mong the opioid epidemic’s most wrenching harms are the increased numbers of parents who struggle to care for their children. This year, more than 30,000 newborns will likely be diagnosed with neonatal abstinence syndrome (NAS), the physiological symptoms of opioid withdrawal. 1 Because the agony is so widespread and so raw, accompanying news stories command front-page attention. Yet these gripping human stories threaten to lead us astray, feeding narratives of hopelessness and stigma that harm people we need to help. know this years When epidemic inner-city America, valued who appeared irreparably damaged
{"title":"Opioid Use by Pregnant and Parenting Women: Let's Not Repeat the Mistakes of 25 Years Ago.","authors":"H. Pollack","doi":"10.1111/1468-0009.12407","DOIUrl":"https://doi.org/10.1111/1468-0009.12407","url":null,"abstract":"mong the opioid epidemic’s most wrenching harms are the increased numbers of parents who struggle to care for their children. This year, more than 30,000 newborns will likely be diagnosed with neonatal abstinence syndrome (NAS), the physiological symptoms of opioid withdrawal. 1 Because the agony is so widespread and so raw, accompanying news stories command front-page attention. Yet these gripping human stories threaten to lead us astray, feeding narratives of hopelessness and stigma that harm people we need to help. know this years When epidemic inner-city America, valued who appeared irreparably damaged","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"91 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-07-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"76458600","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
T he Republican Party has been adamantly opposed to the Affordable Care Act (ACA) since it was signed into law in March 2010. The Republican House has repeatedly voted to repeal the ACA and after Republicans regained control of the Senate in 2014, the Senate voted to repeal it as well. However, Republicans in both houses of Congress passed such bills knowing that President Obama would veto them, as he did most recently in early 2016. Now that Republicans have control of the House of Representatives and the Senate as well as the White House, any legislation that passes Congress will presumably be signed into law by the Republican president. There is a “catch,” however. Republicans hold only a 52-48 lead in the Senate. This slim majority means that the Republican leadership needs 50 of its 52 members to support whatever legislation is being proposed and even then can only be assured of passing legislation that can be considered through the budget reconciliation process, meaning that it affects the budget or government spending. Budget-related bills can be passed with a simple majority and cannot be filibustered. Any other legislation requires the votes of 60 supporting Senators in order to overcome a filibuster, which given the 52 Republicans in the Senate, translates into bipartisan support. The challenge for Republicans is that having promised to “repeal Obamacare” as often as they have, it will be difficult to wait until they are ready with a replacement bill in order to “repeal and replace.” If the GOP caucus feels obligated to pass a bill that just effectively defunds the ACA, as did the bill passed by Republicans in late 2015, they could do that within the first two months of the new administration. The 2015 bill would have repealed the funding for the exchange subsidy tax credits, the funding for the Medicaid expansion, the individual and employer mandates, and the various taxes that fund the ACA, including
{"title":"When Political Imperatives Collide With Policy Objectives.","authors":"G. Wilensky","doi":"10.1111/1468-0009.12236","DOIUrl":"https://doi.org/10.1111/1468-0009.12236","url":null,"abstract":"T he Republican Party has been adamantly opposed to the Affordable Care Act (ACA) since it was signed into law in March 2010. The Republican House has repeatedly voted to repeal the ACA and after Republicans regained control of the Senate in 2014, the Senate voted to repeal it as well. However, Republicans in both houses of Congress passed such bills knowing that President Obama would veto them, as he did most recently in early 2016. Now that Republicans have control of the House of Representatives and the Senate as well as the White House, any legislation that passes Congress will presumably be signed into law by the Republican president. There is a “catch,” however. Republicans hold only a 52-48 lead in the Senate. This slim majority means that the Republican leadership needs 50 of its 52 members to support whatever legislation is being proposed and even then can only be assured of passing legislation that can be considered through the budget reconciliation process, meaning that it affects the budget or government spending. Budget-related bills can be passed with a simple majority and cannot be filibustered. Any other legislation requires the votes of 60 supporting Senators in order to overcome a filibuster, which given the 52 Republicans in the Senate, translates into bipartisan support. The challenge for Republicans is that having promised to “repeal Obamacare” as often as they have, it will be difficult to wait until they are ready with a replacement bill in order to “repeal and replace.” If the GOP caucus feels obligated to pass a bill that just effectively defunds the ACA, as did the bill passed by Republicans in late 2015, they could do that within the first two months of the new administration. The 2015 bill would have repealed the funding for the exchange subsidy tax credits, the funding for the Medicaid expansion, the individual and employer mandates, and the various taxes that fund the ACA, including","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"32 1","pages":"32-35"},"PeriodicalIF":0.0,"publicationDate":"2017-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88224075","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
M. Bautista, M. Nurjono, Y. Lim, E. Dessers, H. Vrijhoef
Policy Points: Investigations on systematic methodologies for measuring integrated care should coincide with the growing interest in this field of research. A systematic review of instruments provides insights into integrated care measurement, including setting the research agenda for validating available instruments and informing the decision to develop new ones. This study is the first systematic review of instruments measuring integrated care with an evidence synthesis of the measurement properties. We found 209 index instruments measuring different constructs related to integrated care; the strength of evidence on the adequacy of the majority of their measurement properties remained largely unassessed. CONTEXT Integrated care is an important strategy for increasing health system performance. Despite its growing significance, detailed evidence on the measurement properties of integrated care instruments remains vague and limited. Our systematic review aims to provide evidence on the state of the art in measuring integrated care. METHODS Our comprehensive systematic review framework builds on the Rainbow Model for Integrated Care (RMIC). We searched MEDLINE/PubMed for published articles on the measurement properties of instruments measuring integrated care and identified eligible articles using a standard set of selection criteria. We assessed the methodological quality of every validation study reported using the COSMIN checklist and extracted data on study and instrument characteristics. We also evaluated the measurement properties of each examined instrument per validation study and provided a best evidence synthesis on the adequacy of measurement properties of the index instruments. FINDINGS From the 300 eligible articles, we assessed the methodological quality of 379 validation studies from which we identified 209 index instruments measuring integrated care constructs. The majority of studies reported on instruments measuring constructs related to care integration (33%) and patient-centered care (49%); fewer studies measured care continuity/comprehensive care (15%) and care coordination/case management (3%). We mapped 84% of the measured constructs to the clinical integration domain of the RMIC, with fewer constructs related to the domains of professional (3.7%), organizational (3.4%), and functional (0.5%) integration. Only 8% of the instruments were mapped to a combination of domains; none were mapped exclusively to the system or normative integration domains. The majority of instruments were administered to either patients (60%) or health care providers (20%). Of the measurement properties, responsiveness (4%), measurement error (7%), and criterion (12%) and cross-cultural validity (14%) were less commonly reported. We found <50% of the validation studies to be of good or excellent quality for any of the measurement properties. Only a minority of index instruments showed strong evidence of positive findings for internal consistenc
{"title":"Instruments Measuring Integrated Care: A Systematic Review of Measurement Properties.","authors":"M. Bautista, M. Nurjono, Y. Lim, E. Dessers, H. Vrijhoef","doi":"10.1111/1468-0009.12233","DOIUrl":"https://doi.org/10.1111/1468-0009.12233","url":null,"abstract":"Policy Points: Investigations on systematic methodologies for measuring integrated care should coincide with the growing interest in this field of research. A systematic review of instruments provides insights into integrated care measurement, including setting the research agenda for validating available instruments and informing the decision to develop new ones. This study is the first systematic review of instruments measuring integrated care with an evidence synthesis of the measurement properties. We found 209 index instruments measuring different constructs related to integrated care; the strength of evidence on the adequacy of the majority of their measurement properties remained largely unassessed.\u0000\u0000\u0000CONTEXT\u0000Integrated care is an important strategy for increasing health system performance. Despite its growing significance, detailed evidence on the measurement properties of integrated care instruments remains vague and limited. Our systematic review aims to provide evidence on the state of the art in measuring integrated care.\u0000\u0000\u0000METHODS\u0000Our comprehensive systematic review framework builds on the Rainbow Model for Integrated Care (RMIC). We searched MEDLINE/PubMed for published articles on the measurement properties of instruments measuring integrated care and identified eligible articles using a standard set of selection criteria. We assessed the methodological quality of every validation study reported using the COSMIN checklist and extracted data on study and instrument characteristics. We also evaluated the measurement properties of each examined instrument per validation study and provided a best evidence synthesis on the adequacy of measurement properties of the index instruments.\u0000\u0000\u0000FINDINGS\u0000From the 300 eligible articles, we assessed the methodological quality of 379 validation studies from which we identified 209 index instruments measuring integrated care constructs. The majority of studies reported on instruments measuring constructs related to care integration (33%) and patient-centered care (49%); fewer studies measured care continuity/comprehensive care (15%) and care coordination/case management (3%). We mapped 84% of the measured constructs to the clinical integration domain of the RMIC, with fewer constructs related to the domains of professional (3.7%), organizational (3.4%), and functional (0.5%) integration. Only 8% of the instruments were mapped to a combination of domains; none were mapped exclusively to the system or normative integration domains. The majority of instruments were administered to either patients (60%) or health care providers (20%). Of the measurement properties, responsiveness (4%), measurement error (7%), and criterion (12%) and cross-cultural validity (14%) were less commonly reported. We found <50% of the validation studies to be of good or excellent quality for any of the measurement properties. Only a minority of index instruments showed strong evidence of positive findings for internal consistenc","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"61 1","pages":"862-917"},"PeriodicalIF":0.0,"publicationDate":"2016-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78351284","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
O ne of my favorite scenes from “All The President’s Men,” the 1976 dramatization of Watergate and The Washington Post, comes early in the film—when the Post’s Bob Woodward (played by Robert Redford) confronts his colleague Carl Bernstein (played by Dustin Hoffman) for surreptitiously rewriting an article. When I saw that clip recently, I saw something I’d never really noticed before. Bernstein is sitting at his desk and taking drags from a cigarette. You wouldn’t see anything like that today—not in the real-life Washington Post newsroom and not in almost any other public indoor environment around the country. That’s because local, state, and federal governments have eradicated indoor smoking from just about everywhere except bars and restaurants. It’s only a matter of time before smoking is gone from those places, too. Roughly two-thirds of US states have already banned smoking in eating and drinking establishments, and within the outliers, which are mostly in the deep South, big cities are taking action on their own. The spread of indoor smoking bans is just one visible byproduct of America’s war on tobacco, a war that has been going on for more than 50 years. By any reasonable account, the forces fighting tobacco have been winning. As of 2014, just 16.8% of American adults smoked, down from 42.4% in 1965.1 All signs point to that number going down more in the future. Of course this war is far from over. Smoking is still more prevalent among the poor. In many developing countries, where US companies are increasingly focusing their efforts, smoking is actually on the rise. Big Tobacco has to look abroad precisely because selling cigarettes here has become harder and harder. It’s an excellent case study in the efficacy of public health campaigns, and maybe in the efficacy of government itself. And yet it gets
1976年改编自水门事件和《华盛顿邮报》(The Washington Post)的电影《总统亲信》(All The President’s Men)中，我最喜欢的一幕出现在电影开头:《华盛顿邮报》的鲍勃·伍德沃德(Robert Redford饰)与同事卡尔·伯恩斯坦(Carl Bernstein饰)对峙，原因是后者偷偷改写了一篇文章。当我最近看到这个片段时，我看到了一些我以前从未真正注意到的东西。伯恩斯坦正坐在办公桌前吸着几口烟。你今天不会看到这样的事情——在现实生活中的《华盛顿邮报》编辑部和全国几乎任何其他公共室内环境中都不会看到。这是因为地方、州和联邦政府已经禁止了除了酒吧和餐馆以外的几乎所有地方的室内吸烟。在这些地方禁烟只是时间问题。美国大约三分之二的州已经禁止在餐饮场所吸烟，而在一些例外情况下(主要是在南方腹地)，大城市也在自行采取行动。室内禁烟令的推广只是美国反烟草战争的一个可见副产品，这场战争已经持续了50多年。从任何合理的角度来看，反对烟草的力量都取得了胜利。截至2014年，只有16.8%的美国成年人吸烟，低于1965年的42.4%。所有迹象都表明，这一数字未来还会进一步下降。当然，这场战争远未结束。吸烟在穷人中更为普遍。在许多发展中国家，吸烟实际上呈上升趋势，而美国公司正越来越多地把精力集中在这些国家。大型烟草公司不得不把目光投向国外，正是因为在这里销售香烟变得越来越难。这是一个很好的研究公共卫生运动有效性的案例，也许也是研究政府本身有效性的案例。然而它得到了
{"title":"Winning the War on Tobacco-and Public Cynicism, Too.","authors":"J. Cohn","doi":"10.1111/1468-0009.12221","DOIUrl":"https://doi.org/10.1111/1468-0009.12221","url":null,"abstract":"O ne of my favorite scenes from “All The President’s Men,” the 1976 dramatization of Watergate and The Washington Post, comes early in the film—when the Post’s Bob Woodward (played by Robert Redford) confronts his colleague Carl Bernstein (played by Dustin Hoffman) for surreptitiously rewriting an article. When I saw that clip recently, I saw something I’d never really noticed before. Bernstein is sitting at his desk and taking drags from a cigarette. You wouldn’t see anything like that today—not in the real-life Washington Post newsroom and not in almost any other public indoor environment around the country. That’s because local, state, and federal governments have eradicated indoor smoking from just about everywhere except bars and restaurants. It’s only a matter of time before smoking is gone from those places, too. Roughly two-thirds of US states have already banned smoking in eating and drinking establishments, and within the outliers, which are mostly in the deep South, big cities are taking action on their own. The spread of indoor smoking bans is just one visible byproduct of America’s war on tobacco, a war that has been going on for more than 50 years. By any reasonable account, the forces fighting tobacco have been winning. As of 2014, just 16.8% of American adults smoked, down from 42.4% in 1965.1 All signs point to that number going down more in the future. Of course this war is far from over. Smoking is still more prevalent among the poor. In many developing countries, where US companies are increasingly focusing their efforts, smoking is actually on the rise. Big Tobacco has to look abroad precisely because selling cigarettes here has become harder and harder. It’s an excellent case study in the efficacy of public health campaigns, and maybe in the efficacy of government itself. And yet it gets","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"56 1","pages":"704-707"},"PeriodicalIF":0.0,"publicationDate":"2016-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80486733","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Policy Points: For accountable care organizations (ACOs) to be successful they need to change the behavior of their physicians. To stimulate this change, a broad range of motivators are being used, including ways to see a greater impact on patients (social purpose) and opportunities to be a more effective physician (mastery), in addition to personal financial incentives. From our analysis of case studies, it does not appear that the full range of motivators is being deployed by ACOs, which suggests an opportunity to develop more sophisticated and wider-ranging portfolios of motivators for greater impact. Context There are approximately 800 accountable care organizations (ACOs) in the United States. In order to achieve the ACO goals of reduced cost, improved outcomes of care, and better population health, it is critical to change how physicians within ACOs deliver care. While knowledge of ACO development and evolution is growing, relatively little is known about the motivational drivers that are being used to effect change among participating physicians. Methods We synthesized 9 well-established and empirically tested theories of motivation into an overarching framework of 6 motivator domains. This framework was then used to explore the types of motivators that leaders use to stimulate change within 4 case study ACOs. We explored the organizational characteristics, strategies, and motivators for changing physicians’ behaviors through in-depth interviews and document review. Findings The case study ACOs more strongly emphasized nonfinancial motivators for changing physician behavior than financial incentives. These motivators included mastery and social purpose, which were used frequently across all case study sites. Overall, the ACO case studies illustrated variability across all motivational domains. While there was evidence of changing motivators as a result of the ACO, the case study ACOs found it difficult to comprehensively change the use of motivators, in part due to dispersed managerial attention and the complexity and diversity of programs and contracts that fragmented efforts to improve. Conclusions Motivating behavior change within ACOs goes beyond financial incentives. ACOs are using a broad range of motivators, including creating ways to make a greater impact on patients and opportunities to be a more effective physician. Overall, it does not appear that ACOs are deploying the full range of available motivators. This suggests an opportunity to develop more sophisticated and wider-ranging portfolios of motivators to drive behavior change.
{"title":"More Than Money: Motivating Physician Behavior Change in Accountable Care Organizations.","authors":"Madeleine Phipps-Taylor, S. Shortell","doi":"10.1111/1468-0009.12230","DOIUrl":"https://doi.org/10.1111/1468-0009.12230","url":null,"abstract":"Policy Points: \u0000For accountable care organizations (ACOs) to be successful they need to change the behavior of their physicians. To stimulate this change, a broad range of motivators are being used, including ways to see a greater impact on patients (social purpose) and opportunities to be a more effective physician (mastery), in addition to personal financial incentives. \u0000From our analysis of case studies, it does not appear that the full range of motivators is being deployed by ACOs, which suggests an opportunity to develop more sophisticated and wider-ranging portfolios of motivators for greater impact. \u0000 \u0000 \u0000 \u0000Context \u0000There are approximately 800 accountable care organizations (ACOs) in the United States. In order to achieve the ACO goals of reduced cost, improved outcomes of care, and better population health, it is critical to change how physicians within ACOs deliver care. While knowledge of ACO development and evolution is growing, relatively little is known about the motivational drivers that are being used to effect change among participating physicians. \u0000 \u0000Methods \u0000We synthesized 9 well-established and empirically tested theories of motivation into an overarching framework of 6 motivator domains. This framework was then used to explore the types of motivators that leaders use to stimulate change within 4 case study ACOs. We explored the organizational characteristics, strategies, and motivators for changing physicians’ behaviors through in-depth interviews and document review. \u0000 \u0000Findings \u0000The case study ACOs more strongly emphasized nonfinancial motivators for changing physician behavior than financial incentives. These motivators included mastery and social purpose, which were used frequently across all case study sites. Overall, the ACO case studies illustrated variability across all motivational domains. While there was evidence of changing motivators as a result of the ACO, the case study ACOs found it difficult to comprehensively change the use of motivators, in part due to dispersed managerial attention and the complexity and diversity of programs and contracts that fragmented efforts to improve. \u0000 \u0000Conclusions \u0000Motivating behavior change within ACOs goes beyond financial incentives. ACOs are using a broad range of motivators, including creating ways to make a greater impact on patients and opportunities to be a more effective physician. Overall, it does not appear that ACOs are deploying the full range of available motivators. This suggests an opportunity to develop more sophisticated and wider-ranging portfolios of motivators to drive behavior change.","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"4 1","pages":"832-861"},"PeriodicalIF":0.0,"publicationDate":"2016-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88605560","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
I n an interview with THE NEW YORK TIMES on September 8, 2016, President Barack Obama reflected on what “he believes . . . will be the most consequential legacy of his presidency.” It wasn’t progress in destroying ISIS or efforts to bring peace to the Middle East; nor was it marriage equality, the Affordable Care Act, or his steady hand in bringing the nation out of recession. Rather, it was his struggles to slow global warming—the inexorable, slow-moving process he considered “the greatest long-term threat facing the world.” The president eloquently spoke of the potential political and social unrest caused by the dislocation of a billion people living in countries threatened by rising sea levels, droughts, intense heat waves, global pollution, new patterns of epidemic disease, and other health risks. Together, these could destabilize the most modern industrial society.1 Obama echoed some of the same points illustrated in a sobering study by the US Global Research Program titled “The Impacts of Climate Change on Human Health in the United States.” “Climate change,” the report argues, “can . . . affect human health in 2 main ways . . . first, by changing the severity of . . . respiratory diseases and cardiovascular diseases due to air pollution; second, by creating unprecedented or unanticipated health problem . . . in places where they have not previously occurred.”2 This past summer, a group of 19 Democratic senators led by Sheldon Whitehouse (D-RI) focused on the political reasons why emergency action has stalled. On July 11 and 12, just days before the Senate adjourned on July 15, they spoke about the “dozens of shadowy organizations” that, according to Senator Harry Reid, “are waging a campaign to mislead the public and undermine American leadership on climate change.” The goal of these organizations, Reid argues, is to destroy the Paris climate agreement and erode support for “clean air initiatives across the country.”3(p1)
{"title":"Webs of Denial: Climate Change and the Challenge to Public Health.","authors":"D. Rosner","doi":"10.1111/1468-0009.12228","DOIUrl":"https://doi.org/10.1111/1468-0009.12228","url":null,"abstract":"I n an interview with THE NEW YORK TIMES on September 8, 2016, President Barack Obama reflected on what “he believes . . . will be the most consequential legacy of his presidency.” It wasn’t progress in destroying ISIS or efforts to bring peace to the Middle East; nor was it marriage equality, the Affordable Care Act, or his steady hand in bringing the nation out of recession. Rather, it was his struggles to slow global warming—the inexorable, slow-moving process he considered “the greatest long-term threat facing the world.” The president eloquently spoke of the potential political and social unrest caused by the dislocation of a billion people living in countries threatened by rising sea levels, droughts, intense heat waves, global pollution, new patterns of epidemic disease, and other health risks. Together, these could destabilize the most modern industrial society.1 Obama echoed some of the same points illustrated in a sobering study by the US Global Research Program titled “The Impacts of Climate Change on Human Health in the United States.” “Climate change,” the report argues, “can . . . affect human health in 2 main ways . . . first, by changing the severity of . . . respiratory diseases and cardiovascular diseases due to air pollution; second, by creating unprecedented or unanticipated health problem . . . in places where they have not previously occurred.”2 This past summer, a group of 19 Democratic senators led by Sheldon Whitehouse (D-RI) focused on the political reasons why emergency action has stalled. On July 11 and 12, just days before the Senate adjourned on July 15, they spoke about the “dozens of shadowy organizations” that, according to Senator Harry Reid, “are waging a campaign to mislead the public and undermine American leadership on climate change.” The goal of these organizations, Reid argues, is to destroy the Paris climate agreement and erode support for “clean air initiatives across the country.”3(p1)","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"102 1","pages":"733-735"},"PeriodicalIF":0.0,"publicationDate":"2016-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84904319","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The United States has problems with oral health. While most Americans’ oral health has improved markedly over 60 years, many millions are left behind and hurting. Societal improvements in science, technology, education, hygiene, community water fluoridation, and school-based services have not been broadly shared.2 Today, 130 million Americans, primarily adults, have no dental coverage. Many Americans with coverage find today’s health insurance cost-sharing requirements a prohibitive barrier to care. Medicare provides no dental coverage for 70% of its enrollees; 40% of them did not visit a dentist in 2014 and 60% have severe or moderate gum disease. Medicaid does cover dental services for low-income children but 17 million of them got no dental care in 2009. In most states, Medicaid covers no or little dental care for poor adults, while 47 million Americans live in areas where finding a dentist can be impossible. Because of these access issues, 25% of adults over age 65 have lost all their teeth (edentulism). In 2009, US hospital emergency departments saw 850,000 visits for preventable dental pain. The avoidable disease called dental caries (or cavities) is 5 times more prevalent than asthma and affects 60% of children age 5 to 17. For those left behind, it’s a crisis. Oral health is an important part of US racial and ethnic health disparities.
{"title":"Might Oral Health Be the Next Big Thing?","authors":"J. McDonough","doi":"10.1111/1468-0009.12225","DOIUrl":"https://doi.org/10.1111/1468-0009.12225","url":null,"abstract":"The United States has problems with oral health. While most Americans’ oral health has improved markedly over 60 years, many millions are left behind and hurting. Societal improvements in science, technology, education, hygiene, community water fluoridation, and school-based services have not been broadly shared.2 Today, 130 million Americans, primarily adults, have no dental coverage. Many Americans with coverage find today’s health insurance cost-sharing requirements a prohibitive barrier to care. Medicare provides no dental coverage for 70% of its enrollees; 40% of them did not visit a dentist in 2014 and 60% have severe or moderate gum disease. Medicaid does cover dental services for low-income children but 17 million of them got no dental care in 2009. In most states, Medicaid covers no or little dental care for poor adults, while 47 million Americans live in areas where finding a dentist can be impossible. Because of these access issues, 25% of adults over age 65 have lost all their teeth (edentulism). In 2009, US hospital emergency departments saw 850,000 visits for preventable dental pain. The avoidable disease called dental caries (or cavities) is 5 times more prevalent than asthma and affects 60% of children age 5 to 17. For those left behind, it’s a crisis. Oral health is an important part of US racial and ethnic health disparities.","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"1 1","pages":"720-723"},"PeriodicalIF":0.0,"publicationDate":"2016-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79537884","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
I t is hardly surprising that rising prescription drug pricing found its way into the 2016 election. Prescription drug costs frequently get more attention than their share of the health care dollar would suggest—approximately 10% of total spending on health care (although it’s more than 16% if both retail drugs and nonretail drug spending such as hospital spending is considered relative to personal health spending).1 Two reasons help explain the disproportionate focus on prescription drugs. First, insurance coverage for prescription drugs has typically been less extensive than the coverage for physician and hospital care. As a result, many people are more aware of pricing changes in prescription drugs because they are more likely to experience some portion of the cost change. Second, spending growth for prescription drugs periodically spikes and focuses attention on drug pricing. This happened from 2000 to 2003 and again in 2014. The former was driven by the release of a large number of new, branded products that replaced older, less expensive drugs. The spending spike in 2014 came after several years of unusually low prescription drug spending growth (a rate slower even than the rest of health care spending, which was also growing relatively slowly). The primary reason for this spike was the introduction of several new biologic or specialty drugs. Most attention went to new drugs treating the hepatitis C virus (HCV)—Gilead’s Sovaldi, which was the highestselling drug in 2014 at $7.9 billion—along with several specialty drugs introduced for cancer, diabetes, and multiple sclerosis. More recently, we saw huge price jumps for two older drugs with expired patents. In 2015, Turing Pharmaceuticals increased the price of Daraprim, an old drug used to treat protozoal and malarial infections, to $750 a pill. In 2016, Mylan raised the price of the EpiPen, a delivery
{"title":"Prescription Drug Pricing Is Not Just an Election Issue.","authors":"G. Wilensky","doi":"10.1111/1468-0009.12223","DOIUrl":"https://doi.org/10.1111/1468-0009.12223","url":null,"abstract":"I t is hardly surprising that rising prescription drug pricing found its way into the 2016 election. Prescription drug costs frequently get more attention than their share of the health care dollar would suggest—approximately 10% of total spending on health care (although it’s more than 16% if both retail drugs and nonretail drug spending such as hospital spending is considered relative to personal health spending).1 Two reasons help explain the disproportionate focus on prescription drugs. First, insurance coverage for prescription drugs has typically been less extensive than the coverage for physician and hospital care. As a result, many people are more aware of pricing changes in prescription drugs because they are more likely to experience some portion of the cost change. Second, spending growth for prescription drugs periodically spikes and focuses attention on drug pricing. This happened from 2000 to 2003 and again in 2014. The former was driven by the release of a large number of new, branded products that replaced older, less expensive drugs. The spending spike in 2014 came after several years of unusually low prescription drug spending growth (a rate slower even than the rest of health care spending, which was also growing relatively slowly). The primary reason for this spike was the introduction of several new biologic or specialty drugs. Most attention went to new drugs treating the hepatitis C virus (HCV)—Gilead’s Sovaldi, which was the highestselling drug in 2014 at $7.9 billion—along with several specialty drugs introduced for cancer, diabetes, and multiple sclerosis. More recently, we saw huge price jumps for two older drugs with expired patents. In 2015, Turing Pharmaceuticals increased the price of Daraprim, an old drug used to treat protozoal and malarial infections, to $750 a pill. In 2016, Mylan raised the price of the EpiPen, a delivery","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"22 1","pages":"712-715"},"PeriodicalIF":0.0,"publicationDate":"2016-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83278638","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Robert A Nathenson, B. Saloner, Michael R Richards, K. Rhodes
Policy Points: Latino immigrants have recently spread beyond traditional US enclaves to “emerging destinations.” The arrival of limited English proficiency (LEP) Spanish-speakers to these areas can challenge the health care system, as translation services may not be readily available for LEP patients. Trained auditors posed as family members of LEP patients seeking primary care in a safety net setting. We found substantially lower appointment availability for LEP adults in emerging destinations compared to traditional destinations. Greater bilingual resources are needed within safety net clinics to accommodate LEP Spanish speakers as this population continues to grow and expand throughout the United States. Context Recent demographic trends show Latino immigrants moving to “emerging destinations” outside traditional Latino enclaves. Immigrants in emerging destinations with limited English proficiency (LEP) may experience greater challenges finding health care services oriented to their linguistic needs than those in traditional enclaves, especially if the supply of language resources in these areas has not kept pace with new demand. Methods This study uses an experimental audit design to directly compare the ability of uninsured Spanish-speaking LEP adults to access interpreter services and to obtain new patient primary care appointments at federally qualified health centers (FQHCs) across traditional and emerging destinations. We additionally compare the appointment rates of English-proficient uninsured and English-proficient Medicaid patients across these destinations that contacted the same FQHCs. English-proficient patients serve as an access benchmark that is independent of differences in Spanish language services. Findings Results indicate that LEP Spanish-speaking patients within emerging destinations are 40 percentage points less likely to receive an appointment than those in traditional destinations. English-proficient groups, by contrast, experience similar levels of access across destinations. Disparities in safety net provider access by destination status are consistent with differences in the availability of bilingual services. Ninety-two percent of FQHCs in traditional destinations offered appointments with either Spanish-speaking clinicians or translation services with non-clinical bilingual staff, while only 54% did so in emerging destinations. LEP patients denied care in emerging destinations must also travel greater distances than in traditional destinations to reach the next available safety net provider. Conclusions Our findings highlight that current language resources in emerging destinations may be inadequate for keeping up with the transforming needs of the patient population. As the Latino immigrant population continues to expand and diffuse, better accommodation within the health care safety net is likely to increase in importance.
{"title":"Spanish-Speaking Immigrants' Access to Safety Net Providers and Translation Services Across Traditional and Emerging US Destinations.","authors":"Robert A Nathenson, B. Saloner, Michael R Richards, K. Rhodes","doi":"10.1111/1468-0009.12231","DOIUrl":"https://doi.org/10.1111/1468-0009.12231","url":null,"abstract":"Policy Points: \u0000Latino immigrants have recently spread beyond traditional US enclaves to “emerging destinations.” The arrival of limited English proficiency (LEP) Spanish-speakers to these areas can challenge the health care system, as translation services may not be readily available for LEP patients. \u0000Trained auditors posed as family members of LEP patients seeking primary care in a safety net setting. We found substantially lower appointment availability for LEP adults in emerging destinations compared to traditional destinations. \u0000Greater bilingual resources are needed within safety net clinics to accommodate LEP Spanish speakers as this population continues to grow and expand throughout the United States. \u0000 \u0000 \u0000 \u0000Context \u0000Recent demographic trends show Latino immigrants moving to “emerging destinations” outside traditional Latino enclaves. Immigrants in emerging destinations with limited English proficiency (LEP) may experience greater challenges finding health care services oriented to their linguistic needs than those in traditional enclaves, especially if the supply of language resources in these areas has not kept pace with new demand. \u0000 \u0000Methods \u0000This study uses an experimental audit design to directly compare the ability of uninsured Spanish-speaking LEP adults to access interpreter services and to obtain new patient primary care appointments at federally qualified health centers (FQHCs) across traditional and emerging destinations. We additionally compare the appointment rates of English-proficient uninsured and English-proficient Medicaid patients across these destinations that contacted the same FQHCs. English-proficient patients serve as an access benchmark that is independent of differences in Spanish language services. \u0000 \u0000Findings \u0000Results indicate that LEP Spanish-speaking patients within emerging destinations are 40 percentage points less likely to receive an appointment than those in traditional destinations. English-proficient groups, by contrast, experience similar levels of access across destinations. Disparities in safety net provider access by destination status are consistent with differences in the availability of bilingual services. Ninety-two percent of FQHCs in traditional destinations offered appointments with either Spanish-speaking clinicians or translation services with non-clinical bilingual staff, while only 54% did so in emerging destinations. LEP patients denied care in emerging destinations must also travel greater distances than in traditional destinations to reach the next available safety net provider. \u0000 \u0000Conclusions \u0000Our findings highlight that current language resources in emerging destinations may be inadequate for keeping up with the transforming needs of the patient population. As the Latino immigrant population continues to expand and diffuse, better accommodation within the health care safety net is likely to increase in importance.","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"59 1","pages":"768-799"},"PeriodicalIF":0.0,"publicationDate":"2016-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79472089","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
H omicide and suicide together claim more than 50,000 lives in the United States each year. The broader base of victims of violence includes 1.2 million people seen in the emergency department annually as a result of assault, according to the National Vital Statistics System. An estimated 10 million Americans suffer physical violence at the hands of an intimate partner.1 For US children, more than 1 in 7 experience and more than 1 in 4 witness violence annually.2 Yet effective responses to violence by the public health and health care systems remain few, far between, and—if they exist at all— underfunded. A decade ago, when I was the health commissioner of Baltimore, I addressed a group of about 40 Catholic priests. The city was in the midst of a spate of shootings and the priests were, understandably, alarmed. I told them: “You see violence as a moral failure. The police see violence as crime. In public health, we see violence as a contagious but preventable behavior.” At the time, I was raising funds for an antiviolence program developed by a global public health expert with experience stopping outbreaks of infectious disease. The program hires community members to work late at night to interrupt the cycle of retaliation. The workers mediate disputes, establish community norms against guns, and connect high-risk youth to education, health care, and jobs. An independent evaluation has found that in the initiative’s focus areas, there is markedly less interest in using guns to settle arguments—and there are fewer shootings.3 Despite a track record of results, the program is still struggling for sustainable funding and is operating at a far smaller scale than necessary. So too are successful hospital-based violence intervention programs, which, in a form of secondary prevention, provide a range of services to patients who suffer injuries from violence. These initiatives may reduce the chances of revictimization by as much as fourfold.4 Given that half of certain victims of violence experience violence again, and as many as
{"title":"Violent Injury as a Preventable Condition.","authors":"J. Sharfstein","doi":"10.1111/1468-0009.12222","DOIUrl":"https://doi.org/10.1111/1468-0009.12222","url":null,"abstract":"H omicide and suicide together claim more than 50,000 lives in the United States each year. The broader base of victims of violence includes 1.2 million people seen in the emergency department annually as a result of assault, according to the National Vital Statistics System. An estimated 10 million Americans suffer physical violence at the hands of an intimate partner.1 For US children, more than 1 in 7 experience and more than 1 in 4 witness violence annually.2 Yet effective responses to violence by the public health and health care systems remain few, far between, and—if they exist at all— underfunded. A decade ago, when I was the health commissioner of Baltimore, I addressed a group of about 40 Catholic priests. The city was in the midst of a spate of shootings and the priests were, understandably, alarmed. I told them: “You see violence as a moral failure. The police see violence as crime. In public health, we see violence as a contagious but preventable behavior.” At the time, I was raising funds for an antiviolence program developed by a global public health expert with experience stopping outbreaks of infectious disease. The program hires community members to work late at night to interrupt the cycle of retaliation. The workers mediate disputes, establish community norms against guns, and connect high-risk youth to education, health care, and jobs. An independent evaluation has found that in the initiative’s focus areas, there is markedly less interest in using guns to settle arguments—and there are fewer shootings.3 Despite a track record of results, the program is still struggling for sustainable funding and is operating at a far smaller scale than necessary. So too are successful hospital-based violence intervention programs, which, in a form of secondary prevention, provide a range of services to patients who suffer injuries from violence. These initiatives may reduce the chances of revictimization by as much as fourfold.4 Given that half of certain victims of violence experience violence again, and as many as","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"10 1","pages":"708-711"},"PeriodicalIF":0.0,"publicationDate":"2016-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81260342","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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