Dave A. Chokshi

Behavioral Economics and Physician Compensation — Promise and Challenges

Health care organizations embracing new payment models may find that applying behavioral economics can boost the effect of new incentives. By creating more favorable decision-making environments, we can take advantage of cognitive biases to encourage high-value care.

Improving Health Care for Veterans — A Watershed Moment for the VA

After revelations of falsification of records, inappropriate scheduling practices, and substantial delays in access to care at VA health care centers, an intense political and media spotlight remains focused on the VA. Will it engender improvements in care for veterans?

The role of private payers in payment reform.

In September, one of California’s largest private payers, Anthem Blue Cross, joined 7 Los Angeles health systems in a new managed care contract with savings and risks shared among the payer and health systems. In a state where premiums have increased at a rate 5 times faster than inflation over the past decade, the new partnership aims to slow spending through mutual price control and clinical coordination among the narrow network of prior rivals, while offering employers and individuals lower premiums and zero deductibles.

J-Shaped Curves and Public Health.

Interventions that alter population-level risk exposure have yielded a number of improvements in public health. Tobaccotaxesareanexampleofsuchpopulation-basedapproaches to disease prevention. In the case of tobacco, the harms of shifting total population exposure through taxationareminimal,becausethereisnosafelevelofconsumption. However, other risk factors do not exhibit the same linear relationship between exposure and mortality—and thereforemayintroducenewcomplexitiesincommunicating with individuals and the public. In particular, many risk factors, such as alcohol consumption, exhibit a J-shaped association when plotting health effects like mortality on the vertical axis against the magnitude of the risk factor on the horizontal axis (Figure). Settingasidepopulationrisk,anyclinicianwhohastried tocounselapatientaboutalcoholusehasencounteredthe question: “But I thought a couple of drinks a night is good for my health?” In this way, the strategies of preventive medicine—bothindividualandpopulationbased—thathave proven quite successful for tobacco control may be less effective when confronting the epidemiologic and perceptional challenges presented by the J-shaped curve.

Redesigning the Regulatory Framework for Ambulatory Care Services in New York

UNLABELLEDnPolicy Points: The landscape of ambulatory care services in the United States is rapidly changing on account of payment reform, primary care transformation, and the rise of convenient care options such as retail clinics. New York State has undertaken a redesign of regulatory policy for ambulatory care rooted in the Triple Aim (better health, higher-quality care, lower costs)-with a particular emphasis on continuity of care for patients. Key tenets of the regulatory approach include defining and tracking the taxonomy of ambulatory care services as well as ensuring that convenient care options do not erode continuity of care for patients.nnnCONTEXTnWhile hospitals remain important centers of gravity in the health system, services are increasingly being delivered through ambulatory care. This shift to ambulatory care is giving rise to new delivery structures, such as retail clinics and urgent care centers, as well as reinventing existing ambulatory care capacity, as seen with the patient-centered medical home model and the movement toward team-based care. To protect the publics interests, oversight of ambulatory care services must keep pace with these rapid changes. With this purpose, in January 2013 the New York Public Health and Health Planning Council undertook a redesign of the regulatory framework for the states ambulatory care services. This article describes the principles undergirding the framework as well as the regulatory recommendations themselves.nnnMETHODSnWe explored and analyzed the regulation of ambulatory care services in New York in accordance with the available gray and peer-reviewed literature and legislative documents. The deliberations of the Public Health and Health Planning Council informed our review.nnnFINDINGSnThe vision of high-performing ambulatory care should be rooted in the Triple Aim (better health, higher-quality care, lower costs), with a particular emphasis on continuity of care for patients. There is a pressing need to better define the taxonomy of ambulatory care services. From the state governments perspective, this clarification requires better reporting from new health care entities (eg, retail clinics), connections with regional and state health information technology hubs, and coordination among state agencies. A uniform nomenclature also would improve consumers understanding of rights and responsibilities. Finally, the regulatory mechanisms employed-from mandatory reporting to licensure to regional planning to the certificate of need-should remain flexible and match the degree of consensus regarding the appropriate regulatory path.nnnCONCLUSIONSnFew other states have embarked on a wide-ranging assessment of their regulation of ambulatory care services. By moving toward adopting the regulatory approach described here, New York aims to balance sound oversight with pluralism and innovation in health care delivery.

Toward an Integrated Federal Health System

This Viewpoint discusses the fragmented nature of the current US federal health system and proposes approaches for achieving a more integrated and efficient system.

Universal health coverage for US veterans: a goal within reach.

The crisis of 2014 within the US Department of Veterans Aff airs (VA) health system, centred on appointment waiting times, has brought to light substantial defi ciencies in access to health care for veterans. Yet the fact that many veterans have no coverage for health care at all receives far less attention from the media and policy makers. Although some Americans might falsely assume that the VA health system covers all veterans, most veterans are covered by private insurance or other government programmes. There are about 22 million veterans in the USA. 8·9 million veterans are enrolled in the VA health benefi ts programme and 6 million receive treatment every year at 151 VA medical centres and other facilities. However, many veterans are not eligible for VA coverage, and even among those eligible, some have not enrolled. The net result is that more than 1 million veterans had no coverage for health care in 2010. Uninsured veterans are more likely to be younger, single, African-American, on low income, and to have been deployed to Iraq or Afghanistan. Compared with insured veterans, uninsured veterans are more likely to use the emergency department and less likely to use outpatient medical care. Moreover, veterans often have substantial unmet health-care needs, with a high prevalence of chronic diseases, mental health disorders including post-traumatic stress disorder, and other sequelae of trauma, including spinal cord injury and traumatic brain injury. In a national survey done by the Washington Post and Kaiser Family Foundation, 43% of war veterans deployed to Iraq and Afghanistan thought that their present physical health was worse than it had been before their military service. Expansion of Medicaid coverage for individuals and families with low incomes under the terms of the Aff ordable Care Act (ACA) could substantially reduce the number of uninsured veterans. The ACA’s individual mandate provides a fi nancial incentive to all US citizens to obtain health insurance or exemption from it. Veterans can qualify for Medicaid in states electing to expand their coverage for health care, for federal tax credits to purchase plans on the Health Insurance Marketplace, or for VA health benefi ts. Although eligibility for insurance is not synonymous with access to health care, universal coverage is an important fi rst step towards access to quality health care. With the introduction of the ACA, universal coverage for veterans could be an achievable goal, albeit one that requires renewed commitment and policy attention. To estimate the present number and distribution of uninsured veterans in the USA, we analysed the 2012 Census Bureau’s American Community Survey. We identifi ed how many US citizens aged between 18 years and 64 years with reported active military service were uninsured at the time of the survey, both at the national level and by state. We then estimated the number of veterans that were eligible for subsidised health care in 2014. For this estimation, we considered state Medicaid criteria before the introduction of the ACA in 2010 as modelled in published research; present state decision making about the Medicaid expansion; ACA-related income cutoff s for tax credits; and eligibility for VA health-care coverage. Eligibility for VA health-care benefi ts is estimated using data from the American Community Survey. We took a conservative approach, identifying those who have a service-connected disability, Vietnam-era service, or household income below the national VA-income threshold. We estimated that in 2012 more than 1·2 million veterans in the USA did not have health insurance, which is similar to previous estimates. The largest populations of uninsured veterans were mainly in southern states that are not currently expanding Medicaid within the ACA: 126 000 in Texas, 95 000 in Florida, 54 000 in North Carolina, and 53 000 in Georgia. California, which is expanding Medicaid in 2014, had 88 000 uninsured veterans (table). Encouragingly, most uninsured veterans are eligible for subsidised coverage of health care. Despite almost half the states not expanding Medicaid, we estimate that 25% of uninsured veterans are eligible for Medicaid, 46% are eligible for ACA tax credits to purchase Health Insurance Marketplace coverage, and 16% are not eligible for Medicaid or tax credits, but could be eligible for VA Number of uninsured veterans Expanding Medicaid*

An All-Payer Risk Model for Super-Utilization in a Large Safety Net System

Identifying patients at high risk for super-utilization of inpatient and emergency services—and proactively managing their care—are key strategies for healthcare systems aiming to improve population health and control costs. Traditional claims-based risk scores are inadequate for uninsured patients and patients with insurance churn, and many safety net systems do not have an electronic health record (EHR) capable of advanced analytics. As the largest safety net system in the country, NYC Health + Hospitals serves a high-need population, including thousands of patients with multiple, interlinked medical, behavioral health, and social issues. More than half of the system’s patients had an emergency room (ER) visit in the past year. Seventeen percent had two or more visits, and 250 patients averaged at least a day a week in one of our emergency rooms. NYC Health + Hospitals also provides half of all uninsured emergency and inpatient care for New Yorkers, including more than 80% of uninsured non-emergency services. To be successful, risk prediction strategies must encompass NYC Health + Hospitals’ entire patient population.

The “Public Charge” Proposal and Public Health: Implications for Patients and Clinicians

On September 22, 2018, the Department of Homeland Security (DHS) proposed a change to immigration policy that would make receipt of certain public assistance, such as health coverage through Medicaid, grounds for denying immigrants lawful permanent residence in the United States.1 The proposed policy applies to lawfully present immigrants who hope to become legal permanent residents as well as foreignborn persons seeking to move to the United States (eg, to be reunified with family members and to work), but not to asylees (persons in the United States or at a port of entry who cannot return to their country because of persecution) or refugees (persons outside of their country of nationality who cannot return to that country because of concerns about persecution). Requiring that persons not be a “public charge,” a term used by US immigration officials for individuals considered likely to become primarily dependent on the government for subsistence, is not a new policy; it dates back to 1882. However, this policy has been previously interpreted primarily in terms of cash assistance.

A Bipartisan “Moonshot” in Health: Improving Care for High-Need Patients

work but also studies gut-brain signaling in intestinal sensory epithelial cells. Organoids resembling a variety of organs including liver, pancreas, stomach, heart, kidney, brain, and even mammary and salivary glands are being used by other scientists in a range of biomedical fields as they investigate different disease states and work to develop potential treatments, such as drugs and transplantable tissue. “The exciting promise about organoids is that one can generate them from people— those with or without disease, such as irritable bowel syndrome—and assess their cellular and functional characteristics,” said Julius. This could be done with patientderived pluripotent stem cells to create and compare colonic organoids representing diseased and normal states. Other researchers are using this technology to model and develop potential therapies for conditions ranging from neurodevelopmental disorders and cancer to infectious diseases such as Zika. The UCSF team and others will continue to use intestinal organoids to determine whether gastrointestinal disorders alter the prevalence or function of ECs or their communication with sensory nerve fibers. If so, certain receptors on ECs and associated nerve fibers may be attractive drug targets. “Certainly, the field is growing rapidly fueled by the potential of altering the brain from the gut,” said Bohórquez. “The details of these exchanges are still out there to document and as they begin to emerge, therapeutic applications will follow.”