will seek to deliver coordinated medical care in low-income communities, in an effort to improve population health while reducing wasted spending in the state’s Medicaid program, which has an annual budget of more than $10 billion.

An analysis of hospital billing records and demographic data by Rutgers researchers across 13 low-income communities in New Jersey found that as an area’s per capita income rises, the number of patients who seek medical care in the hospital falls dramatically.

But the Rutgers team also discovered that hospital systems in some low-income areas perform better than expected, given their per capita income and other socioeconomic disadvantages.

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For example, Camden performs better than expected after statistically adjusting for the city’s high level of socioeconomic disadvantage. But high rates of avoidable visits in Jersey City and Asbury Park changed little after socioeconomic adjustments, suggesting that avoidable hospitalizations reflect factors other than income, such as the lack of access to primary care doctors.

“The findings show how well a hospital system can perform in the face of poverty,” said Rachel Cahill, director of health care improvement and transformation at the Nicholson Foundation, which funded the Rutgers study. “The fact that some low-income areas are performing well despite their dire situations indicates that there is great potential for improvement.”

The report, Cahill says, has important policy implications as New Jersey rolls out the three-year Medicaid ACO pilot. Eight community-based health care coalitions throughout New Jersey have applied to the state to create Medicaid ACOs, which will assume responsibility to care for Medicaid members within their geographic territory. The Medicaid ACOs will receive a share of the money that Medicaid saves if they can deliver high quality, efficient care.

“In many low-income communities, lowering avoidable hospital use and cost requires emphasis on the social determinants of health,” said the report’s lead author, Derek DeLia, associate research professor at the CSHP. “This is especially true in communities that perform better than expected after adjusting for socioeconomic factors. In these communities, interventions that give special consideration to the daily stresses and problems associated with poverty — such as unsafe neighborhoods, unstable housing, lack of transportation, or limited access to healthy foods — can play a greater role in improving health and reducing avoidable medical episodes than a purely medical care focus.”

Linda Schwimmer, vice president of the New Jersey Health Care Quality Institute, said: “The results of this study are illuminating and can help guide future efforts to improve care in these communities. We know that many factors beyond the provision of health care services contribute to a person’s overall health, and many of those factors, like housing, proper nutrition (and) educational opportunity, are largely tied to the income and the overall wealth of a given community.”

In addition to broader societal challenges, “many of these communities lack certain health care infrastructure — like primary care — that can exacerbate the situation. The upshot is that this report will help these communities better understand what is driving readmissions and other health care utilization, and will help developing Medicaid ACOs and other provider collaborations better target their interventions and community partnerships.” 

The Camden Coalition of Healthcare Providers, which has been working to improve health care to the poor in Camden for more than a decade, is among the groups that plan to become a Medicaid ACO. And DeLia said the Camden is already looking beyond health care to tackle the social factors that drive public health.

“In Camden they realize that people who are in the hospital multiple times are people who have unstable housing. So they have decided they need to talk to the housing authority and get these patients connected with a stable housing situation.”

And he said the other communities creating Medicaid ACOs “probably understand that it is not just medical, you’ll have to deal with housing, transportation, child care,” and a range of other factors outside the walls of the hospital that impact population health.

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Beth Fitzgerald

Beth Fitzgerald

Beth Fitzgerald reports on health care, small business and higher education. She joined NJBIZ in 2008 after a 34-year career at the Star-Ledger and has been reporting on business in New Jersey since 1978. Her email is beth@njbiz.com and she is @bethfitzgerald8 on Twitter.

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