Faculty Bibliography

OBJECTIVES/OBJECTIVE:To provide an overview of key elements of the Affordable Care Act. To evaluate ways in which the Affordable Care Act will likely impact the practice of critical care medicine. To describe strategies that may help health systems and providers effectively adapt to changes brought about by the Affordable Care Act. DATA SOURCES AND SYNTHESIS/METHODS:Data sources for this concise review include search results from the PubMed and Embase databases, as well as sources relevant to public policy such as the text of the Patient Protection and Affordable Care Act and reports of the Congressional Budget Office. As all of the Affordable Care Act's provisions will not be fully implemented until 2019, we also drew upon cost, population, and utilization projections, as well as the experience of existing state-based healthcare reforms. CONCLUSIONS:The Affordable Care Act represents the furthest reaching regulatory changes in the U.S. healthcare system since the 1965 Medicare and Medicaid provisions of the Social Security Act. The Affordable Care Act aims to expand health insurance coverage to millions of Americans and place an emphasis on quality and cost-effectiveness of care. From models which link pay and performance to those which center on episodic care, the Affordable Care Act outlines sweeping changes to health systems, reimbursement structures, and the delivery of critical care. Staffing models that include daily rounding by an intensivist, palliative care integration, and expansion of the role of telemedicine in areas where intensivists are inaccessible are potential strategies that may improve quality and profitability of ICU care in the post-Affordable Care Act era.

CONTEXT/BACKGROUND:The cost of American medical education has increased substantially over the past decade. Given racial/ethnic inequalities in access to financial resources, it is plausible that increases in student debt burden resulting from these increases in cost may not be borne equally. OBJECTIVE:To evaluate racial/ethnic disparities in medical student debt. DESIGN SETTING AND PARTICIPANTS/METHODS:Authors collected self-reported data from a non-representative sample of 2414 medical students enrolled at 111/159 accredited US medical schools between December 1(st) 2010 and March 27(th) 2011. After weighting for representativeness by race and class year and calculating crude anticipated debt by racial/ethnic category, authors fit multivariable regression models of debt by race/ethnicity adjusted for potential confounders. MAIN OUTCOME MEASURES/METHODS:Anticipated educational debt upon graduation greater than $150,000. RESULTS:62.1% of medical students anticipated debt in excess of $150,000 upon graduation. The proportion of Blacks, Whites, Hispanics, and Asians reporting anticipated educational debt in excess of $150,000 was 77.3%, 65.1%, 57.2% and 50.2%, respectively. Both Black and White medical students demonstrated a significantly higher likelihood of anticipated debt in excess of $150,000 when compared to Asians [Blacks (OR=2.7, 1.3-5.6), Whites (OR=1.7, 1.3-2.2)] in adjusted models. CONCLUSION/CONCLUSIONS:Black medical students had significantly higher anticipated debt than Asian students. This finding has implications for understanding differential enrollment among minority groups in US medical schools.