access to care


Viewpoint: Consider Tough Penalties To Boost Disabled Patients’ Access To Care

We already know that patients with disabilities face major obstacles when trying to access basic medical care. Now, a team of researchers are proposing some novel strategies to help fix the system, including withholding payments to health care organizations and making accreditation contingent on compliance with disability law.

The researchers, Dr. Tara Lagu and colleagues at Baystate Medical Center, Tufts University School of Medicine, and a Massachusetts not-for-profit organization, the Disability Law Center, suggest that this is the first time these types of strategies have been proposed.

“The goal of this paper was to start the conversation,” says Dr. Lagu via email.

Dr. Tara Lagu, M.D., MPH (Courtesy)

Dr. Tara Lagu, M.D., MPH (Courtesy)

Lagu’s groundbreaking earlier study on access to care for people with disabilities found that even in the current high-tech health care environment, many elements of routine medical care — like getting a patient on to an exam table — remain elusive.

The latest article, published in JAMA Internal Medicine, describes the range of barriers, including:

“…physical barriers to entering health care establishments, lack of accessible equipment, lack of a safe method for transferring the patient to an examination table, and the lack of policies that facilitate access.The barriers persist despite 2 federal laws (the Americans With Disabilities Act [ADA] of 1990 and Section 504 of the Rehabilitation Act of 1973) that explicitly state that health care settings must be accessible to patients with disabilities.

And here, Lagu offers some possible solutions:

As our study last year reported, patients with disabilities face real difficulties when they try to access health care. This suggested that our current strategy for enforcement, lawsuits, have fallen short. In part, this is because patients don’t want to bring lawsuits against doctors with whom they have an existing relationship and because lawsuits are extremely unpopular with physicians. More importantly, lawsuits have failed to initiate system-wide change: it is not clear that, in recent years, there have substantial improvements in access to care for patients with disabilities.

For these reasons, we believe that novel strategies are needed. As we considered what such strategies might look like, we considered other mechanisms of enforcement that have been successful at motivating change in health care settings, and we came to four possibilities: withholding payment, making accreditation contingent on compliance, regulation, and lawsuits at the state or national level aimed at initiating large-scale policy change. Continue reading

Report: Disabled Mass. Residents Face Major Health Disparities

health disparities

A new report highlights the many ways in which Massachusetts residents with disabilities “fare worse” than those without disabilities when it comes to their own physical and mental health as well as access to quality medical care from doctors sensitive to their needs.

This phenomenon isn’t new. Previous research found that many barriers still exist that prevent disabled patients from accessing specialty medical care. And for those with developmental and intellectual disabilities, sometimes finding a doctor willing to treat even common medical conditions can be difficult.

The latest report, by researchers at UMass Medical School’s Disability, Health and Employment Unit working and the Health and Disability Program at the state Department of Public Health, also suggests that the state could do more to ensure that disabled patients have access to health care providers who both understand and can help with the specific medical challenges of this population.

I asked the researchers, led by Monika Mitra, PhD, assistant professor in UMass Medical School’s Department of Family Medicine and Community Health, to lay out the key messages of the report. Here are some of their findings:

• 24% of those with disabilities are current smokers compared to 16% of adults without disabilities.
• Both men (7%) and women (24%) with disabilities were more likely to report lifetime sexual violence compared to men (4%) and women (19%) without disabilities.
• Adults with disabilities (64%) were twice as likely to report being overweight as those without disabilities (34%).

In addition, people with disabilities surveyed in the study reported the following health-related concerns:

• Affordable housing (77% of respondents reported this was a problem);​
• Adequate dental care (64%);
• Adequate mental health services (62%);
• Finding a doctor who is sensitive to disability issues (55%);
• Transportation to doctor’s appointments (54%);
• Communication supports, such as large print, Braille, Computer Assisted Realtime Translation (CART) readers, etc. (52%);
• Managing chronic conditions, such as diabetes (50%);
• Paying for prescription medications (48%);
• Finding a doctor who accepts public health insurance (48%); and
• Accessible gyms (45%).

Continue reading

Study: The Deadly Toll Of Opting Out Of The New Medicaid Expansion



Here are some serious numbers from Harvard researchers regarding the 25 states that have opted out of expanding Medicaid coverage under the Affordable Care Act:

We estimate that due to the opt-outs 7.78 million people who would have gained coverage will remain uninsured. This will result in between 7,115 and 17,104 more deaths than had all states opted-in.

Writing for the journal Health Affairs blog, researchers led by Samuel Dickman, a medical student at Harvard Medical School/Cambridge Health Alliance, estimate further severe health woes linked to states’ decisions to forgo expanded Medicaid, including:

•712,037 more persons diagnosed with depression
•240,700 more persons suffering catastrophic medical expenses
•422,533 fewer diabetics receiving medication
•195,492 fewer women receiving mammograms
•443,677 fewer women receiving pap smears


Here’s more from the Cambridge Health Alliance news release (and for full disclosure, all of the study authors are members of the national group, Physicians For a National Health Program, which advocates that the U.S. adopt a Canadian-style single payer health system. PNHP did not pay for any part of this research, according to a spokesperson):

Dickman and his colleagues, longtime health researchers at Harvard Medical School and the City University of New York drew on demographic data from the Census Bureau’s 2013 Current Population Survey and estimates on Medicaid take-up rates from the Congressional Budget Office and elsewhere to characterize those who would remain uninsured in states opting out of Medicaid expansion.

They developed estimates of the health effects of remaining uninsured based on previous studies that used state-level data on Medicaid expansions and death rates, the National Health and Nutrition Examination Survey Mortality Follow-up, and the Oregon Health Insurance Experiment.

In addition to arriving at national estimates, the researchers were able to break the findings down by state.

For example, in Texas, the largest state opting out of the Medicaid expansion, approximately 2 million people who would otherwise have been insured will remain uninsured as a result of the state’s action.

“Texas’ refusal to accept federal money to expand Medicaid will result in 184,192 more people experiencing depression, 62,610 more people suffering catastrophic medical expenses, and as many as 3,035 avoidable deaths,” said Dr. Steffie Woolhandler, a professor of public health at the City University of New York who is also on the faculty at Harvard Medical School. Continue reading

Taking The ‘Maine Track’ Home To Be A Country Doctor

Fourth-year medical student Chad Szylvian and wife Meghan -- soon on their way to Maine. (Courtesy)

Fourth-year medical student Chad Szylvian and wife Meghan — soon on their way to Maine. (Courtesy)

Friday was “Match Day” for medical students across the country. Some surely hoped to be placed at the biggest-name hospitals in the biggest cities possible. Tufts Medical School student Chad Szylvian’s hopes pointed in a different direction — and if there were more medical students like him, rural areas of America might not be facing as critical a shortage of doctors as they do now. Here, in a “Match Day” essay, he discusses his choice.

By Chad Szylvian
Guest contributor

I had only pictured “Match Day” a couple of times before it finally arrived. It seemed like a strange idea that fourth-year medical students would gather together in a room to all simultaneously open little envelopes that told us which hospital had selected us for residency. I knew that I would feel anxious. I knew that I would feel excited. I hoped I would feel relief. But I hadn’t been sure that the little envelope would tell me it was time to go home.

Today, the envelope told me just that.

I grew up in Maine, which does not have a medical school offering an MD program. As an undergraduate applying to medical schools, I knew that I would have to pursue my medical training away from home. Then, in my junior year at Boston College, my mother sent me a clipping from our newspaper back home. It described a new program with Tufts University School of Medicine and Maine Medical Center. They were calling it the “Maine Track.” The idea was simple: allow students to complete academic training at Tufts, while gaining clinical experiences at rural hospitals in Maine.

I quickly learned that my choice of family medicine as a specialty would always require an explanation.

My exposure to rural medicine through this program began in my first week of medical school, and continued throughout. I completed rural immersions, community-based apprenticeships in primary care, clerkships, and electives – all in my home state. I spent a month shadowing a talented, innovative primary care physician in the western mountains. I spent a week at a community clinic on the coast. I spent an afternoon on a primary care home visit to an elderly couple’s rural home.

I knew, from very early on, that there would never be another kind of medicine for me. If my experience is any indicator, this kind of early and continuous exposure to rural medicine is critical for diverting students out of the competitive clamor for specialization and into careers in rural primary care. Continue reading

Psychiatric Care Hard To Get, Even For The Insured, Study Finds

It turns out a good shrink (or just about any shrink) is hard to find, even in the medical mecca of greater Boston.

According to a new study by Harvard researchers, access to outpatient psychiatric care is extremely limited here, and it doesn’t make much difference if the patient has top-notch health insurance or is suffering from a dire mental illness. As part of this “simulated patient” study, published Thursday as a letter in the Annals of Emergency Medicine, researchers posed as severely depressed patients with excellent health insurance and tried to get an appointment for psychiatric care at a facility in downtown Boston. But of the 64 facilities they called, they were only able to get 8 appointments, and only 4 of those were within two weeks.

“The takeaway here is that having insurance is obviously important but it is not suffficient when it comes to access to psychiatric care,” says Dr. J. Wesley Boyd, an attending psychiatrist at the Harvard-affiliated Cambridge Health Alliance, and the study’s lead author. “What does it say when there’s a patient with a potentially life-threatening disorder, such as the severe depression portrayed in our callers’ scenario, who is is essentially abandoned at a time of great need?”

To test their hypothesis that the availability of psychiatric services has greatly diminished (due to a combination of paltry reimbursement rates and budget cutbacks) Boyd and his colleagues embarked on a stealth plan involving a little bit of dramatic play. A psychiatric resident, Andy Linsenmeyer, pretended to be a patient named Andrew Meyer suffering from severe depression and in need of psychiatric care.

Linsenmeyer and an undergraduate student researcher, both posing as patients, chose 64 medical centers listed on the Blue Cross Blue Shield of Massachusetts website all within a 10-mile radius of downtown Boston, and set out to call each one. (Blue Cross played no role in the study). This is what the “patient” said when he got someone on the phone: “I was seen in the emergency room last night for depression and discharged with instructions to get a followup psychiatric appointment in two weeks.” He said he was covered under a Blue Cross Preferred Provider Organization health plan. Continue reading

Q&A: When A Health Wonk Runs For Office

Christine Barber

The little news item caught my eye: A health policy analyst was running for alderman in Somerville.

A member of Health Wonk Nation seeking public office! That’s unusual, isn’t it? (Though you’d think so many of them would be driven crazy by the irrational aspects of our health care system that they’d get into politics out of desperation.)

I wondered how an analyst’s deep knowledge of the Byzantine ins and outs of the system might play out at political-platform time. So today I asked the candidate, Christine Barber. She’s a senior policy analyst at the nonprofit Community Catalyst, and used to be a research analyst on the legislature’s Committee on Health Care Financing.

Q: Does your platform in your run for office include any planks on health care?

Yes and no. I’m running for ward alderman to represent my neighborhood, which is Winter Hill and Ten Hills in Somerville. I’ve spent my career working on health care coverage, typically at the state and national levels because that’s where it’s typically regulated. A lot of the improvements to cutting costs, improving quality, improving access — a lot of those really need to happen at least at the state level and in some cases the national level.

That said, I think there’s some work we do at the municipal level that is as critically important, but more in the public-health realm than the health coverage realm.

A few things that are important to me that I think can be improved in my neighborhood are:
— Food access and nutrition: Access to vegetables and fresh foods, preferably local foods
— Public transportation: We’re slated for the green line extension but while we wait, we need to rethink our bus service.
— Rethinking bicycle access: We don’t have good bike lanes. Overall, we need to be thinking of other ways to get where we’re going because air quality in Somerville is consistently poor.
–Encouraging the overall health of our residents.
–Keeping our streets safe: Children walk to school every day; making sure they’re safe on their travels, and making sure crime is down and that people feel safe. Obviously that affects their health and wellbeing.

Q: Are there any ways your deep understanding of health care issues affects what you want to do in office? Continue reading