T he public must have better information to make sound decisions about which hospitals would be the best choices for themselves or for their families. Currently, many such decisions are based on where their physicians have admitting privileges, advice from friends who had prior experiences with specific hospitals, or the general reputations of hospitals and medical centers in the community. But to augment the bases for such important decisions, several elaborate hospital rankings and ratings have been developed. The two best-known evaluations of hospitals are those published by the US Centers for Medicare and Medicaid Services (CMS) and by the weekly news magazine US News & World Report. The CMS star rating, ranging from a rank of 1 (the lowest) to 5 (the highest), evaluates some 4,600 hospitals and is designed to provide comprehensive, quality information about patient care. It ranks hospitals on 64 quality measurements, including patient care for myocardial infarctions and pneumonia, post-surgical infection rates, joint replacement complications, and emergency room waiting times.1 However, the CMS rankings currently do not include data on the quality of care or patients’ health outcomes.2 The US News & World Report ratings evaluate some 5,000 medical centers based on such metrics as death rates, patient safety, and hospital reputation, which are reported by 30,000 physicians.3 In the 2016 CMS report, only 102 (2.2%) of the 4,600 hospitals received an overall rating of 5 stars, 934 (20.3%) received a 4-star rating, 1,770 (38.5%) received a 3-star rating, 723 (15.7%) received a 2-star rating, and 133 (2.9%) received a 1-star rating. An additional 937 (20.4%) received no rating because they either did not report, or did not have, the minimal amount of data required to make a decision. This last scenario might occur with the quality measurement of new or small hospitals or those admitting an insufficient number of patients.
公众必须有更好的信息来做出明智的决定，哪些医院对他们自己或他们的家人来说是最好的选择。目前，许多这样的决定是基于他们的医生在哪里有准入特权，来自以前在特定医院工作过的朋友的建议，或者医院和医疗中心在社区中的总体声誉。但是，为了增加这些重要决策的依据，一些精心设计的医院排名和评级已经被开发出来。美国医疗保险和医疗补助服务中心(CMS)和新闻周刊《美国新闻与世界报道》(US news & World Report)发布的两份最著名的医院评估报告。CMS的星级评级从1(最低)到5(最高)不等，对大约4,600家医院进行了评估，旨在提供有关患者护理的全面、高质量信息。它根据64项质量指标对医院进行排名，包括对心肌梗死和肺炎患者的护理、术后感染率、关节置换并发症和急诊室等待时间然而，CMS排名目前不包括护理质量或患者健康结果的数据《美国新闻与世界报道》根据死亡率、病人安全和医院声誉等指标对大约5000家医疗中心进行了评估，这些指标由3万名医生报告在2016年的CMS报告中，4600家医院中，只有102家(2.2%)获得了5星的总体评级，934家(20.3%)获得了4星评级，1770家(38.5%)获得了3星评级，723家(15.7%)获得了2星评级，133家(2.9%)获得了1星评级。另有937家(20.4%)没有评级，因为它们要么没有报告，要么没有做出决定所需的最低数量的数据。最后一种情况可能发生在新医院或小医院或收治病人数量不足的医院的质量测量中。
{"title":"How Helpful Are Hospital Rankings and Ratings for the Public's Health?","authors":"C. Deangelis","doi":"10.1111/1468-0009.12227","DOIUrl":"https://doi.org/10.1111/1468-0009.12227","url":null,"abstract":"T he public must have better information to make sound decisions about which hospitals would be the best choices for themselves or for their families. Currently, many such decisions are based on where their physicians have admitting privileges, advice from friends who had prior experiences with specific hospitals, or the general reputations of hospitals and medical centers in the community. But to augment the bases for such important decisions, several elaborate hospital rankings and ratings have been developed. The two best-known evaluations of hospitals are those published by the US Centers for Medicare and Medicaid Services (CMS) and by the weekly news magazine US News & World Report. The CMS star rating, ranging from a rank of 1 (the lowest) to 5 (the highest), evaluates some 4,600 hospitals and is designed to provide comprehensive, quality information about patient care. It ranks hospitals on 64 quality measurements, including patient care for myocardial infarctions and pneumonia, post-surgical infection rates, joint replacement complications, and emergency room waiting times.1 However, the CMS rankings currently do not include data on the quality of care or patients’ health outcomes.2 The US News & World Report ratings evaluate some 5,000 medical centers based on such metrics as death rates, patient safety, and hospital reputation, which are reported by 30,000 physicians.3 In the 2016 CMS report, only 102 (2.2%) of the 4,600 hospitals received an overall rating of 5 stars, 934 (20.3%) received a 4-star rating, 1,770 (38.5%) received a 3-star rating, 723 (15.7%) received a 2-star rating, and 133 (2.9%) received a 1-star rating. An additional 937 (20.4%) received no rating because they either did not report, or did not have, the minimal amount of data required to make a decision. This last scenario might occur with the quality measurement of new or small hospitals or those admitting an insufficient number of patients.","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"28 1","pages":"729-732"},"PeriodicalIF":0.0,"publicationDate":"2016-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74846633","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}
{"title":"\"Big Food\" Is Making America Sick.","authors":"L. Gostin","doi":"10.1111/1468-0009.12209","DOIUrl":"https://doi.org/10.1111/1468-0009.12209","url":null,"abstract":"","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"13 1","pages":"480-4"},"PeriodicalIF":0.0,"publicationDate":"2016-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85457773","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}
A s I write these words in the early weeks of summer, the Ebola fever panic of 2014 has long since receded into our collective rearview mirror and the number of Zika virus cases, along with the discovery of more and more babies with Zika-induced microcephaly, is steadily increasing. By the time you read this column, swarms of Aedes aegypti and Aedes albopictus mosquitoes carrying the virus will have likely traveled from South America to points north, east, and west, accompanied by the predictable media hoopla that characterizes every American epidemic. Sadly, the interregna between the many contagious crises of the still young 21st century have been characterized by a global amnesia. As the “epi curve” of each scourge descends, public health officials, elected leaders, and the population at large turn their attention to other issues at the expense of planning for the next newly emerging infectious disease. And just as predictably, the appearance of each new pandemic or epidemic inspires a situation in which our public health officials must waste valuable time and energy securing adequate government funding to fight and contain the new threat. Ironically, in 1983, the US Congress established a public health emergency fund, much like the one for the Federal Emergency Management Agency (FEMA) uses to rapidly respond to natural disasters. Yet the balance of that federal public health emergency fund, as of June 2, 2016, was a mere $57,000! This sorry situation serves to remind us of, perhaps, the savviest paragraph on public health ever composed; it is one I will quote in 2 parts as this essay progresses. Let’s begin with the opening lines of what ought to be memorized as public health gospel:
{"title":"\"Public Health Is Purchasable\".","authors":"H. Markel","doi":"10.1111/1468-0009.12202","DOIUrl":"https://doi.org/10.1111/1468-0009.12202","url":null,"abstract":"A s I write these words in the early weeks of summer, the Ebola fever panic of 2014 has long since receded into our collective rearview mirror and the number of Zika virus cases, along with the discovery of more and more babies with Zika-induced microcephaly, is steadily increasing. By the time you read this column, swarms of Aedes aegypti and Aedes albopictus mosquitoes carrying the virus will have likely traveled from South America to points north, east, and west, accompanied by the predictable media hoopla that characterizes every American epidemic. Sadly, the interregna between the many contagious crises of the still young 21st century have been characterized by a global amnesia. As the “epi curve” of each scourge descends, public health officials, elected leaders, and the population at large turn their attention to other issues at the expense of planning for the next newly emerging infectious disease. And just as predictably, the appearance of each new pandemic or epidemic inspires a situation in which our public health officials must waste valuable time and energy securing adequate government funding to fight and contain the new threat. Ironically, in 1983, the US Congress established a public health emergency fund, much like the one for the Federal Emergency Management Agency (FEMA) uses to rapidly respond to natural disasters. Yet the balance of that federal public health emergency fund, as of June 2, 2016, was a mere $57,000! This sorry situation serves to remind us of, perhaps, the savviest paragraph on public health ever composed; it is one I will quote in 2 parts as this essay progresses. Let’s begin with the opening lines of what ought to be memorized as public health gospel:","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"32 1","pages":"441-7"},"PeriodicalIF":0.0,"publicationDate":"2016-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73510870","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 May 2016, the Obama Administration issued longawaited regulations implementing §1557 of the Affordable Care Act (ACA).1 Broad in scope, §1557 does what virtually no civil rights law has done before: it extends the principle of nondiscrimination to the content of health insurance, that is, coverage standards themselves. At the same time, however, the challenge of insuring nearly all residents within the world’s costliest health care system, coupled with long-standing insurer traditions designed to shield companies, sponsors, and policyholders from excessive costs, underscores the many complexities involved in balancing coverage with equity. Section 1557 provides that no individual shall be barred from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, any part of which receives federal financial assistance. The concept of federal financial assistance reaches not just grants or public insurance payments but also tax credits, government payment subsidies, and contracts of insurance. The principle of discrimination incorporates the cornerstones of US civil rights law—Title VI of the Civil Rights Act of 1964 (race, color, and national origin), Title IX of the Education Amendments of 1972 (sex), §504 of the Rehabilitation Act of 1973 (disability), and the Age Discrimination Act of 1975 (age). The reach of existing civil rights laws into health care has been considerable and transformative in its own right. But these laws were generally interpreted as falling short of reaching health insurance coverage itself.2 The US Supreme Court ruled that disability antidiscrimination law does not bar state Medicaid programs from imposing across-the-board limits on hospital coverage, even though such limits may leave people with disabilities without access to adequate treatment. Lower courts have similarly ruled in the past that disability nondiscrimination law does
{"title":"The Affordable Care Act and Civil Rights: The Challenge of Section 1557 of the Affordable Care Act.","authors":"S. Rosenbaum","doi":"10.1111/1468-0009.12207","DOIUrl":"https://doi.org/10.1111/1468-0009.12207","url":null,"abstract":"I n May 2016, the Obama Administration issued longawaited regulations implementing §1557 of the Affordable Care Act (ACA).1 Broad in scope, §1557 does what virtually no civil rights law has done before: it extends the principle of nondiscrimination to the content of health insurance, that is, coverage standards themselves. At the same time, however, the challenge of insuring nearly all residents within the world’s costliest health care system, coupled with long-standing insurer traditions designed to shield companies, sponsors, and policyholders from excessive costs, underscores the many complexities involved in balancing coverage with equity. Section 1557 provides that no individual shall be barred from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity, any part of which receives federal financial assistance. The concept of federal financial assistance reaches not just grants or public insurance payments but also tax credits, government payment subsidies, and contracts of insurance. The principle of discrimination incorporates the cornerstones of US civil rights law—Title VI of the Civil Rights Act of 1964 (race, color, and national origin), Title IX of the Education Amendments of 1972 (sex), §504 of the Rehabilitation Act of 1973 (disability), and the Age Discrimination Act of 1975 (age). The reach of existing civil rights laws into health care has been considerable and transformative in its own right. But these laws were generally interpreted as falling short of reaching health insurance coverage itself.2 The US Supreme Court ruled that disability antidiscrimination law does not bar state Medicaid programs from imposing across-the-board limits on hospital coverage, even though such limits may leave people with disabilities without access to adequate treatment. Lower courts have similarly ruled in the past that disability nondiscrimination law does","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"37 1","pages":"464-7"},"PeriodicalIF":0.0,"publicationDate":"2016-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"90947953","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}
{"title":"The VA Continues to Struggle-Especially in Terms of Improved Access.","authors":"G. Wilensky","doi":"10.1111/1468-0009.12204","DOIUrl":"https://doi.org/10.1111/1468-0009.12204","url":null,"abstract":"","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"34 1","pages":"452-5"},"PeriodicalIF":0.0,"publicationDate":"2016-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"89921185","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. Rodríguez, R. Henke, S. Bibi, P. Ramsay, S. Shortell
UNLABELLED Policy Points The rate of adoption of chronic care management processes (CMPs) by physician organizations has been fairly slow in spite of demonstrated effectiveness of CMPs in improving outcomes of chronic care. Exnovation (ie, removal of innovations) by physician organizations largely explains the slow population-level increases in practice use of CMPs over time. Expanded health information technology functions may aid practices in retaining CMPs. Low provider reimbursement by Medicaid programs, however, may contribute to disinvestment in CMPs by physician organizations. CONTEXT Exnovation is the process of removal of innovations that are not effective in improving organizational performance, are too disruptive to routine operations, or do not fit well with the existing organizational strategy, incentives, structure, and/or culture. Exnovation may contribute to the low overall adoption of care management processes (CMPs) by US physician organizations over time. METHODS Three national surveys of US physician organizations, which included common questions about organizational characteristics, use of CMPs, and health information technology (HIT) capabilities for practices of all sizes, and Truven Health Insurance Coverage Estimates were integrated to assess organizational and market influences on the exnovation of CMPs in a longitudinal cohort of 1,048 physician organizations. CMPs included 5 strategies for each of 4 chronic conditions (diabetes, asthma, congestive heart failure, and depression): registry use, nurse care management, patient reminders for preventive and care management services to prevent exacerbations of chronic illness, use of nonphysician clinicians to provide patient education, and quality of care feedback to physicians. FINDINGS Over one-third (34.1%) of physician organizations exnovated CMPs on net. Quality of care data feedback to physicians and patient reminders for recommended preventive and chronic care were discontinued by over one-third of exnovators, while nurse care management and registries were largely retained. Greater proportions of baseline Medicaid practice revenue (incidence rate ratio [IRR] = 1.44, p < 0.001) and increasing proportions of revenue from Medicaid (IRR = 1.02, p < 0.05) were associated with greater CMP exnovation by physician organizations on net. Practices with greater expansion of HIT functionality exnovated fewer CMPs (IRR = 0.91, p < 0.001) compared to practices with less expansion of HIT functionality. CONCLUSIONS Exnovation of CMPs is an important reason why the population-level adoption of CMPs by physician organizations has remained low. Expanded HIT functions and changes to Medicaid reimbursement and incentives may aid the retention of CMPs by physician organizations.
尽管慢性护理管理过程(cmp)在改善慢性护理结果方面已被证明有效，但医生组织采用cmp的速度相当缓慢。医师组织的创新(即移除创新)在很大程度上解释了cmp在实践中使用缓慢的人口水平增长。扩大卫生信息技术功能可能有助于留住cmp的做法。然而，医疗补助计划的低供应商报销可能导致医生组织对cmp的投资减少。背景创新是去除对提高组织绩效无效的创新，对常规运营具有破坏性的创新，或与现有组织战略、激励机制、结构和/或文化不太适应的创新的过程。随着时间的推移，创新可能会导致美国医生组织对护理管理流程(cmp)的整体采用率较低。方法对美国医师组织进行了三次全国性调查，包括组织特征、cmp的使用、各种规模的医疗实践的健康信息技术(HIT)能力等常见问题，以及Truven健康保险覆盖评估，对1048家医师组织进行纵向队列研究，评估组织和市场对cmp创新的影响。cmp包括针对4种慢性疾病(糖尿病、哮喘、充血性心力衰竭和抑郁症)中的每种疾病的5种策略:登记使用、护士护理管理、患者提醒预防和护理管理服务以防止慢性疾病恶化、使用非医师临床医生提供患者教育以及向医生反馈护理质量。超过三分之一(34.1%)的医生组织在网上更新了cmp。超过三分之一的创新者停止了对医生的护理质量数据反馈和对推荐的预防和慢性护理的患者提醒，而护士护理管理和登记在很大程度上得到保留。更大比例的基线医疗补助实践收入(发病率比[IRR] = 1.44, p < 0.001)和医疗补助收入比例的增加(IRR = 1.02, p < 0.05)与医生组织更大的CMP创新相关。与HIT功能扩展较少的实践相比，HIT功能扩展较大的实践更新了较少的cmp (IRR = 0.91, p < 0.001)。结论中医创新是医师组织对中医采用率低的重要原因。HIT功能的扩展以及医疗补助报销和激励措施的变化可能有助于医生组织保留cmp。
{"title":"The Exnovation of Chronic Care Management Processes by Physician Organizations.","authors":"H. Rodríguez, R. Henke, S. Bibi, P. Ramsay, S. Shortell","doi":"10.1111/1468-0009.12213","DOIUrl":"https://doi.org/10.1111/1468-0009.12213","url":null,"abstract":"UNLABELLED\u0000Policy Points The rate of adoption of chronic care management processes (CMPs) by physician organizations has been fairly slow in spite of demonstrated effectiveness of CMPs in improving outcomes of chronic care. Exnovation (ie, removal of innovations) by physician organizations largely explains the slow population-level increases in practice use of CMPs over time. Expanded health information technology functions may aid practices in retaining CMPs. Low provider reimbursement by Medicaid programs, however, may contribute to disinvestment in CMPs by physician organizations.\u0000\u0000\u0000CONTEXT\u0000Exnovation is the process of removal of innovations that are not effective in improving organizational performance, are too disruptive to routine operations, or do not fit well with the existing organizational strategy, incentives, structure, and/or culture. Exnovation may contribute to the low overall adoption of care management processes (CMPs) by US physician organizations over time.\u0000\u0000\u0000METHODS\u0000Three national surveys of US physician organizations, which included common questions about organizational characteristics, use of CMPs, and health information technology (HIT) capabilities for practices of all sizes, and Truven Health Insurance Coverage Estimates were integrated to assess organizational and market influences on the exnovation of CMPs in a longitudinal cohort of 1,048 physician organizations. CMPs included 5 strategies for each of 4 chronic conditions (diabetes, asthma, congestive heart failure, and depression): registry use, nurse care management, patient reminders for preventive and care management services to prevent exacerbations of chronic illness, use of nonphysician clinicians to provide patient education, and quality of care feedback to physicians.\u0000\u0000\u0000FINDINGS\u0000Over one-third (34.1%) of physician organizations exnovated CMPs on net. Quality of care data feedback to physicians and patient reminders for recommended preventive and chronic care were discontinued by over one-third of exnovators, while nurse care management and registries were largely retained. Greater proportions of baseline Medicaid practice revenue (incidence rate ratio [IRR] = 1.44, p < 0.001) and increasing proportions of revenue from Medicaid (IRR = 1.02, p < 0.05) were associated with greater CMP exnovation by physician organizations on net. Practices with greater expansion of HIT functionality exnovated fewer CMPs (IRR = 0.91, p < 0.001) compared to practices with less expansion of HIT functionality.\u0000\u0000\u0000CONCLUSIONS\u0000Exnovation of CMPs is an important reason why the population-level adoption of CMPs by physician organizations has remained low. Expanded HIT functions and changes to Medicaid reimbursement and incentives may aid the retention of CMPs by physician organizations.","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"181 1","pages":"626-53"},"PeriodicalIF":0.0,"publicationDate":"2016-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80245722","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}
{"title":"Mass Production of Systematic Reviews and Meta-analyses: An Exercise in Mega-silliness?","authors":"M. Page, D. Moher","doi":"10.1111/1468-0009.12211","DOIUrl":"https://doi.org/10.1111/1468-0009.12211","url":null,"abstract":"","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"51 1","pages":"515-9"},"PeriodicalIF":0.0,"publicationDate":"2016-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83647354","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: E-cigarettes are new products that are generating policy issues, including youth access and smokefree laws, for local and state governments. Unlike with analogous debates on conventional cigarettes, initial opposition came from e-cigarette users and retailers independent of the multinational cigarette companies. After the cigarette companies entered the e-cigarette market, the opposition changed to resemble long-standing industry resistance to tobacco control policies, including campaign contributions, lobbying, and working through third parties and front groups. As with earlier efforts to restrict tobacco products, health advocates have had the most success at the local rather than the state level. Context E-cigarettes entered the US market in 2007 without federal regulation. In 2009, local and state policymakers began identifying ways to regulate their sale, public usage, taxation, and marketing, often by integrating them into existing tobacco control laws. Methods We reviewed legislative hearings, newspaper articles, financial disclosure reports, NewsBank, Google, Twitter, and Facebook and conducted interviews to analyze e-cigarette policy debates between 2009 and 2014 in 4 cities and the corresponding states. Findings Initial opposition to local and state legislation came from e-cigarette users and retailers independent of the large multinational cigarette companies. After cigarette companies entered the e-cigarette market, e-cigarette policy debates increasingly resembled comparable tobacco control debates from the 1970s through the 1990s, including pushing pro-industry legislation, working through third parties and front groups, mobilizing “grassroots” networks, lobbying and using campaign contributions, and claiming that policy was unnecessary due to “imminent” federal regulation. Similar to the 1980s, when the voluntary health organizations were slow to enter tobacco control debates, because they saw smoking restrictions as controversial, these organizations were reluctant to enter e-cigarette debates. Strong legislation passed at the local level because of the committed efforts of local health departments and leadership from experienced politicians but failed at the state level due to intense cigarette company lobbying without countervailing pressure from the voluntary health organizations. Conclusions Passing e-cigarette regulations at the state level has become more difficult since cigarette companies have entered the market. While state legislation is possible, as with earlier tobacco control policymaking, local governments remain a viable option for overcoming cigarette company interference in the policymaking process.
{"title":"E-cigarette Policymaking by Local and State Governments: 2009-2014.","authors":"Elizabeth Cox, R. Barry, S. Glantz","doi":"10.1111/1468-0009.12212","DOIUrl":"https://doi.org/10.1111/1468-0009.12212","url":null,"abstract":"Policy Points: \u0000E-cigarettes are new products that are generating policy issues, including youth access and smokefree laws, for local and state governments. \u0000Unlike with analogous debates on conventional cigarettes, initial opposition came from e-cigarette users and retailers independent of the multinational cigarette companies. \u0000After the cigarette companies entered the e-cigarette market, the opposition changed to resemble long-standing industry resistance to tobacco control policies, including campaign contributions, lobbying, and working through third parties and front groups. \u0000As with earlier efforts to restrict tobacco products, health advocates have had the most success at the local rather than the state level. \u0000 \u0000 \u0000 \u0000Context \u0000E-cigarettes entered the US market in 2007 without federal regulation. In 2009, local and state policymakers began identifying ways to regulate their sale, public usage, taxation, and marketing, often by integrating them into existing tobacco control laws. \u0000 \u0000Methods \u0000We reviewed legislative hearings, newspaper articles, financial disclosure reports, NewsBank, Google, Twitter, and Facebook and conducted interviews to analyze e-cigarette policy debates between 2009 and 2014 in 4 cities and the corresponding states. \u0000 \u0000Findings \u0000Initial opposition to local and state legislation came from e-cigarette users and retailers independent of the large multinational cigarette companies. After cigarette companies entered the e-cigarette market, e-cigarette policy debates increasingly resembled comparable tobacco control debates from the 1970s through the 1990s, including pushing pro-industry legislation, working through third parties and front groups, mobilizing “grassroots” networks, lobbying and using campaign contributions, and claiming that policy was unnecessary due to “imminent” federal regulation. Similar to the 1980s, when the voluntary health organizations were slow to enter tobacco control debates, because they saw smoking restrictions as controversial, these organizations were reluctant to enter e-cigarette debates. Strong legislation passed at the local level because of the committed efforts of local health departments and leadership from experienced politicians but failed at the state level due to intense cigarette company lobbying without countervailing pressure from the voluntary health organizations. \u0000 \u0000Conclusions \u0000Passing e-cigarette regulations at the state level has become more difficult since cigarette companies have entered the market. While state legislation is possible, as with earlier tobacco control policymaking, local governments remain a viable option for overcoming cigarette company interference in the policymaking process.","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"27 1","pages":"520-96"},"PeriodicalIF":0.0,"publicationDate":"2016-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87656692","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 the biggest health care stories these days doesn’t get nearly the attention it deserves. It is the slowbut-steady expansion of Medicaid, the program that’s been providing insurance to the poor since the 1960s, as part of the Affordable Care Act (ACA). If you follow the political debates about “Obamacare,” chances are you hear much more about changes to the private insurance market and what those changes mean for consumers. But the number of people who have coverage thanks to the law’s Medicaid expansion (roughly 15 million as of 2016) is actually a bit larger than the number getting coverage through the exchanges (roughly 13 million).1 The Medicaid expansion’s impact on economic security and public health is probably larger too. In June, I got an early glimpse of what a bigger Medicaid program could mean for Louisiana, thanks to a group visit for journalists organized by the Henry J. Kaiser Family Foundation. Until recently, Louisiana was among the states whose officials were refusing to expand Medicaid eligibility as the ACA’s architects had originally envisioned. But in 2015, John Bel Edwards ran for governor on a promise to join the expansion—that is, to make Louisiana’s version of Medicaid available to all people in households with incomes below 133% of the poverty line. (In 2016, that’s $15,800 for an individual and $26,813 for a family of 3.) Edwards won and on January 12, 2016, one day after taking office, he signed an executive order implementing the expansion. The ink was barely dry when state agencies began trying to sign up as many people as possible—by automatically enrolling those who were already receiving other forms of state assistance and by conducting outreach efforts through health clinics and other venues that serve lowincome communities. Coverage was set to begin paying for services on July 1, 2016. By the time of my visit, roughly 2 weeks before that start
最近最大的医疗保健故事之一并没有得到应有的关注。这是医疗补助计划缓慢但稳定的扩张，该计划自20世纪60年代以来一直为穷人提供保险，作为《平价医疗法案》(ACA)的一部分。如果你关注关于“奥巴马医改”的政治辩论，你可能会听到更多关于私人保险市场的变化，以及这些变化对消费者意味着什么。但是，由于该法案的医疗补助扩张而获得保险的人数(截至2016年约为1500万人)实际上比通过交易所获得保险的人数(约为1300万人)略多医疗补助扩大对经济安全和公共健康的影响可能也更大。今年6月，由于亨利·j·凯泽家庭基金会(Henry J. Kaiser Family Foundation)组织的记者团体访问，我初步了解了扩大医疗补助计划对路易斯安那州可能意味着什么。直到最近，路易斯安那州的官员还拒绝像ACA的设计者最初设想的那样扩大医疗补助资格。但在2015年，约翰·贝尔·爱德华兹(John Bel Edwards)竞选州长时承诺加入扩大计划——也就是说，让路易斯安那州的医疗补助计划惠及所有收入低于贫困线133%的家庭。(2016年，个人消费为15,800美元，三口之家为26,813美元。)爱德华兹获胜，并于2016年1月12日，即上任一天后，签署了一项行政命令，实施扩建。当州政府机构开始尝试让尽可能多的人注册时，墨迹未干——通过自动注册那些已经接受其他形式的国家援助的人，并通过健康诊所和其他服务低收入社区的场所开展推广工作。保险范围将于2016年7月1日开始支付服务费用。到我去的时候，大约是在开学前两周
{"title":"What Louisiana Tells Us About the ACA Medicaid Expansion.","authors":"J. Cohn","doi":"10.1111/1468-0009.12205","DOIUrl":"https://doi.org/10.1111/1468-0009.12205","url":null,"abstract":"O ne of the biggest health care stories these days doesn’t get nearly the attention it deserves. It is the slowbut-steady expansion of Medicaid, the program that’s been providing insurance to the poor since the 1960s, as part of the Affordable Care Act (ACA). If you follow the political debates about “Obamacare,” chances are you hear much more about changes to the private insurance market and what those changes mean for consumers. But the number of people who have coverage thanks to the law’s Medicaid expansion (roughly 15 million as of 2016) is actually a bit larger than the number getting coverage through the exchanges (roughly 13 million).1 The Medicaid expansion’s impact on economic security and public health is probably larger too. In June, I got an early glimpse of what a bigger Medicaid program could mean for Louisiana, thanks to a group visit for journalists organized by the Henry J. Kaiser Family Foundation. Until recently, Louisiana was among the states whose officials were refusing to expand Medicaid eligibility as the ACA’s architects had originally envisioned. But in 2015, John Bel Edwards ran for governor on a promise to join the expansion—that is, to make Louisiana’s version of Medicaid available to all people in households with incomes below 133% of the poverty line. (In 2016, that’s $15,800 for an individual and $26,813 for a family of 3.) Edwards won and on January 12, 2016, one day after taking office, he signed an executive order implementing the expansion. The ink was barely dry when state agencies began trying to sign up as many people as possible—by automatically enrolling those who were already receiving other forms of state assistance and by conducting outreach efforts through health clinics and other venues that serve lowincome communities. Coverage was set to begin paying for services on July 1, 2016. By the time of my visit, roughly 2 weeks before that start","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"42 1","pages":"456-9"},"PeriodicalIF":0.0,"publicationDate":"2016-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83601139","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: The expansive goals of the Health Information Technology for Economic and Clinical Health (HITECH) Act required the simultaneous development of a complex and interdependent infrastructure and a wide range of relationships, generating points of vulnerability. While federal legislation can be a powerful stimulus for change, its effectiveness also depends on its ability to accommodate state and local policies and private health care markets. Ambitious goals require support over a long time horizon, which can be challenging to maintain. The future of health information technology (health IT) support nationally is likely to depend on the ability of the technology to satisfy its users that its functionalities address the interests policymakers and other stakeholders have in using technology to promote better care, improved outcomes, and reduced costs.
Context: The Health Information Technology for Economic and Clinical Health (HITECH) Act set ambitious goals for developing electronic health information as one tool to reform health care delivery and improve health outcomes. With HITECH's grant funding now mostly exhausted but statutory authority for standards remaining, this article looks back at HITECH's experience in the first 5 years to assess its implementation, remaining challenges, and lessons learned.
Methods: This review derives from a global assessment of the HITECH Act. Earlier, we examined the logic of HITECH and identified interdependencies critical to its ultimate success. In this article, we build on that framework to review what has and has not been accomplished in building the infrastructure authorized by HITECH since it was enacted. The review incorporates quantitative and qualitative evidence of progress from the global assessment and from the evaluations funded by the Office of the National Coordinator for Health Information Technology (ONC) of individual programs authorized by the HITECH Act.
Findings: Our review of the evidence provides a mixed picture. Despite HITECH's challenging demands, its complex programs were implemented, and important changes sought by the act are now in place. Electronic health records (EHRs) now exist in some form in most professional practices and hospitals eligible for HITECH incentive payments, more information is being shared electronically, and the focus of attention has shifted from adoption of EHRs toward more fundamental issues associated with using health information technology (health IT) to improve health care delivery and outcomes. In some areas, HITECH's achievements to date have fallen short of the hopes of its proponents as it has proven challenging to move meaningful use beyond the initial low bar set by Meaningful Use Stage 1. EHR products vary in their ability to support more advanced functionalities, such as patient engagement and population-based care management. Many barriers to inte
{"title":"Assessing HITECH Implementation and Lessons: 5 Years Later.","authors":"Marsha Gold, Catherine McLAUGHLIN","doi":"10.1111/1468-0009.12214","DOIUrl":"10.1111/1468-0009.12214","url":null,"abstract":"<p><strong>Policy points: </strong>The expansive goals of the Health Information Technology for Economic and Clinical Health (HITECH) Act required the simultaneous development of a complex and interdependent infrastructure and a wide range of relationships, generating points of vulnerability. While federal legislation can be a powerful stimulus for change, its effectiveness also depends on its ability to accommodate state and local policies and private health care markets. Ambitious goals require support over a long time horizon, which can be challenging to maintain. The future of health information technology (health IT) support nationally is likely to depend on the ability of the technology to satisfy its users that its functionalities address the interests policymakers and other stakeholders have in using technology to promote better care, improved outcomes, and reduced costs.</p><p><strong>Context: </strong>The Health Information Technology for Economic and Clinical Health (HITECH) Act set ambitious goals for developing electronic health information as one tool to reform health care delivery and improve health outcomes. With HITECH's grant funding now mostly exhausted but statutory authority for standards remaining, this article looks back at HITECH's experience in the first 5 years to assess its implementation, remaining challenges, and lessons learned.</p><p><strong>Methods: </strong>This review derives from a global assessment of the HITECH Act. Earlier, we examined the logic of HITECH and identified interdependencies critical to its ultimate success. In this article, we build on that framework to review what has and has not been accomplished in building the infrastructure authorized by HITECH since it was enacted. The review incorporates quantitative and qualitative evidence of progress from the global assessment and from the evaluations funded by the Office of the National Coordinator for Health Information Technology (ONC) of individual programs authorized by the HITECH Act.</p><p><strong>Findings: </strong>Our review of the evidence provides a mixed picture. Despite HITECH's challenging demands, its complex programs were implemented, and important changes sought by the act are now in place. Electronic health records (EHRs) now exist in some form in most professional practices and hospitals eligible for HITECH incentive payments, more information is being shared electronically, and the focus of attention has shifted from adoption of EHRs toward more fundamental issues associated with using health information technology (health IT) to improve health care delivery and outcomes. In some areas, HITECH's achievements to date have fallen short of the hopes of its proponents as it has proven challenging to move meaningful use beyond the initial low bar set by Meaningful Use Stage 1. EHR products vary in their ability to support more advanced functionalities, such as patient engagement and population-based care management. Many barriers to inte","PeriodicalId":78777,"journal":{"name":"The Milbank Memorial Fund quarterly","volume":"94 3 1","pages":"654-87"},"PeriodicalIF":0.0,"publicationDate":"2016-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5020152/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88598353","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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