Milbank Quarterly最新文献

Policy Points Universal Design and Inclusion: Mandate all digital health platforms, devices, and services be built on universal design principles and codeveloped with people with disabilities, ensuring compatibility with assistive technology and emergency response features. Standardized Disability Data Collection: Implement mandatory, standardized disability data collection in electronic health records with robust privacy protections, addressing the Patient Protection and Affordable Care Act Section 4302 gaps while enabling personalized care and research. Accessibility as Civil Rights: Treat accessibility as a civil rights issue with strict enforcement of Section 508, Americans With Disabilities Act, and Section 1557, including the patient interoperability mandate, penalties for noncompliance, and legal recourse for patients. Funding and Incentives: Establish funding incentives prioritizing disability equity, digital literacy programs, value-based payment models, and workforce training for healthcare professionals using disability-inclusive digital health tools.

Policy Points Certified community behavioral health clinics (CCBHCs) commonly partner with emergency response systems in mobile crisis response through 911 referral arrangements, wherein behavioral health practitioner-only teams respond to 911 calls, and co-response partnerships, wherein a CCBHC clinician joins a police or emergency medical services team. Both the internal staff capacity of the CCBHC and external police capacity are associated with when CCBHCs partner with emergency response systems in mobile crisis response, although their effects differ by partnership: Co-response is more likely when CCBHCs have greater internal capacity, whereas 911 referral is more common in communities with lower police capacity. Stakeholders seeking to increase CCBHC-emergency response system partnerships may need to apply different strategies depending on the type of arrangement they aim to expand.

Context: Individuals with behavioral health disorders are more likely to experience substantial harm from a police encounter, prompting reforms to minimize encounters between police and people experiencing a behavioral health crisis. One strategy involves expanding partnerships between certified community behavioral health clinic (CCBHC) mobile crisis teams and emergency response systems, often through two models: 911 referral, wherein a CCBHC's behavioral health practitioner-only team responds to 911 calls, and co-response, wherein a CCBHC clinician joins a police or emergency medical services (EMS) team. We examine whether the internal capacity of the CCBHC and external police capacity influence when CCBHCs engage in these partnerships.

Methods: Using data from the only national survey of CCBHCs, this study applies multivariable logistic regression to assess whether CCBHC staff capacity and police capacity are associated with CCBHC-emergency response system partnerships in mobile crisis, controlling for organizational characteristics of the CCBHC and demographic and socioeconomic features of its service area.

Findings: One-third (33.0%, 95% confidence interval [CI], 26.0-40.0) of CCBHCs report a 911 referral partnership, and nearly half (48.5%, 95% CI 41.1-55.9) report a co-response arrangement. While police capacity is not significantly associated with co-response, a one standard deviation increase in police capacity corresponds to an 11.0-percentage-point (95% CI -19.5 to -2.5) decrease in the predicted probability of a 911 referral partnership. CCBHC capacity is not associated with 911 referral arrangements, but CCBHCs in the top tertile of CCBHC capacity are 19.2 (95% CI 4.3-34.2) percentage points more likely to report a co-response partnership.

Conclusions: The internal capacity of CCBHCs and external police capacity are associated with when CCBHCs partner with emergency response systems in mobile crisis. Because a robust behavioral health crisis system like

Policy Points The economics and outcomes of modern primary care are substantially driven by investment in interprofessional clinical team members aimed at delivering complex, population health-oriented care. Neither interprofessional primary care team investment nor the work products expected in return are well represented in current commonly used productivity metrics. Stakeholder perspective-guided scoping review followed by expert panel input on measure development showed the feasibility of applying economic methods for assessing primary care productivity relative to multiple high-value products.

Context: Current primary care productivity measures do not account for investment in interprofessional primary care teams in relation to primary care goals and thus are insufficient for assessing and improving primary care efficiency and productivity. We explored alternative productivity measurement methods.

Methods: We conducted a scoping review of English language literature between 2008 and 2023 to identify articles that assessed primary care practice productivity and efficiency. We reviewed the full texts of articles to assess their analytic models including inputs, outputs, and context measures. Using scoping review results to inform content, we conducted a modified Delphi expert panel to discuss potential use cases, analytic approaches, and data elements for new primary care productivity measures. Panelists anonymously voted on recommendations for guiding near-term measure development and testing.

Findings: Evidence review identified 25 included studies. The majority (76%, 19/25) used an economic model-based productivity calculation, predominantly estimated using data envelopment analysis (DEA), with stochastic frontier analysis accounting for most of the remainder. Primary care staffing was the most common input, included in 84% of the 19 economic model studies. As outputs, over half (53%) of studies included measures of quality of care, whereas the same proportion included numbers of clinical activities. No studies used patient-reported experiences of care. Expert panelists recommended that initial measure development focus on primary care practice efficiency improvement, building the measure on routinely collected health system data, accounting for the clinical team's full-time equivalent staffing, and incorporating quality of care. Panelists endorsed DEA while also acknowledging that other approaches had potential.

Conclusions: We identified measurement approaches that aligned with both economic and foundational primary care principles but none that were implemented for routine use. Opportunities exist to develop metrics that accurately reflect primary care structures, goals, and values.

Policy Points Local jurisdictions have some policymaking discretion related to immigration. Local immigration policy contexts are associated with differences in health insurance coverage among US-born, naturalized, and noncitizen Latinos. Entrenched immigration policy-related social inequities may have a greater influence on health insurance disparities than local policymaking.

Context: Federal and state immigration policies influence access to health insurance for Latino populations. Local jurisdictions also have immigration-related policymaking power, but there has been limited study of their influence on health care access. We examined the relationship between county-level immigration policy contexts and health insurance coverage of Latino adults and youth in California using two measures that capture local-level policy decisions and immigration policy-related social inequity.

Methods: We constructed two measures of local-level immigration policy contexts by developing seven indicators of local policy enactment and implementation and 11 indicators of immigration-related social inequity. We collected data on each indicator for California's 58 counties. We coded each indicator and scored counties to construct two indices. We merged the county data with a sample of Latino adults and youth in the 2021 American Community Survey (n = 249,979). We then conducted mixed-effects modeling to test the associations between the local policymaking and social inequity indices and health insurance and tested interactions by citizenship for both adults and youth. Predicted probabilities were estimated.

Findings: There were no significant associations or interactions by citizenship between county-level policymaking and health insurance for Latino adults or youth. In contrast, there were significant associations and interactions by citizenship between immigration-related social inequity and health insurance. Among adults, naturalized and US citizens had higher predicted probabilities of being uninsured in counties with high compared with low social inequity, but there were no differences for noncitizens. Among youth, noncitizens and those with noncitizen parents had higher predicted probabilities of being uninsured in counties with high social inequity.

Conclusions: Local policy contexts and social inequity related to immigration policymaking are associated with differences in health insurance coverage among US-born, naturalized, and noncitizen Latinos.

Policy Points Despite the goal of "all communities thriving," health equity-focused scientists and advocates have inadvertently made it easier for those "opposed to equity" to falsely convince many White communities that health equity-promoting policies and programs do not benefit them or their health. At a time when policy proposals and executive orders are likely to have major and potentially unjust impacts on the health and well-being of US communities, including White communities, it is crucial that health equity-related definitions, measurement, framing, and community engagement efforts build narratives, messages, and relationships that allow more people to see themselves in the health-equity tent.

Policy Points Community health workers (CHWs) recognize that health care and public health institutions and representatives value their roles, but these institutions are often unaware of the labor required to obtain the expertise that CHWs leverage. Despite a recognition of the value of the CHW role, CHWs feel their roles are not properly compensated or acknowledged, and they face other structural barriers that perpetuate the precarity of the role. As the CHW landscape for compensation and certification changes, these conditions need to be considered to better support and sustain this workforce.

Context: Community health workers (CHWs) are frontline public health workers who support the well-being and capacity building of residents disproportionately affected by health inequities. The purpose of this study is to examine diverse perspectives on the conditions for CHW success as CHWs were engaged in rapidly implemented, highly responsive education, vaccination, and recovery efforts during the COVID-19 pandemic in a large county in Southern California.

Methods: The Community Activation to Transform Local Systems (CATALYST) study leveraged a community-based participatory research approach to conduct a case study of CHW COVID-19 responses in Orange County, California. From 2023 to 2024, we conducted 16 semistructured, in-depth interviews and eight focus group discussions with CHWs (n = 60). Interviews and focus group discussions were recorded, transcribed, and analyzed following an adapted flexible coding approach, including inductive and deductive codes.

Findings: Findings highlight three key themes: 1) CHWs recognize that institutions value their expertise and capacity to build connections with community members, 2) CHWs' labor to build their expertise often goes unacknowledged, and 3) CHWs face financial and structural constraints that undermine the value ascribed to their contributions. Despite this, CHWs stress the importance of proper recognition and fair compensation to reflect the critical role CHWs serve in advancing community health.

Conclusions: Institutions recognize CHWs' impact; however, CHWs feel that the aspects of their work that build their expertise often go unnoticed and undervalued. To sustain CHWs as integral members of the public health workforce, especially during crises and recovery, institutions need to recognize the full extent of CHW roles and provide adequate financial and structural support essential to preserve the model's viability and impact. Findings from this case study may inform policies and practices for governmental and health care systems that rely upon and contract with CHWs to mitigate health inequities. Such practices include evolving CHW accreditation and reimbursement policies and initiatives.

Policy Points States are concerned about rising health care spending, and this study identifies states that have established health care cost commissions and describes the political and economic factors associated with their establishment. As of August 2024, 17 states had established commissions to reduce the growth of health care spending using various methods, including setting spending growth targets. Politically Democratic states and those with higher commercial hospital prices and higher Medicaid spending were more likely to establish such commissions. Because federal health care reform is difficult to enact, states are enacting their own reforms, tailored to their needs and political feasibility.

Context: States are becoming increasingly concerned about rising health care spending because it crowds out budgets for education and other obligations and it burdens consumers, exposing them to medical debt and bankruptcies. This study identifies states that have established health care cost commissions (HCCCs), examines state-level political and economic factors associated with their establishment, and reports which of these states have also enacted health care competition-related laws that further equip these commissions.

Methods: To identify states with HCCCs and competition-related laws, we reviewed prior reports, supplemented by our own research on state websites and from organizations that track state-level legislative and executive activity in health care. We estimated a regression model to understand how political and economic factors are related to these commissions being established.

Findings: As of August 2024, 17 states had established HCCCs that aim to reduce the growth of health care costs using a variety of methods, such as collecting health care use and spending data and setting spending growth targets. States that lean politically Democratic were more likely to establish these commissions, particularly those states with higher commercial hospital prices or higher Medicaid spending as a share of the state budget, or both. States with HCCCs have also enacted competition-related laws but to varying degrees.

Conclusions: Because health care reform is difficult to enact at the federal level, many states are enacting their own reforms, tailored to their needs and political feasibility with many establishing HCCCs to limit health care spending increases. Future research should study the impact of these commissions on health care spending that increases short-term spending yet moderates long-term spending, including the feasibility and impact of increased spending on primary care services as well as the impact of spending on new health care technologies.

Policy Points The 2015 to 2020 Delaware Contraceptive Access Now (DelCAN) initiative followed other long-acting reversible contraception-focused contraceptive initiatives in Colorado and in St. Louis, Missouri. and preceded statewide contraceptive-access initiatives in South Carolina, Massachusetts, and North Carolina with additional initiatives planned. Our principle conclusion is that the DelCAN did not achieve its goal of reducing the fraction of births from unintended pregnancies. However, we find evidence of a substantial magnitude of decrease in unplanned pregnancies that can be attributed to the initiative, and that this decrease occurred entirely among Medicaid-covered women.

Context: The 2015 to 2020 Delaware Contraceptive Access Now (DelCAN) initiative was motivated by Delaware's having among the highest rates of unintended pregnancies in the United States, of which were either wanted later or unwanted. The expectation of the DelCAN initiative was that by providing greater contraceptive access, especially to long-acting reversible contraception, Delaware's unintended-pregnancy rates could be substantially reduced. In this study, we assess the role of the DelCAN in explaining, for live births, changes in women's pregnancy intentions around the time of conception.

Methods: We examine not only pregnancy intentions, but also the planned status of the pregnancies, including whether the woman was trying to get pregnant and whether she or her partner was using contraception when an unplanned pregnancy occurred. We use the Pregnancy Risk Assessment Monitoring System data with difference-in-difference estimators to compare Delaware with six states in 2007 to 2020 with respect to the planned status of pregnancies ending in births and with 14 states in 2012 to 2020 with respect to the intended status of pregnancies ending in births. Because several components of the DelCAN were designed to facilitate contraceptive access for low-income women, we conduct both an overall analysis and separate analyses for Medicaid-covered and non-Medicaid-covered women.

Findings: The DelCAN was not associated with reductions in unintended pregnancies ending in births in Delaware relative to comparison states but was associated with an increase in pregnancies that were wanted sooner. DelCAN was also associated with an increase in planned pregnancies concentrated among Medicaid-insured women and produced through reductions in pregnancies occurring when not using contraception.

Conclusions: Pregnancy intentions and pregnancy planning should be treated as distinct concepts in contraceptive-access program design and evaluation. Programs should attend to both pregnancies wanted later and pregnancies wanted sooner to address public health goals in concert with enhancing women's reproductive autonomy.

Policy Points Antitrust enforcement has been too narrowly focused on predicting postmerger market share and not enough on the likely impact of mergers and acquisitions on production efficiency and quality. Care delivery redesign is a term that captures various innovations and changes in the organization and delivery of health care, which may lead to increased production efficiency and improved quality of care. Regulators and policymakers can use the framework to develop empirical measures to assist in understanding changes in production processes as well as in resultant outcomes. Significant opportunities exist to improve data collection and require reporting to better assist regulators with antitrust enforcement and help policymakers create effective legislation. Examples include improving compliance with required hospital and insurer transaction price data reporting, growing the availability of all-payer claims databases, improving existing Medicare cost reporting, and achieving consensus on quality measures that are best used to measure the impact of consolidation. There is a fundamental need to systematically track health care organizations and their affiliations and component parts (e.g., hospitals, physician practices, skilled nursing facilities, etc.) longitudinally, especially as organizations expand across markets and state boundaries and are owned by various entities, including private equity.