What are the Health Needs of the Low Income Population, and How Have They Changed Since the Affordable Care Act?

Principal Investigator: Peter J. Cunningham, Ph.D.

Funding Source: Commonwealth Fund


The purpose of the proposed project is to examine the health needs of the low income population, and whether the Affordable Care Act has differentially affected key vulnerable subgroups within the low income population, such as racial/ethnic minorities, recent immigrants, the uninsured and underinsured, and individuals with physical and mental health problems.   Specifically, the project will examine: (1) the demographic characteristics, health status, and health care resources of people with family incomes at 250% of poverty or lower, and how these characteristics have changed since the ACA; (2) Changes in medical cost burdens for the low income population since the implementation of the ACA, and; (3) Changes in access to care for the low income population since the ACA.  We propose using the Medical Expenditure Panel Survey (MEPS) to examine these trends, as it is the most comprehensive national survey available on Americans’ health, health care access, utilization, and expenditures, and therefore is the only source of data that allows for an integrated analysis of all three objectives.   Also, the project uses the MEPS to build on previous research funded by The Commonwealth Fund on medical cost burdens, as it is the only source of data that can show out-of-pocket expenditures by type of service, as well as the percent of total health care expenditures paid out-of-pocket.  MEPS public use files for 2014 will become available in September, 2016, and therefore this project will yield some of the earliest results showing comprehensively how the health and health care needs of the low income population have changed since the ACA.  We estimate the proposed costs of the project to be $192,437 over a 12 month period, beginning August 1, 2016.

Delivering High-Quality HIV Care in the South: System-Level Policy Alternatives

Principal Investigator: April D. Kimmel, Ph.D.

Funding Source: National Institute on Minority Health and Health Disparities

Project Summary:

While clinical care for HIV has made tremendous advances, the majority of persons living with HIV in the US do not receive the evidence-based care that will allow them to fully extend life and improve health. Lack of effective HIV care is particularly problematic in the Southern region, the epicenter of the US HIV epidemic and where poverty, uninsurance, rurality, and a constrained health workforce further threaten effective care. Research suggests that system-level factors, or the structural and policy-related aspects of health care delivery, have the potential to improve quality of care and health outcomes. But little is known about their role in the context of HIV care delivery, quality of care, and health outcomes. The proposed research will study how two modifiable system-level factors—geographic accessibility to care and physician payment policies—affect quality of HIV care and population outcomes, including new HIV infections, along the HIV care continuum in the US South. Because racial and ethnic minorities face increased barriers to HIV care, we pay special attention to how these system-level factors may contribute to disparities in quality of HIV care and population outcomes along the HIV care continuum. The research involves developing a novel database that combines multiple data sources, including Medicaid administrative claims files, HIV surveillance data, and county and state characteristics from national datasets. Our approach will rely on state-of-the-art spatial network analysis and data visualization (mapping), statistical tests using econometric methods, and systems science forecasting techniques that have been used to study quality of care and population health outcomes. The work moves beyond examination of core quality of HIV care measures to include HIV-related preventive care measures that collectively are critical to reducing HIV morbidity and mortality. In investigating these factors, the study will answer a number of important questions. How do geographic accessibility, measured in travel time to receive care, and physician payment for services affect quality of HIV care in the South? Are these effects different among racial and ethnic minorities? Do improvements in geographic accessibility or increased physician payments reduce new HIV infections and racial and ethnic disparities along the HIV care continuum? The proposed study will address these questions and others. By quantifying the role of system-level factors in quality of HIV care and population health along the HIV care continuum, as well as understanding disparities in these effects, the research will provide valuable information to state and federal policy makers who seek to address systemic challenges to effective HIV care, efficiently allocate scarce resources, and improve public health.

Central Africa International Epidemiologic Database to Evaluate AIDS (IeDEA)

Site Principal Investigator: April D. Kimmel, Ph.D.

Funding Source: National Institutes of Health: National Cancer Institute, National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and National Institute on Drug Abuse.

Project Summary:

Elimination of HIV infection as a cause of human illness and death, and achieving "zero HIV transmission" have been embraced by the AIDS research and treatment communities as achievable. As HIV care and treatment programs are implemented throughout Africa, critical advances in research and policy are needed, so that care and treatment resources can be deployed to optimal benefit: decreasing both new HIV transmissions and HIV-related morbidity and mortality. Among the most important challenges to maximizing the public health benefits of HIV care and treatment programs are late diagnosis of HIV-infection, low rates of linkage to care, and high rates of late ART initiation which in turn ar associated with high rates of mortality, more costly clinical management and continued HIV transmission. In addition there remain unanswered clinical questions for persons living with HIV (PLWH) even with optimal ART. For PLWH in SubSaharan Africa (SSA), ART has been highly effective in decreasing HIV-related morbidity (and mortality), but the association of HIV with metabolic diseases and other conditions of aging (e.g. cancers), and the impact of under- or over-nutrition are not well defined. Newly funded as CA-IeDEA four years ago, we have built a new Central Africa IeDEA (CA- IeDEA), and have 1.) Compiled and managed secondary source patient-level data on ~52,000 patients through both extraction from existing electronic data and new on-the-ground systems for efficient capture of clinical data in low-resource clinical settings; 2.) Been highly productive scientifically with >20 publications even while data collection was in development, and 3.) have continued to foster African leadership and build local research capacity. We propose now to increase the database modestly (to ~80,000 patients) to increase the representativeness of HIV in the region geographically and in service delivery strategies and success and to expand our implementation science approaches to optimize short- and long-term HIV care outcomes both in Central Africa and globally, continue to investigate epidemiologic questions with clinical impact, with a focus on the comorbidities of aging and women's reproductive health.

Advantages, Disadvantages and Consequences of OpenNotes in Cancer Settings

Principal Investigator: Richard Brown, Ph.D.

Co-Principal Investigator: Jordan Alpert, Ph.D.

Funding Source: National Cancer Institute R25 CA093423

Cancer patients in the VCU health system (VCUHS) are now able to access their electronic medical record through a patient portal. This initiative is called OpenNotes and enables patients to access information, such as scans, x-rays and radiology reports, often before seeing their oncologist. OpenNotes has been positively received in primary care settings, but its impact has not yet been explored in cancer settings. In this study we are exploring how this unfettered access to complex information may be positively and negatively impacting physician – patient communication. This formative research will explore patient, clinician and OpenNotes advocate views about, and experiences of patient access to medical data before oncologist consultations. Semi-structured Interviews will be conducted along with analysis of oncologists’ notes, comparing written messages before and after OpenNotes was adopted in the VCUHS.

Communication Strategies during Fertility Preservation Discussions

Principal Investigator: Richard Brown, Ph.D.

Co-Principal Investigator: Jordan Alpert, Ph.D.

Funding Source: National Cancer Institute R25 CA093423

Although the American Society of Clinical Oncology recommends discussions of fertility preservation between patients and providers prior to treatment, evidence suggests that fertility risks are not effectively communicated. This study will explore how conversations between patients and oncologists transpire, discover the type of information sought and identify communicative behaviors that occur during consultations. To achieve this, discussions among oncologists and patients will be audio recorded and subsequently analyzed. 

Petersburg Wellness Engagement Project

Principal Investigator: Maghboeba Mosavel, Ph.D.

Funding Source: National Institute on Minority Health and Health Disparities

The goal of this research is to assess: 1) The strengths and resources critical for addressing obesity, 2) The social-cultural perceptions of obesity, and 3) The family-based, community-wide interventions that can be supported citywide to increase physical fitness and improve nutritional choices. Specific aims include conducting a needs assessment informed by community input from multiple sources, and developing and implementing a pilot intervention that will address individual, family, community and societal factors to galvanize the community to increase physical activity and improve nutritional choices and options that will reduce obesity.

Minority Based NCI Community Oncology Research Program

Principal Investigator: Andrew J. Barnes, Ph.D.

Funding Source: National Cancer Institute Grant No. 1UG1CA189869-01


Massey Cancer Center (MCC) will serve as the primary component site for an NCORP Minority/Underserved Community Site  award in partnership with nine collaborating community component sites. The overall objectives of this partnership are to extend novel, innovative, and effective minority recruitment approaches to an expanded base of community component sites, increase opportunities for minority and medically underserved individuals to participate in Cancer Clinical Trial Research (CCTR), and to integrate Cancer Care Delivery Research (CCDR) into the overall MB-NCORP. Accordingly, the specific aims of this proposal are to (1) establish a research infrastructure that will further enable community component sites to conduct CCTR with an emphasis on trials relevant to minority and medically underserved populations, (2) conduct NCI-approved CCTR at the MCC primary component site and throughout the community component sites, and (3) integrate Cancer Care Delivery Research (CCDR) into the overall MB-NCORP.

Study Design

The research design of the MB-NCORP offers a full menu of cancer studies including those in cancer prevention and control, screening, treatment, imaging, and CCDR. The proposed research is relevant to the mission of the NCI as MCC and the community component sites will bring cancer clinical trials and research to low-income, minority, and medically underserved individuals who otherwise would not have access to such studies. These studies will address many diverse factors from patient, provider, organizational, and policy perspectives that contribute to known disparities in cancer detection, treatment, and outcomes. Targeting the minority/underserved populations in their communities is a critical step toward alleviating the cancer care disparities prevalent in these populations.

Intended Policy Outcomes

The proposed research is relevant to public health as it will bring cancer clinical trials and cancer care delivery research to minority and underserved individuals in their own communities. The inclusion of these individuals in the research will both broaden the applicability of the research and help to reduce the health cancer disparities in the minority and underserved populations of cancer patients.

Accountable Care Organizations: Development, Taxonomy, Quality and Cost Effect

Principal Investigator: Askar S. Chukmaitov, M.D., Ph.D.

Funding Source: Agency for Healthcare Research and Quality Grant No. 1R01HS023332-01


The Affordable Care Act (ACA) of 2010 goals are to improve the quality of care and contain health care costs while eventually expanding health coverage to millions of uninsured Americans.  The ACA includes provisions to begin addressing these goals, partly through the development of Accountable Care Organizations (ACOs).

Rapid development of public ACOs with active hospital participation is underway. The CMS initiated the Medicare Shared Saving Program (MSSP) and the Pioneer ACO Program.  To provide policy guidance, we make innovative use of currently available data for 2009-2014 to examine whether new ACO structures and competencies that health care policy makers, researchers, and practitioners have identified as critical for achieving ACA goals fulfill the promise of improving health care quality and containing health care costs.

Study Design

The effects of changes in a range of hospital-related ACO structures developed via taxonomic analysis will be evaluated by examining changes in hospital quality of care and costs for Medicare patients treated by hospitals participating in the CMS ACO programs, before and after their designation, and in comparison with the Medicare patients treated in hospitals that are not participating in the CMS ACOs.  The taxonomy of hospitals participating in the CMS ACOs will enable tracking ACO progress and success.  Social, market, and geographic factors, and hospital organizational drivers conducive to ACO development will be evaluated using the nationwide data. 

Intended Policy Outcomes

This study focuses on hospitals as their participation in CMS ACOs offers utmost potential for cost containment and quality improvement by incentivizing value rather than volume and coordinating care across providers. Hospital performance will be measured by comprehensive sets of quality and cost outcomes that assess effectiveness of care coordination on the continuum of care across providers and hospital cost containment for all Medicare patients.

Incentives to Encourage Primary Care Use: A Randomized Controlled Trial in Safety Net

Principal Investigator: Maria Thomson, Ph.D.

Funding Source: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Grant No. R01HS022534


The study supports a randomized controlled trial of incentives for an initial primary care visit within six months of enrollment in a healthcare coverage program. The lack of healthcare coverage leads to poor health and inappropriate healthcare use among the uninsured. Medicaid expansions to the uninsured adult population are a means of improving access to primary care. However, the evidence from these expansions on reducing hospitalizations and emergency department use is mixed, suggesting that barriers to primary care remain, in spite of coverage.

Interventions, such as incentives (also known as conditional cash transfers), may be a means to steer patients toward a model of care that emphasizes prevention, primary care for nonemergent needs and primary care chronic disease management. Cash incentives may generate a desired behavioral response for a relatively small price.

Study design

Study subjects are drawn from a low-income adult population that gains coverage and access to community-based primary care services under a program administered by an academic safety-net hospital. Researchers will offer financial incentives to encourage an initial primary care visit within six months of enrollment and evaluate whether the primary care visit altered subsequent health-seeking behavior and influenced patient satisfaction and other outcomes such as self-reported health status. Using a mixed-methods approach, the study will compare outcomes among patients who receive one of two levels of incentives ($25 or $50) versus those who receive usual care.

Intended policy outcomes

Incentives should steer patients in their decision to seek primary care, reduce barriers to care, ultimately improve patient health and reduce utilization and costs through patients’ relationships with a primary care physician.

Informal caregiver burden in advance cancer: economic and health outcomes

Principal Investigator: Robin Matsuyama, Ph.D.

Funding Source: National Institutes of Health/National Cancer Institute

Families of cancer patients are increasingly asked to shoulder the duties of providing day-to-day care for patients.  Often, those caregiving services are complex and may take away from the ability of caregivers to perform many of their other obligations and may even cause them to have to leave their paid employment.  This study will examine how caregiver burden affects both health and economic outcomes of caregivers.

ELSI Sub-Study on the Ethical, Legal and Social Issues of the Human Genome Project

Principal Investigator: Maghboeba Mosavel, Ph.D.

Funding Source: National Disease Research Interchange

The Genotype-Tissue Expression (GTEx) project offers a biobanking resource for the scientific community to study human gene expression and is relationship to common diseases like diabetes, Alzheimer’s, heart disease, and cancer.  The goal of the GTex project is to densely genotype tissues collected from a variety of deceased organ and tissue donors. In addition to biobanked tissue, the GTEx project provides researchers an atlas of genomic data paired with donor medical and social history information.

As part of the GTEx project, the Ethical, Legal and Social Issues (ELSI) sub-study seeks to understand the factors that affect consent to tissue donation for biobanking purposes and to improve the informed consent process.  The ELSI project interviews the family decision makers who are approached to donate to GTEx by organ procurement organization staff as part of a request for tissue donation for transplantation. In addition, the ELSI study is investigating the impact of the stressful environment in which the GTEx donation requests occur and testing a communication training program for organ procurement organization staff who request for tissue donation to the GTEx biobank.

RoadMaps to Health, Robert Wood Johnson Foundation Action Award

Principal Investigator: Maghboeba Mosavel, Ph.D.

Funding Source: Robert Wood Johnson Foundation, Action Award

The Petersburg Wellness Consortium (PWC) was awarded the RoadMaps to Health Action Award by the Robert Wood Johnson Foundation. The Roadmaps to Health Coaching Program offers guidance to strengthen communities’ capacity to create a culture of health for all residents. County Health Rankings & Roadmaps community coaches support community teams in selecting coaching goals, reflecting on effectiveness of current approaches, focusing strategically to get the most leverage for efforts, considering evidence informed strategies, and considering how to evaluate efforts. The PWC was established by Dr. Mosavel and her community partners in 2012 to improve Petersburg's health and wellness by optimizing resources and partnerships. It is a volunteer run organization and have been able to secure funding from various sources to address health inequities in Petersburg. The RWJ Action Awards work will accelerate or advance a Culture of Health by positioning the Petersburg Wellness Consortium to be an inclusive and sustainable umbrella organization to improve health in Petersburg. The PWC will accomplish this by building on existing and emerging assets to enhance continued efforts at improving health, working towards sustaining current partnerships and developing new partnerships with key organizations, and working towards sustainable change that focuses on systems, policies and environmental solutions. The coaching team includes the City Manager, a community activist, Dr. Mosavel as team leader, Virginia Department of Health –Crater Road District, Cameron Foundation, YMCA of Petersburg and Virginia Cooperative Extension Services.