Gene therapies can potentially cure lifelong chronic diseases, dramatically improve patients’ lives, and reduce decades of medical spending. Still, according to recent research, over half of new cell and gene therapies face significant coverage restrictions from commercial insurers. With dozens of high-cost gene therapies expected to reach the market over the next decade, will patients in the U.S. be able to access these drugs?

According to the Food and Drug Administration, gene therapy is a technique that “modifies a person’s genes to treat or cure disease.” Nearly 50 cell and gene therapies are already approved in the U.S., with hundreds more in development. Unlike traditional drugs, gene therapies are typically administered once and priced accordingly, often exceeding $1 million per patient.

That price tag exposes a fundamental flaw in American health insurance. Insurers pay the full cost of a gene therapy upfront, but the financial benefits—fewer hospitalizations, fewer complications, and better quality of life—accrue over decades. In a system where patients frequently change insurance plans, the insurer that pays for the cure is rarely the one that benefits from it.

An insurer could spend $2-3 million dollars on a gene therapy today, only to see the patient switch plans next year. In that case, the insurer may recoup just a fraction of the savings, while the next insurer benefits for free. Similar to high-priced hepatitis C drugs a decade ago, for state Medicaid programs and smaller insurers operating on thin margins and short budget cycles, this misalignment can make even life-saving therapies financially untenable.

The federal government has begun to respond. In January 2025, the Center for Medicare and Medicaid Innovation (CMMI) launched a new payment model for gene therapies in Medicaid. Under the program, the federal government negotiates outcomes-based contracts on behalf of state Medicaid agencies and provides technical support. These agreements, which tie payment to real-world effectiveness, are an important towards financial sustainability.

While the CMMI gene therapy model has many benefits and is a good first step, it has limits. It applies only to Medicaid and not commercial insurance. And it does not solve the biggest structural problem in gene therapy financing: what happens when patients change insurers.

To truly unlock access to gene therapies, policymakers must address this portability problem head-on.

First, insurers should stop accepting one-time, upfront pricing as the default. Instead, gene therapies should be paid for through value-based arrangements that spread payments over time (e.g., 10-15 years) and link those payments to patient outcomes. This approach would reduce financial risk for insurers and better reflect the uncertainty that still exists about long-term durability.

Second, payment obligations for gene therapies should follow patients when they change insurance plans. If a patient switches insurers, the remaining payments should transfer as well, rather than staying with the original payer. Similar to current pre-existing condition coverage rules under the Affordable Care Act, the government should maintain rules that insurers cannot deny coverage based on these payment obligations.

Third, federal regulators should modernize existing rules to allow subscription-based payment models to function at scale. Under these arrangements, insurers pay a predictable per-member fee to gain access to certain high-cost therapies. Today, overlapping regulations from antitrust law to Medicaid drug rebate reporting requirements can make these models legally risky or administratively impractical, even when they could expand access and control costs.

Finally, policymakers should seriously consider a national reinsurance pool for gene therapies. Under such a system, a central fund would cover part of the cost whenever a payer approves a gene therapy, minimizing financial shocks to state Medicaid programs and smaller insurers, and spreading costs nationally to reflect the national benefits of curing rare, genetic diseases.

A national pool would also solve several problems at once: it would address insurer churn, enable long-term tracking of patient outcomes, and ensure that the federal government’s substantial investment in gene therapy research translates into real-world access.

Today, the U.S. health insurance system has few financial incentives for health insurers to pay for potentially life-changing gene therapies––even when they work. Without reforms, gene therapies risk becoming medical miracles that exist largely out of reach. America has invested billions in discovering gene therapies. Now we need to invest in a payment system capable of delivering them.

Research for this piece was supported by Arnold Ventures.

It began over six years ago. Shaken awake by my nervous system, all night and every night, I fell into a deep hole of exhaustion.

Two years seeing five neurologists and trying a dozen medications taught me that regaining my life wasn’t a pill away.

“My heart still pounds at night,” I told my doctor. He recommended breathwork. Not a little breathwork. A lot. I breathed in for 4 seconds and out for 6. I did this for 20 minutes, twice per day, for months.

Then I saw it.

I saw that I did everything from a place of stress. I was intense all the time. Work wasn’t just getting the job done, it was pounding the keyboard as fast and hard as possible, demanding the highest standards in the least time. Recreation was just another box to check on the to-do list. My nervous system was telling me it couldn’t take it anymore, not if I wanted to sleep anyway.

My intense self would have to go. In a moment, I threw him out, banished him. This was the hardest breakup I’ve ever experienced.

Hard because he was the center of my life, the organizing principle, the motivator, the achiever. For him and his accomplishments, I was rewarded. He was how I excelled in school and in the workplace. He was how I managed at home, stayed on top of it all. Without him, who was I? How would I do anything?

I grieved the loss of myself for two years.

Then I found a path out, not all at once, but little by little. I could not change my nervous system so that I could return to who I was, but I could transform my relationship with it — with myself — to become who I needed to be.

How? I had no idea, so I did everything I could think of: therapy, journaling, meditation, dancing alone, dancing with trees, walking miles barefoot, drawing, painting. I even painted with my feet! Gradually, over time, transformation arrived as grief faded. I learned to live with and love my nervous system, to love myself.

Loving myself required removing layers of armor I’d worn so long I couldn’t see or feel. It takes bravery to remove the armor, to drop the shield. We are designed to fear the arrows of pain, disappointment, and misfortune, so we guard. But very few arrows come from outside. Almost all are from inside. Armor to protect from the world also shields us from ourselves.

The shield is always at the ready. The first sight of an external threat and BAM! Up it goes. There’s almost no chance of harm getting through. Knowing that, bravery comes more easily. The risk of lowering it is smaller than it feels.

The more time I spend with less armor, the more I feel what the deep breath reaches. Into my core it finds that I am OK just as I am — fully and fundamentally, as a birthright.

I am not different from you in these ways. Your mind messes with you as much as mine does me. Our minds tell us: “If I hadn’t…,” “If only I could…,” “When I finally lose (or gain)…,” “This will not end well.” The truth is, the ends of our minds’ stories are not yet written. The ends we fear rarely arrive.

If we bravely breathe deeply, for long enough — 20 minutes, twice a day, for months if needed — we might shed some heavy armor. Without it, one really can walk more gently.

In my piece in last Sunday’s Worcester Telegram & Gazette, I explore the FDA’s new Commissioner’s National Priority Voucher program and what it could mean for the agency’s scientific independence and public trust.  

You can read more here. 

In 2021, the Centers for Medicare and Medicaid Services issued new rules requiring hospitals to post publicly available price lists for 300 common services (such as planned surgeries, X-rays, and MRIs). The idea was simple; if patients could compare prices, they would shop for cheaper options. That, in turn, would spur competition among hospitals, drive down costs, and ultimately make health care more affordable.

Yet five years later, Americans are spending even more on health care and, as of 2023, national health spending continues to outpace inflation. The effects of the rule, if any, have been minimal. Why hasn’t price transparency made health care more competitive? And what can this experiment teach us?

First, hospitals account for roughly 30 percent of health care spending––but they’re only part of the problem. Costs are also rising because of an aging population, higher physician fees, and escalating drug prices, many of which are beyond hospitals’ control.

Second, few people even know the information exists. A Gallup survey conducted from late 2023 to early 2024 found that 73% of Americans were unaware they could look up hospital prices for common services. Among adults over 65, the group most likely to need care, just 11 percent had ever checked a price before going to the hospital.

Third, compliance is highly variable; a 2024 report by the Department of Health and Human Services’ Office of Inspector General found that only 63 of 100 hospitals in a random sample were following the rule. Many post incomplete data, or report it in ways that are not accessible to most patients.

Fourth, patients don’t behave like typical consumers. Patients often value trust and continuity with their doctors and are usually insulated from sticker prices by insurance. Even if one hospital charges less, patients’ out-of-pocket costs largely depend on their insurance design––and lower prices rarely translate into smaller bills. Hospital prices also exclude physician fees, which can be out-of-network and substantial.

Finally, for many Americans, there’s no real choice. In 2022, nearly half of all metropolitan areas had only one or two hospital systems providing inpatient care. In rural communities, where patients live twice as far from a hospital, or lack transportation altogether, the idea of “shopping” for care is largely meaningless.

So what can we learn from the hospital price transparency experience?

One lesson is clear: transparency may be necessary to decrease healthcare prices, but it certainly isn’t sufficient. Even with greater enforcement of existing regulations, publishing prices alone can’t fix a market where patients don’t shop, hospitals don’t compete, and insurers obscure true costs.

As a preliminary step, regulators need to enforce existing price transparency rules. In 2025, President Trump issued an executive order calling for greater enforcement of hospital price transparency rules, and the Center for Medicare and Medicaid Services (CMS) issued a formal Request for Information soliciting public input to improve enforcement. Awareness, accuracy, and usability also matter. Currently, it is not possible for CMS to determine if the prices published by hospitals are complete and accurate. Patients can’t act on data they can’t find or understand. Hospitals must offer clear, consumer-friendly tools that estimate real out-of-pocket costs, not just post dense spreadsheets meant for regulators.

Policymakers also should be realistic about the potential impact of transparency rules. If price transparency were to have an impact, we would expect it to be greatest on self-pay patients (who are most cost-sensitive), shopping only for elective services. In a study of Florida hospitals conducted by researchers from the Brookings Institute and published in the journal Production and Operation Management, this “best-case scenario” resulted in a nearly 25% reduction in prices for strictly elective services, and a 12% reduction for self-pay patients overall. These numbers may be close to the theoretical ceiling for price transparency.

Most importantly, transparency is meaningless without competition. The U.S. healthcare market is now more consolidated than at any time in history and has experienced significant horizontal and vertical integration over recent year in the past several years—partially driven by increased private equity investment. Hospital consolidation increases costs for everyone. Policymakers and lawmakers should advocate for solutions to increase antitrust enforcement mechanisms, such as allowing the Federal Trade Commission to take enforcement actions against not-for-profit corporations, increasing budgets of agencies tasked with enforcing antitrust laws,  and introduce reporting requirements for even small hospital mergers.

Despite the difficulties inherent in transparency, it shouldn’t be abandoned, just understood for what it is––one piece of a larger puzzle––and not a fix. Policy solutions should address flaws in existing price transparency rules and simultaneously address other causes of high prices in the U.S. healthcare system. Price transparency remains a worthy goal. But to be effective, it must be coupled with meaningful enforcement, real competition, and better tools for the people it was meant to help.

Research for this piece was supported by Arnold Ventures.

Many Americans have come to rely on Medicare. The vast majority (~88%) of the funding for inpatient hospitalizations originates from a 2.9% payroll tax split evenly between US employers and employees. These funds go into an account known as the Medicare Part A Hospital Insurance trust fund.

If Medicare’s hospital insurance fund runs out of money, Medicare won’t go bankrupt. However, the US’ single largest insurer will likely be forced to slash reimbursement for inpatient hospitalization – meaning that if hospitals charge Medicare $100 for care they provide, Medicare would only be able to pay around $89 back.

To account for this projected deficit, absent Congressional intervention Medicare could be forced to decrease services (potentially limiting services such as skilled nursing) and pass on a higher percentage of costs to beneficiaries. For older Medicare beneficiaries – many of whom live on limited or fixed incomes – such an outcome may be untenable.

Decreasing either inpatient reimbursement or utilization would also place financial strain on hospitals. Many hospitals that rely on inpatient Medicare payments, such as safety-net institutions (that provide high amounts of uncompensated care) and rural hospitals, operate under low margins and may be especially susceptible to limiting services and closure.

In the Medicare trustees’ report, worsening financial projections are attributed to several key factors: rising healthcare costs, an aging population, and a payroll tax system that’s not keeping pace with demand.

As the population continues to age at the highest rate in US history, beneficiaries are living longer with more comorbidities, increasing inpatient hospitalization and hospice costs. Combined with unexpectedly low growth in the economy and payroll taxes, Medicare financial projections project depletion of the primary fund by 2033.

Similar solvency concerns have cropped up before. But what could Congress do this time?

With no other changes, Medicare’s looming insolvency leaves policymakers with difficult choices. Under its current structure, benefits will either be cut, or revenues will have to increase. Unless Congress changes the laws governing Medicare – and either shifts expenses or allows Part A to be funded by general revenues – then existing options will remain unattractive. And the longer Congress delays, the more abrupt and painful those changes will be.

One option is to increase tax revenues. The Medicare payroll tax has remained largely unchanged for decades. When facing a similar scenario in 2010, the Affordable Care Act addressed solvency concerns by increasing taxes for a limited pool of high-earning taxpayers.

In the 2025 report, the trustees projected that an increase in the Medicare payroll tax rate from 2.90% to 3.25% would maintain sustainability for at least 75 years. While politically difficult, such an adjustment could be enacted gradually and may serve to preserve inpatient benefits.

Raising taxes is politically challenging, so reform efforts could also include attempts to limit spending growth. Policymakers could consider more aggressively implementing value-based payment models that bundle inpatient and post-acute care together (such as bundled payments for certain operations, which have shown promise).

Another option, which Congress chose in 1997, moved payment responsibilities for home health services from the trust fund to general revenues, an accounting slight-of-hand that decreased Part A expenditures. In the Trustees’ report, the authors project that an immediate decrease in expenditures by 8% would be enough to ensure long-term solvency – so even small decreases or shifts in spending could be impactful. While such a solution be unlikely to fix long-term issues, it could buy several years of time.

Aside from short-term fixes, Congress could use this opportunity to identify a strategy to replenish the Medicare hospital fund over the long-term. Strategies could include establishing new sources of tax revenue for Part A, or ceding Congressional authority to the Medicare Trustees to independently allow certain tax increases or restructuring to promote financial solvency. Congress could also permanently avoid issues by dissolving the trust fund and financing Part A out of Medicare’s general revenues.

Regardless of what Congress decides, no solution will be easy. No one likes paying more taxes, and Medicare reforms are politically charged. However, Medicare itself remains popular and ensuring its sustainability is likely to resonate with voters. Many may decide that the short-term pain of a tax increase outweighs the long-term pain of a non-functional Medicare. Regardless, policymakers should consider steps to ensure the long-term viability of Medicare Part A – and act before it’s too late.

Research for this piece was supported by Arnold Ventures.

In 2018, Massachusetts passed an omnibus law that set a national standard, establishing a statewide plan and advisory council to respond to the needs of constituents living with Alzheimer’s and related dementia. But since, we haven’t passed much to make things easier for families or health care providers, and we’re starting to really struggle. 

There are over 145,000 Massachusetts residents living with Alzheimer’s and many more caring for them. The state also shells out billions ($2 billion in Medicaid alone in 2025) to care for this group, and costs will only continue to rise. The bottom line is that residents and the Commonwealth can’t continue like this – we need more help. 

I wrote about this problem last weekend for the Massachusetts-based Worcester Telegram & Gazette. In my piece, I highlight three bills gaining momentum in the State House this session that would make a big difference for patients and families impacted by Alzheimer’s and related dementia. Given Massachusetts’ outsized role in medicine and innovation, the question is not whether we can lead again, but whether lawmakers will choose to. 

You can read the full piece here. 

In a new piece with The Health Care Blog, I argue that hospitals can soften much of this by choosing how those costs are absorbed. Safety-net hospitals participating in the 340B Drug Pricing Program already receive significant drug discounts intended to support care for low-income patients – now they just need to redirect a portion of those funds to cover care that now falls outside Medicaid’s shortened look-back period. Read more about the problem and proposed solution here.

Over seven million Americans are currently living with Alzheimer’s disease and countless others suffer from other forms of dementia and cognitive impairment. As the prevalence of dementia and related diseases continues to rise, how we define dementia-friendliness matters.  

Recent rankings of dementia-friendliness emphasize disease burden and late-stage dementia capacity, like the number of memory care beds available. This definition is both antiquated and incomplete, though. Breakthroughs in early detection, disease-modifying treatments, and clinical trials are reshaping what it means to live with Alzheimer’s and dementia – but access to this progress depends heavily on state policy.  

In my recent piece for Health Affairs Forefront, I argue for redefining dementia-friendliness around the state policies that make early diagnosis, high-quality care, and community support possible. Across the country, states are already leading the way by expanding coverage for biomarker testing, investing in the workforce, supporting caregivers, and coordinating care across the disease continuum.   

You can read more here.

Policymakers and advocates often promote drug price transparency to lower costs and improve equity. While transparency is an important first step toward accountability and informed public budgeting, it does not guarantee affordable prices or fair access to medicines. Creating a consistent national framework could replace the current patchwork of state laws and improve oversight of how drugs are priced.

Read the full piece here.

Since the 1970s, video gaming has been a leisure activity for all types of people. Perhaps surprisingly, most gamers are older and nearly half are female, a stark contrast from the prevailing stereotype of the basement dwelling, Mountain Dew swigging teenage male.

With the rapid evolution of technology and affordability, gaming has become even more commonplace. While the industry has faced its share of economic challenges, revenues have still been strong – $58.7 billion in 2024 in the United States alone. For perspective, in the same period, the movie industry brought in about $30 billion, globally.

The accessibility and popularity has led to concerns that excessive gaming can cause violence and addiction. There may be some truth here; research has led to the addition of gaming disorder in the American Psychological Association’s diagnostic manual.

Those diagnosed with gaming disorder are likely to have neurological changes similar to those with a drug, alcohol, or gambling addiction. Estimates vary but experts believe that up to 17% of gamers meet the clinical criteria for gaming disorder. These individuals may experience a variety of consequences, including difficulty performing at work or school, strained interpersonal relationships, poor sleep quality, and repetitive hand stress injuries.

Contrary to the negative outcomes of excessive use however, current literature indicates that responsible gaming can actually have benefits.

For one, moderate gaming use can be good for your brain, and these advantages are not just tied to one genre of video game.

One study found that gamers who play action games possess an enhanced processing speed and task switching ability compared to individuals who do not. Similarly, role-playing games like World of Warcraft promote cognitive flexibility by challenging ingrained patterns of thinking and offering alternative options for decision making.

Games particularly focused on overcoming challenges also boost one’s mood and confidence during and after play. Those with visually stimulating elements can further evoke feelings of relaxation and appreciation. (Think of all the rainbow roads in Mario Kart!)

Alternately, sandbox games, or open-world games that are played with others in a non-linear way, are effective in fighting loneliness and improving socialization. Some best-sellers that have found success in this are Animal Crossing: New Horizons and Minecraft.

Because moderate gaming is generally linked to reduced stress and improved self-esteem, it is sometimes clinically prescribed to treat anxiety and depression.

One study found that participants who played 30 to 45 minutes of video games four times a week along with taking medication saw a greater reduction in their anxiety symptoms than those who only took medication. Another study found that children were able to better manage their anxiety before surgery after clinically-guided play.

The benefits of gaming don’t stop at cognitive and mental health, but rather, there may also be tangible physical benefits.

Research is beginning to show that this might be truer for certain populations than others. For example, non-typically developing kids appear to benefit from active video games called exergames. These games require the player to interact with the game using physical movement. There is growing evidence that, not only do these games promote physical activity, but they improve gross motor skills, mobility, and physical stability. These benefits are magnified when exergames are used along with traditional clinical interventions.

Another population who might physically benefit from video games is older adults, for whom overall health and quality of life is often linked to their activity level.

For these gamers, a recent paper found that exergames helped increase their strength and fitness. The benefits were greatest when gaming sessions lasted at least an hour and when individuals kept playing for several months. These games also offer other benefits such as improved balance which may be a powerful tool for those who care for older adults in long-term care facilities. Increasingly research is learning more about gaming and its benefits, but it isn’t without its pitfalls.

It’s worth noting that while much of the public concern about video gaming is focused on addiction, that’s not the only issue. Online gaming culture in particular can be toxic.

Getting “pwned” by a 10-year old while playing Fortnite is not the only peril to navigate while gaming online. Hate speech and toxic behavior runs rampant and largely unchecked on online gaming platforms. One recent report found that three quarters of teenage gamers in the United States experienced harassment while playing online, including cyberbullying, “doxxing,” and “swatting.” That same survey found that adult gamers had a similar experience, though fewer reported online bullying than in the year prior.

To be clear, most online gamers are not hateful jerks. But those who are, seem to be pretty good at it. For this reason, a greater effort needs to be made towards improving the safety and civility of online gaming.

Players have long known that modern gaming is far from mindless and offers compelling storytelling and immersive experiences. Research is beginning to show how games can contribute to positive health outcomes – mentally and physically. Still, video games are like any other form of media: not inherently harmful, but not entirely without risks. They’re best enjoyed in moderation and in good company.

Almost all Americans agree that prescription costs are too high, and the president is rightly focusing on this issue as a cornerstone of his second term. But while the president has mastered the headlines, he has not mastered the policy. His latest proposals like the most favored nation movement or pharmaceutical tariffs promise savings while quietly driving up prices and jeopardizing access to essential medicine. 

I wrote about the gap between Trump’s flashy headlines and a true, pragmatic roadmap for prescription drug policy last weekend for the Worcester Telegram and Gazette. You can read more here.  

The United States’ (US) health care system often falls short in delivering coordinated, accessible care for the 12.5 million dual-eligible Americans, who are typically older (65+), living with chronic health conditions or disabilities, and have limited income or resources. This is largely due to the combination of fragmented networks, unmet social needs, and provider shortages.

While only one solution, digital health care marketplaces can address many of these barriers to care.

Fragmented Networks
Despite ongoing reform efforts, dual-eligible enrollees still struggle to navigate a fragmented system. Medicare and Medicaid weren’t designed to work together and differ in benefits, provider networks, and eligibility — with state-by-state variation adding to the confusion. Integrated care models aim to streamline services, but currently reach few enrollees, and evidence of their impact remains limited.

Digital health marketplaces, like Zocdoc and Solv, help make it easier for patients to find care by allowing them to search for and book appointments with providers who accept both insurances. Zocdoc, founded in 2007, covers over 250 specialties and includes providers at federally qualified health centers. Alternately, Solv, a younger start-up, focuses on urgent care. Though, both platforms offer real-time appointment availability — often within 24 to 72 hours — shortening the long wait times many patients typically face. They also include features tailored to dual-eligible users: Zocdoc lets patients enter secondary insurance via intake forms, and Solv allows users to upload both insurance cards to their account.

Unmet Social Needs
Unmet social needs are widespread among dual-eligible enrollees and are another reason access to care is tricky. Factors like poverty, housing instability, limited digital literacy, language barriers, and lack of transportation frequently have led to delays or missed appointments.

While digital tools can’t eliminate all barriers, platforms like Zocdoc and Solv offer features that help some. Both platforms offer artificial intelligence assistants to support users with limited digital literacy and provide telehealth services that help reduce transportation barriers. Zocdoc further integrates with Google and Apple Maps to assist patients in navigating to in-person appointments. Zocdoc also provides multilingual support, provider filters for language and gender, and reviews to guide patients toward culturally responsive care.

Provider Shortages
Finding providers who accept both Medicare and Medicaid is especially difficult in areas experiencing provider shortages. One study found that a third of counties with the largest dual-eligible populations face significant primary care shortages—particularly in Southeastern states, where restrictive laws limit the roles of nurse practitioners and physician assistants. These gaps make timely care harder to access and leave patients with few alternatives.

While platforms like Zocdoc and Solv can’t directly fix this systemic issue, they do help patients navigate the options that are already out there. For example, in 2022, around 15% of Zocdoc bookings were made by federally funded patients, including dual-eligible enrollees, and over 85% of its providers (excluding mental health) accept Medicare or Medicaid. However, it remains unclear what percentage of these bookings were exclusive to dual-eligible enrollees. This data is not publicly available from Solv either.

Limitations
There are notable limitations to consider with these marketplaces.

First, there are few alternatives in the market, and limited evidence on how well these platforms perform. While one study suggests that booking through Zocdoc is associated with lower no-show rates, another study indicates Medicaid patients have fewer nearby appointment options than Medicare and private patients despite overall availability.

Second, because Zocdoc and Solv are primarily appointment-booking platforms, they do not provide ongoing care coordination and cannot address structural access or coverage issues. This requires legislative action from policymakers to strengthen existing programs.

Third, these platforms only seem to work if enough providers participate, but provider fees may continue to discourage involvement. Zocdoc now charges doctors between $40-140 per new appointment, a shift from their previous, controversial annual subscription fee of $3,600. While Solv does not publicly disclose its pricing, they report that fees are charged by location (rather than per user), with annual, quarterly, or monthly payment options available.

Lastly, there are still some usability issues with the platforms. For example, Zocdoc and Solv do not currently allow users to select multiple insurance providers simultaneously when filtering search results. Adding this functionality would significantly streamline the process.

Next Steps
With the dual-eligible population projected to grow by 6% annually—reaching over 15 million Americans by 2028—addressing these limitations is becoming increasingly urgent. Zocdoc appears to be moving in this direction by enhancing provider engagement through partnerships with the Department of Veterans Affairs, electronic health record systems, and practice management software companies. Solv, likewise, is broadening its reach, having partnered with the Urgent Care Association on a consumer awareness campaign.

Digital tools won’t fix a broken system—but they can make it easier to navigate. For dual-eligible enrollees, platforms like Zocdoc and Solv are helping bridge the gap between intention and access. With the right support, they could become more than just the “OpenTable for urgent care”—they could be the front door to a fairer, more connected health care system.

Research for this piece was supported by Arnold Ventures.

To date, our answers have largely focused on counting—company R&D investment, drug approvals, and patents. But such metrics can favor quantity over quality, making it harder to distinguish between transformative and incremental advances. Relying on them alone risks misallocating resources, weakening patient outcomes and healthcare sustainability, and overlooking high-value therapies.

Complementary measures of innovation aim to capture dimensions traditional metrics overlook, such as clinical effectiveness, societal benefit, and equitable access. Some emphasize broader value—including scientific spillovers, greater access, and long-term public health gains—while others highlight the gap between discovery and usable therapies.

Still, there is no unified, broadly applicable framework that integrates the full spectrum of biopharma innovation—from traditional volume-based indicators to value-oriented measures such as therapeutic effectiveness, real-world impact, and policy relevance.

To address this gap, we systematically reviewed interdisciplinary literature on innovation metrics to identify a comprehensive set that captures clinical, economic, and societal value. The resulting rubric is designed to be both rigorous and practical—providing strategic guidance for those who develop, evaluate, fund, and benefit from biopharma innovation.

A Multidimensional Innovation Rubric

Our systematic literature review identified innovation metrics in 2,350 articles across medicine, public health, economics, strategy, finance, and operations, of which 617 were relevant to biopharmaceuticals. From them, we constructed a six-dimensional rubric to comprehensively evaluate biopharmaceutical innovation from early discovery to real-world implementation:

• Scientific and Technological Advances: Captures innovation and productivity using metrics such as NMEs, IND applications, and patents. Emerging indicators such as AI-enabled R&D and digital biomarkers offer forward-looking insights.
• Clinical Outcomes: Highlights therapeutic impact through metrics such as safety, efficacy, and patient-reported outcomes, emphasizing real-world patient benefits and delays in disease progression.
• Operational Efficiency: Measures efficiency in development and production using trial success rates, R&D timelines, supply chain resilience, and adaptive trial designs.
• Economic and Societal Impact: Evaluates economic returns and societal benefits through cost-effectiveness analyses, budget impacts, and productivity improvements.
• Policy and Regulatory Effectiveness: Assesses how regulatory frameworks support innovation through approval speed, breakthrough designations, and surrogate endpoint integration.
• Public Health and Accessibility: Examines broader health impacts, including reduced disease incidence, healthcare access improvements, and equitable geographic distribution, ensuring innovations meet widespread public health needs.

Stakeholder Perspectives: Making the Rubric Actionable

Our rubric specifically addresses five critical stakeholders in the biopharmaceutical ecosystem—pharmaceutical companies, investors, payers (including insurers and healthcare providers), patients, and policymakers. Each group shapes and benefits from innovation, requiring tailored metrics aligned with their strategic objectives and operational contexts.

Fig. 1 Adoption of Innovation Metrics by Stakeholder Groups.

Notes: This figure illustrates current practices and opportunities across six dimensions of biopharmaceutical innovation metrics. Solid circles (🔵) indicate commonly used metrics, while open circles (◯) highlight potential metrics currently underutilized.

Figure 1 illustrates how stakeholders currently measure innovation and where gaps exist that emerging metrics could fill. Today, they strongly rely on traditional metrics like NMEs, patents, and financial indicators, which are straightforward, easily quantifiable, and historically established. However, they have lagged in adopting emerging metrics that offer nuanced insights into patient-centered outcomes, long-term societal benefits, and healthcare access. Metrics identified as “potential” emerged consistently from recent literature and stakeholder discussions, reflecting their growing recognition and practical feasibility. Key findings include:

• Pharmaceutical companies primarily use scientific and operational metrics—such as NMEs, patents, and R&D efficiency—to guide investments and manage portfolios. Expanding focus to patient-reported outcomes could improve market forecasts and strategic choices. For example, a biotech firm developing an mRNA platform might seem undervalued by NME counts, but recognizing the platform’s flexibility and future potential reveals significant strategic value.
• Investors typically assess innovation through financial metrics (projected revenues, profitability) and technological indicators (patents, platforms). Incorporating societal productivity gains, regulatory compliance, and geographic reach can better align investments with long-term impact and reduce risk. This could lead an apparently risky investment in a potential Alzheimer’s therapy to become more attractive when considering long-term productivity gains and reduced caregiving burdens.
• Payers focus on clinical effectiveness and economic value (cost-effectiveness, pricing alignment) in reimbursement decisions. Including metrics like adherence rates, healthcare utilization, and operational reliability could further support coverage. The proposed rubric would formalize analyses already applied to one-time gene therapies that, despite high upfront costs, may show superior long-term value when accounting for lifetime savings, improved adherence, and fewer hospitalizations.
• Patients prioritize clinical outcomes—safety, efficacy, quality of life—and access. Real-world evidence, geographic availability, and timely market access help them advocate for improvements. For example, a biologic for autoimmune conditions may modestly extend life but substantially improve daily functioning. Patient-reported outcomes and adherence data capture this added value.
• Policymakers use public health and economic outcomes to guide resource allocation. Metrics like supply chain resilience and regulatory responsiveness improve preparedness. Incorporating these metrics into an innovation framework would formally capture the strategic and public health value of an otherwise commercially unviable antimicrobial drug.

Adopting a multidimensional framework introduces trade-offs, including added complexity, resource competition, and potential conflicts among metrics. Stakeholders must prioritize dimensions aligned with their strategic goals and regulatory contexts. For example, payers might emphasize clinical and cost-effectiveness, while pharmaceutical companies may prioritize operational efficiency and scientific productivity.

Redefining Biopharmaceutical Innovation

Next steps include piloting the framework in health technology assessment (HTA) case studies, aligning metrics to each dimension, and incorporating stakeholder input to refine usability. The goal is not to replace existing evaluation systems, but to enhance them with a multidimensional structure grounded in cross-sector evidence.

The rubric broadens how we define innovation—incorporating clinical effectiveness, patient-centered outcomes, and broader societal impact alongside traditional volume-based indicators. If policymakers and payers adopt these complementary metrics in evaluation and reimbursement frameworks, they can better align investment and R&D incentives with high-value, transformative innovation. Emphasizing long-term health outcomes, real-world effectiveness, and broader economic value would bring innovation policy closer to patient needs and societal priorities. These shifts would help ensure that innovative therapies are recognized for both their scientific and real-world impact.

In short, PBMs have great influence over the logistics and cashflow of the prescription drug industry, setting prices for patients and controlling their access to medicines. But what exactly do they do?

Federal law first mandated prescriptions for certain medicines in the 1950s. In response, health insurance companies added prescription drug benefits to their policies. PBMs arose to help insurers implement these new benefits.

Today, PBMs manage all components of health plans’ (payers’) prescription drug benefit. The “Big Three” – CVS Caremark, OptumRx, and Express Scripts – control 60 percent of the US market, managing about 80 percent of all prescriptions and serving nearly 300 million Americans.

To understand how PBMs operate, we can trace the flow of both prescription drugs and funds in the supply chain.

The flow of the drug is relatively straightforward: Wholesalers purchase drugs from manufacturers, who in turn sell them to pharmacies, who in turn distribute them to patients.

The flow of funds is much more convoluted. While manufacturers are selling their drugs to wholesalers, they are also negotiating with PBMs to include those drugs in health plans’ pharmacy benefits. PBMs secure rebates or discounts from drug makers in exchange for preferred placement on a health plan’s formulary, its list of preferred drugs. The more preferred the placement on the formulary (e.g., with lower cost sharing), the more likely the drug will be chosen for or by patients over other options, leading to greater use and greater profit. In exchange for managing this process, health plans pay PBMs.

Lastly, PBMs reimburse pharmacies for dispensing drugs to patients, and PBMs then bill health plans for the cost of the prescription.

There are two concerns in this process though: vertical integration and spread pricing.

Vertical integration occurs when a PBM’s parent company owns multiple parts of the drug supply chain, such as the insurer, the PBM itself, the pharmacy, etc. Some even manufacture drugs overseas.

Take CVS Health, for example. CVS Health owns Aetna (health insurer), Caremark (PBM), and CVS pharmacy (as well as specialty and mail-order pharmacies). CVS Health has, therefore, vertically integrated its entire operation.

This vertical integration contributes to the “Big Three” PBMs having less competition and more power to steer patients to their own pharmacies and insurers, leading to more profits.

In fact, the Federal Trade Commission (FTC) found that the “Big Three” reimbursed unaffiliated pharmacies at lower rates than their own pharmacies. They also marked up drugs at their own pharmacies by hundreds and thousands of percent, resulting in over $7 billion in revenue from 2017 to 2022.

Spread pricing is another challenge.

Spread pricing is a practice by which PBMs charge the health plan a certain amount for a drug but then turn around and pay the pharmacy less for the same drug. The difference is the spread, often retained (in part or in full) by the PBM as profit.

Spread pricing means that PBMs reimburse independent pharmacies less than what those pharmacies paid for the drugs from the wholesaler, resulting in a loss. Over 25,000 independent pharmacies in the US closed between 2010 and 2020 because of these losses. According to a 2024 FTC report, the top three PBMs generated about $1.5 billion in profits from spread pricing from just 51 specialty drugs from 2017 to 2022.

Ultimately, for patients, vertical integration and spread pricing mean less pharmacy access and choice for patients, alongside higher out-of-pocket costs and premiums.

In response to these concerns, both state and federal governments are increasing their regulatory authority over PBMs.

All 50 states have passed legislation to regulate PBMs. Some laws focus on protecting small pharmacies by ensuring unaffiliated pharmacies are reimbursed at the same rates as PBM-affiliated ones. Others limit patient cost-sharing or require PBMs to be licensed to operate. Additionally, 27 states require PBMs to comply with reporting and transparency requirements.

One state has gone even further: Arkansas now prohibits PBMs from operating their own retail pharmacies in the state, disrupting vertical integration.

Federally, seven PBM-focused, bipartisan, bicameral bills have been introduced this congressional cycle. They focus largely on prohibiting spread pricing, increasing transparency and reporting requirements, and changing how drug manufacturers and PBMs negotiate. Some bills also define penalties for PBMs that don’t play by the rules and give the federal government more enforcement power.

The influence of PBMs in the prescription drug supply chain has grown in recent decades, as have their profits. In response, states and the federal government have proposed or enacted laws to regulate PBMs and lower prescription drug costs for patients. What legislative approaches will regulate PBMs in a way that actually lowers costs for patients, though, is yet to be determined.

Research for this article was supported by Arnold Ventures.

Why should going to the doctor be any different?

Health care subscriptions seek to answer this question – and disrupt the marketplace in the process.

By eliminating insurance hurdles and encouraging preventive care, health care subscriptions can make care more accessible for some. Yet, they often require upfront payments, digital access, or employer sponsorship, potentially excluding low-income, uninsured, or rural patients.

What Are Health Care Subscriptions?

A health care subscription can be a lot like signing up for YouTube Premium or Spotify. You pay a monthly or yearly fee for access to services like checkups, virtual visits, and discounted prescriptions. Unlike traditional insurance, health care subscriptions are offered more directly by providers, giving patients greater flexibility, fewer hidden costs, and more control over their health care decisions. These models often provide direct access to doctors without copays, deductibles, or claims paperwork.

For providers, subscriptions ensure steady revenue and reduce administrative burdens. Clinically, they allow providers more time with patients, focusing on care rather than claims billing associated with fee-for-service payment models. Patients benefit from predictable costs and streamlined access to their provider, which encourage better quality care, preventative care, and chronic disease management, while removing financial barriers for some.

More specifically, Direct Primary Care (DPC) enhances accessibility, with some providers sharing personal phone numbers for quicker responses, faster appointment scheduling, and shorter wait times. It’s especially helpful for elderly patients or those who struggle to visit the doctor regularly.

Subscription models generally operate independently of traditional insurance. While most health care subscribers in the U.S. keep their insurance to cover specialist care, hospitalizations, or emergency services, uninsured individuals may rely on subscriptions as their primary form of health care, despite the coverage gaps.

These models have gained traction in urban and suburban areas, particularly among affluent and insured individuals frustrated with long wait times in the traditional system. Marketing often targets middle- and upper-income patients, emphasizing quick access, longer appointments, and 24/7 communication.

In low- and middle-income countries, health care subscription could expand access to essential medicines by spreading pharmaceutical costs over time, pooling resources to lower drug prices, and improving distribution. While not a universal solution, they offer a scalable way to improve affordability and consistency in resource-limited settings.

What Aren’t Health Care Subscriptions?

Health care subscriptions themselves are not a replacement for traditional health plans, but rather a supplement designed to address specific needs or populations. For example, the DPC model may be most beneficial for middle-income individuals, while the Amazon One Medical subscription caters for urban professionals who prioritize convenience.

However, these models often exclude uninsured, rural, or lower-income patients due to financial and digital access barriers. These include unreliable or non-existent internet access, limited tech fluency, language barriers, and the cost of internet services. Inadequate infrastructure and a lack of affordable, culturally sensitive content further restricts access for underserved communities.

As corporations like Amazon expand into subscription-based health care, market consolidation raises concerns about pricing power, reduced competition, and long-term affordability. Because these models operate outside of insurance regulations, they may lack accountability in quality measures. Without transparency, they risk recreating the same access gaps as traditional health care, shifting control from insurers to corporations without ensuring equitable care.

Recommendations for a More Equitable Model

To ensure health care subscriptions expand access rather than reinforce disparities, companies must prioritize affordability and inclusivity. Sliding-scale pricing, income-based subsidies, or pay-as-you-go models could make memberships more accessible to low-income patients. Expanding services beyond urban centers (e.g., through mobile clinics, telehealth infrastructure in rural areas, and partnerships with community health organizations) would help ensure underserved groups aren’t left behind.

Transparency is also critical. Companies should disclose pricing structures, patient outcomes, and enrollment demographics to assess whether their models equitably improve access. Public-private collaborations, such as integrating subscription models with Medicaid or public clinics, could incorporate them into existing systems rather than creating parallel, exclusionary options.

The clear upfront pricing of health care subscriptions can empower consumers to make more informed decisions. However, without these efforts to improve accountability, transparency, and integration with public health systems, subscriptions risk reinforcing disparities rather than advancing health equity.

Health care subscriptions arose as a response to many of the challenges faced by the health care sector. They make big promises, and their surging popularity suggests that some may be able to deliver. As these models grow, we should all take care that this innovation benefits everyone and doesn’t become another pay-to-play scheme.

In response, policies such as the Choice Act of 2014 and the MISSION Act of 2018 have aimed to expand care options for Veterans. Despite these efforts, access issues persist, raising critical questions about whether increasing provider supply can help reduce wait times and improve care delivery. Given the complex nature of health care access, understanding how provider availability interacts with factors like patient demand, scheduling practices, and clinician productivity is crucial for designing effective policy interventions.

New Research

Published in Health Economics, researchers at the Partnered Evidence-based Policy Resource Center (PEPReC) investigated the relationship between provider supply and access to primary care in VHA. Their investigation sheds light on how the number of available health care providers impact patients’ ability to receive timely care. By analyzing access trends across different regions, the researchers provide valuable insights into how variations in provider supply affect the overall efficiency of the health care system.

Methods

Using multiple administrative datasets (e.g., VA Corporate Data Warehouse and Area Health Resource File), PEPReC researchers combined provider data with patient access metrics across different regions. They developed a model of wait times for new patients seeking primary care at VHA medical centers.

Based on a supply and demand framework, the model was used to help assess factors that influence wait times and estimate by how much an increase in the number of providers can reduce the wait time to seeing a primary care provider.

Findings

PEPReC researchers’ findings suggest that increasing provider supply may lower wait times and improve overall patient outcomes. Specifically, they found that a 10 percent increase in the number of full-time clinical providers at a facility (i.e., clinician capacity) is associated with a 0.48-day reduction in wait times (2.1 percent of the 22.9 day average wait time for a new patient primary care appointment).

Researchers also found that increases in the number of visits that clinicians can perform per day, which may be influenced by scheduling protocols, is associated with lower wait times. Moreover, patient access to alternative health insurance options is associated with lower VHA wait times.

Conclusion

Addressing the adequacy of provider supply remains a critical step toward improving health care access. As policy efforts continue to focus on expanding health care access, strategies that bolster the primary care workforce will be essential in ensuring equitable access to care for all populations.

This investigation highlights the significant impact of provider supply on wait times, offering insights from a clinic operations perspective. Keeping wait times low and improving timely access can improve patient outcomes. Targeted policy interventions, such as incentivizing providers to practice in underserved areas and implementing evidence-based scheduling improvements, could help bridge gaps in access to care and improve health outcomes for Veterans nationwide.

In my recent piece for The Portland Press Herald, I explore how nature supports our health and well-being—and how these attacks on our parks threaten both.

Read the full article here.

These unethical practices include patient brokering, deceptive marketing, and fraud. Patient brokering, for instance, involves third parties profiting from referring individuals to treatment facilities, while deceptive marketing misrepresents services to attract patients and their families. These unethical practices harm those seeking care, resulting in unsafe treatment environments, inadequate care, and, in some cases, overdose deaths.

Unethical actors have exploited the increased insurance coverage of SUD treatment provided by the Affordable Care Act. Although some states have taken steps to combat these unethical practices, there is limited evidence on the effectiveness of these efforts.

New Research

In the study, “State-level actions targeting unethical substance use disorder treatment practices: A qualitative study,” we examined state-level efforts to address unethical SUD treatment practices. We explored the types of actions taken, factors that facilitate successful interventions, and barriers that hinder effective policy implementation. The goal was to better understand the variety of state-level efforts (e.g., certification requirements for recovery homes and trainings to raise awareness and improve education around SUD) to address unethical practices in these settings in the U.S.

Methods

From June 2022 to February 2023, we conducted semi-structured interviews with 15 key informants from 11 organizations, including national and state-level advocacy groups and state agencies. We selected the informants for their expertise in SUD treatment, policy implementation, or regulation. We analyzed the data by identifying recurring themes across interviews. This method helped identify patterns in responses related to the scope of unethical practices, the state actions taken to address them, and the context in which these actions were implemented.

Findings

Informants described several unethical practices in the SUD treatment field, such as patient brokering, deceptive marketing, overbilling and insurance fraud, and poor practices in recovery housing. These issues were often interrelated with both individuals and organizations working together to exploit vulnerable patients for profit.

Some states, such as Florida and Colorado, have made progress in addressing unethical practices by establishing task forces and enacting legislation; in total, twelve states have enacted laws targeting patient brokering or deceptive marketing. Informants viewed task forces or coordinating bodies with clear objectives to improve SUD treatment or prevent unethical practices as relatively effective. Legislation was seen as most effective when paired with more centralized efforts (e.g., national quality standards), strategic leadership, and a clearly designated agency responsible for regulation and enforcement. Informants also suggested stronger federal enforcement, since many unethical actors operate across state lines in the U.S., which limits the effectiveness of state-level responses.

Additionally, informants stressed the importance of adequate resources (i.e., funding and staffing) and highlighted how public awareness plays a key role in prompting action against unethical practices. While task forces and advocacy groups help raise awareness, they often lack the authority to enforce change without stronger regulatory support.

Conclusion

The siloed nature of SUD treatment from other medical services in the current health system has led to fragmented, inconsistent care and service gaps for patients with SUD. While laws targeting patient brokering and deceptive marketing may help deter unethical practices, the desired effect may be unlikely without adequate funding, clear regulatory authority, and the ability to coordinate across state lines. To address these challenges, states looking to implement new policies can learn from existing legislation but must also ensure they have the necessary tools and coordination to tackle this complex issue effectively.

Since the dawn of biomedical research, philanthropy has played a pivotal role in defining the direction of biomedical innovation. The Rockefeller Foundation, for example, was a central institutional supporter of the collaboration between physicists and biologists leading to the birth of the field of microbiology in the 1920s.

Today there are many health-related foundations focused on innovating in health care, with particularly well-funded efforts being connected to cases where high-net worth individuals, or their loved ones, get afflicted with a rare disease. These foundations serve as an important model to subsidize private innovation efforts as well as increase the chances a drug is approved by the FDA.

Still, there is potential for foundations to more strongly bolster competition in the market for biotech — in both venture philanthropy and social justice philanthropy….

Read more on Stat First Opinion, here.

Research for this piece was supported by Arnold Ventures.

To address these challenges, the federal government offers states funding for the State Health Insurance Assistance Program (SHIP). With federal oversight from the Administration for Community Living (ACL), states independently run SHIP counseling centers that provide outreach and education to Medicare beneficiaries, as well as individual counseling to help beneficiaries navigate Medicare’s many caveats. Despite being around for decades, SHIP services are not well known, and little academic work has evaluated their operations, successes, or challenges.

New Research

Evaluators at Boston University School of Public Health explored SHIP service access in a recent paper with Health Affairs Scholar. In it, they investigate SHIP staff members’ experiences providing counseling services to Medicare beneficiaries and potential barriers to SHIP service access.

Data and Methods

Researchers conducted a qualitative study interviewing SHIP coordinators and counselors. To identify potential participants, they randomly selected SHIP sites representing different levels of median household income, urban or rural status, and the number of available Medicare plans. Recruitment was facilitated through the ACL and state SHIP directors, who helped connect researchers and practitioners. Interviews were conducted via Zoom between April and September 2023.

In all, 22 SHIP coordinators and counselors were interviewed across 15 states. Participants offered a diverse mix of backgrounds, experience, and responsibilities within SHIP programs. Coordinators had experience ranging from 6 months to 17 years, with some transitioning from state or county agencies into the SHIP role.

Separate interview guides were developed for coordinators and counselors, and they were reviewed by ACL staff. Coordinators were asked about recruitment and retention strategies for volunteers and staff, while counselors were asked about common beneficiary concerns, particularly those affecting dual-eligible and low-income folks.

Findings

The study found that SHIP services are crucial in guiding Medicare beneficiaries through complex enrollment decisions, particularly for low-income and dually eligible individuals. Persistent challenges limit their impact, however, including staffing shortages, accessibility barriers, and growing complexity of Medicare information and misinformation. Some staff expressed frustration with the complexity of the information within the Medicare system and some indicated they would benefit from additional training, particularly on Medicaid and dual eligibility for Medicare and Medicaid.

Researchers also asked counselors about modes of service delivery and potential barriers to access. Staff report that virtual counseling became more frequent during the onset of the COVID-19 pandemic and is more popular for beneficiaries in rural settings. But, it isn’t a one-size-fits-all solution. Staff report that many beneficiaries, especially those with mobility or transportation limitations, prefer virtual counseling, whereas those without access to technology and/or are dually eligible prefer in-person counseling. Language barriers were common among beneficiary recipients, although most counselors reported satisfaction using a phone-based language-line interpretation service. Counselors did face difficulties, however, with translating Medicare jargon and in cases in which beneficiaries declined to use the translation line.

SHIP staff reported that counseling sessions covered a wide range of topics, with significant attention paid to helping clients understand the differences between Traditional Medicare and Medicare Advantage plans. Counselors helped clients assess their needs based on factors such as health care usage, pre-existing conditions, and financial considerations. Low-income and dually eligible individuals were frequently counseled on Medicaid, Medicare Savings Programs, and low-income subsidies (e.g., the Extra Help program). A key challenge faced by counselors was dealing with misinformation from television advertisements or brokers, which led beneficiaries to make uninformed decisions about their Medicare options.

Limitations

While the qualitative approach provides in-depth insights into SHIP operations and challenges from the perspective of SHIP staff, it does not capture beneficiaries’ perspectives. Similarly, interview participation relied on state SHIP directors for participant referrals, which may have introduced selection bias both in the staff and sites recruited to participate.

Conclusion

SHIPs hold a vital role in guiding Medicare beneficiaries through complex coverage decisions. Counselors frequently combat misinformation from ads and brokers, often assisting with unintended enrollments. Expanding training to include information on Medicaid and increasing paid staff are essential to strengthening SHIP’s ability to provide accurate, unbiased support to those who need it most.

New Research
In April 2024, evaluators from the Puget Sound VA and Partnered Evidence-based Policy Resource Center (PEPReC) published a paper “Caring Letters Sent by a Clinician or Peer to At-Risk Veterans” in the Journal of the American Medical Association Network Open. The primary objective was to examine the outcomes of the VCL caring letters intervention and determine whether there were differences in outcomes by signatory (letters sent by a clinician versus a peer). Authors previously reported details implementing the intervention.

Methods
Authors conducted an effectiveness-implementation hybrid type 1 evaluation. They performed a randomized evaluation of the impact of peer versus clinician letters on outcomes, as well as an observational evaluation of outcomes associated with caring letters receipt. Data collection included linking VCL contact records with national VHA administrative. All Veterans who contacted the VCL with an identifiable address in the VHA’s Corporate Data Warehouse (CDW) and who contacted the crisis line between June 11, 2020, and June 10, 2021, were screened for inclusion in the caring letters cohort. Veterans were randomized to receive 9 caring letters for 1 year from either a clinician or peer Veteran signatory. Enrollment occurred between June 11, 2020, and June 10, 2021, with 1 year of follow-up. Analyses were completed between July 2022 and August 2023.

Main Findings
Peer signatory and clinician signatory recipients had similar rates of suicide attempts within 12 months of their call to VCL (7.4%, 7.6%, respectively). They also had similar rates of secondary outcomes, including mortality (3.8% of peer and 3.7% of clinician recipients died within 12 months of the index call) and health care use (69.0% of peer recipients and 68.5% of clinician recipients had at least 1 outpatient mental health visit in the 12 months following the index call).

When comparing outcomes among those who received either type of caring letters to those who did not receive caring letters, 6,801 caring letter recipients (7.7%) and 10,910 nonrecipients (7.8%) had a suicide attempt in the 12 months following the index call. There was no evidence of an association between receipt of caring letters and mortality. However, Veterans who received caring letters were significantly more likely to have subsequent inpatient and outpatient care (e.g., mental health care, ED visits).

Conclusion
Caring letters were not associated with suicide attempts or all-cause mortality, but they were associated with higher probabilities of outpatient and inpatient mental health care use, ED visits, and any outpatient or inpatient VA care use. No differences in outcomes were identified when cards were sent from a peer Veteran vs a clinician the recipient had not met. These results will be used by the VCL to optimize the caring letters intervention.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who support VA efforts to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

“DEI in research means that all populations, regardless of race, ethnicity, or gender, are included in rigorous science to find the best treatments and cures possible.

Two-thirds of Americans with Alzheimer’s are women. Older Black and Hispanic Americans are at greater risk of developing the disease than their white counterparts. We cannot investigate Alzheimer’s disease without considering DEI.” 

While palliative care plays a pivotal role for patients, data demonstrating its effectiveness and cost-effectiveness can be muddled by confounding and selection bias.

For example, people with severe illness are more likely to receive palliative care. Illness severity is also correlated with poor outcomes. But problems can arise if an analysis doesn’t account for the ways in which illness severity is associated with both likelihood of palliative care and with poor outcomes. This might lead to an incorrect inference that palliative care is harmful

To better understand these relationships, a team of investigators from Trinity College (Dublin), Boston University, and the University of Southern California conducted a systematic review of ‘natural experiments’ in palliative care.

Natural experiments, also called quasi-experiments, are useful in contexts like palliative care where it would be unethical or impractical to conduct clinical trials. In natural experiments, investigators apply statistical techniques to previously collected data to make treatment and comparison groups look as similar as possible, other than receipt of treatment. To review the extent to which natural experiments exist in the palliative care literature, investigators considered four research designs.

• Interrupted time series analysis: repeated measures of a given outcome in a population over time.
• Difference-in-differences: controlled before-and-after studies that examines outcomes at two or more time points for two groups.
• Regression discontinuity: compare outcomes for two groups on either side of an arbitrary threshold.
• Instrumental variables: explain variation in the treatment variable but have no independent effect on the outcome of interest.

With these study designs in mind, investigators were guided by four research questions:

1. How many studies have evaluated palliative care using causal frameworks and what specific methods were used?
2. What results have been reported from these studies?
3. What are these studies’ strengths and weaknesses?
4. What are the implications for expanding use of this methodological framework given research challenges in palliative care?

To answer these questions, investigators identified peer-reviewed studies from seven databases, two hand-searched journals, and grey literature. The search returned nearly 750 articles which  were narrowed down to 17 relevant studies that met inclusion criteria. These studies were available in English and included study designs investigating causal inference with observational data.

To ensure thoroughness and quality, multiple reviewers reached consensus for study inclusion during data extraction and screening. Individual studies were assessed for methodological quality using both a custom-built tool and the STROBE checklist.

Results

Most studies (seven of 17) used a difference-in-differences study design; five employed instrumental variables and another five employed interrupted time series analysis. Studies spanned from 2002 to 2021, and the median year of publication was 2018.

Nine studies examined intensity of care (e.g., acute hospitalizations length of stay, and intensive care unit admissions). Others examined palliative care’s effects on costs.

Overall, most studies showed that palliative care reduced health care costs, lowered health care utilization, and resulted in less aggressive care at end of life (consistent with prior reviews on the subject).

There were some differences from prior systematic reviews, though. For example, the magnitude of cost-savings was lower than previously reported in less rigorous research designs and null results were common (i.e., palliative care had no effect on health care utilization or costs).

Investigators noted a few limitations related to the individual studies they found, as well as the systematic review they undertook. Namely, reporting standards varied across all three experimental frameworks (difference-in-difference, interrupted time series, instrumental variables) used by individual studies. Regarding this systematic review, investigators noted that they included a wide variety of treatments and policy changes in their criteria, as well as a broad population. Therefore, investigators assert that only general conclusions can be made without deriving meta-analysis effect estimates.

Takeaway

Palliative care is a critical component of health care for patients with serious illnesses and their families, yet research about this care can be blurred by confounding and selection bias. This systematic review demonstrates that natural experiments are one important tool to strengthen the evidence base for palliative care being effective for patients and cost-effective for the wider system.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who support VA efforts to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

Insurers are required to cover mental health care under the Mental Health Parity and Addiction Equity Act. Yet, almost a third of therapists still don’t accept insurance at all or limit the number of insured clients they treat. The ongoing therapist shortage, exacerbated by the pandemic, has made the hunt for a provider even more difficult. Therapists that do take insurance are often fully booked.  

And accepting insurance has its perks, like widening access to a larger client pool.  

So why would a therapist not accept insurance in the first place? It turns out, it doesn’t pay as much and can be a real hassle.  

Low pay 

A 2023 Government Accountability Office report concluded that low insurance reimbursement rates are one of the main reasons why mental health care has become so inaccessible. Therapists just don’t recoup their costs with insurance, so there isn’t much incentive to accept it.  

The national average cost of a psychotherapy session is $100-$200/hour, varying based on state, licensure, specialty, and demand for services. While reimbursement rates aren’t publicly available, we do know that they are low, sometimes only a fraction of the cost to provide care.  

For instance, fee-for-service Medicaid rates in 2022 for common psychiatry services, including psychotherapy, were only 81% of Medicare’s rates. And Medicare reimbursement rates for behavioral health are already low, hitting far below what other care providers are reimbursed for. 

Providers who work with private insurance have voiced that reimbursement rates can be “insulting.” It also doesn’t help that rates haven’t significantly increased in decades. 

Given the overhead costs of maintaining licensure and owning or participating in a private practice, these low rates are unsustainable. What’s more, salaried therapists in community rehabilitation centers often make even less, as little as $30,000 a year.  

The end result is that the profession isn’t a financially attractive path to take, contributing to the therapist shortage.  

Insurance is a pain to deal with, too. 

Beyond the pay, the logistical challenges that come with insurance are another reason why mental health care providers often opt out.  

For one, the administrative responsibilities add up. Filing insurance claims and advocating on behalf of a client requires a learning curve, all done in unpaid time. Getting credentialed with an insurance company is also time-consuming, and reimbursement isn’t immediate. 

Insurers impact the care provided, too. For example, to receive reimbursement, therapists must make an official diagnosis. This can be problematic because mental health diagnoses are not always helpful for treatment. Clients may not even meet diagnostic criteria, especially during the first few sessions. Yet, diagnoses remain permanent in health records regardless.  

Insurers can then also dictate how much care they will pay for, such as the number of sessions or the length of the sessions. Those decisions don’t always align with what the therapist and client know is necessary for healing.  

The alternative: paying more out-of-pocket 

For these reasons, clients are often left paying cash and seeking reimbursement from their plan for an out-of-network visit, if their plan even offers any out-of-network therapy coverage. Sometimes therapists offer sliding payment scales based on the client’s financial situation, for which an affordable rate is agreed upon by both the therapist and client.  

Still, these options often mean higher out-of-pocket costs compared to having in-network insurance coverage or paying to see a primary care provider. 

While mental health care parity is the goal, we are clearly far from it. To this day, insurers unlawfully delay and deny coverage, perhaps to encourage patients with chronic mental illnesses – who are more expensive to cover – to drop coverage or switch to another insurer. 

We are in the throes of a mental health crisis as a nation. With care out of reach for so many though, solving the crisis feels unattainable. Paying mental health workers more, incentivizing insurance acceptance, and increasing reimbursement rates may alleviate some of the access burden. 

Mental health has been undervalued as a profession, a policy priority, and an important part of overall health for far too long. The effects of unaffordable access to care are not going away, especially as demand for care grows and the workforce struggles to keep up. It’s time we listen to the voices of both those providing and receiving care, and treat mental health like any other form of care. 

New Research

A recent retrospective cohort analysis published in the Journal of General Internal Medicine examined the relationship between physician tenure and clinical productivity in the Veterans Health Administration (VHA). The paper explored how tenure length affects productivity (i.e., the number of patient encounters per clinic day) among attending physicians. It also compared productivity trends between internally hired physicians—those who had any residency or fellowship training within the VHA—and externally hired physicians.

Methods

Researchers used the VHA’s Corporate Data Warehouse to collect detailed data on physician employment characteristics, specialty, and monthly patient encounters. Data was analyzed from 34,878 attending physicians across 27 specialties, covering over 1.5 million physician-months of outpatient encounters between October 1, 2017, and August 1, 2023. They used statistical models to examine productivity differences over time, adjusting for factors such as specialty, facility, and time effects, and sensitivity analyses to test the robustness of the results. The analyses were conducted for both the entire sample including all 27 specialties and four specialty subgroups—primary care, psychiatry, large medical specialties, and large surgical specialties.

Main Findings

Newly hired physicians had on average 1.72 fewer patient encounters per clinic day during their first quarter compared to their more experienced colleagues who had worked at VHA for more than two years. However, this productivity gap shrunk over time, with new hires having only 0.44 fewer encounters per clinic day by their eighth quarter. Among the specialty subgroups, medical and surgical specialty new hires reached productivity equivalent to more experienced employees by their eighth quarter. Additionally, physicians who had any residency or fellowship training within VHA (“internal hires”) had higher initial productivity and a quicker adjustment to full productivity than those hired externally, particularly in primary care and large surgical specialties.

Conclusion

These findings suggest that while newly hired attending physicians initially exhibit lower productivity, they experience significant improvement within the first two years. Moreover, those with prior VHA training adapt more quickly, highlighting the potential benefits of internal training programs. These insights are important for health care systems assessing the long-term costs and access implications associated with physician turnover and onboarding. Understanding these dynamics can aid in developing strategies to support new physicians, optimize training programs, and ultimately enhance patient care within VHA and similar health care settings.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who support VA efforts to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

Americans also know that football comes with head injuries, concussion, and even fatal illness like chronic traumatic encephalopathy (CTE). It’s a fact many of us have come to accept, sending our kids ourselves into play each season, knowing the risks.  

That has seemingly changed in recent years with the slow rise of protective equipment like the Guardian Cap and the Q-Collar. While uptake of this equipment is low so far, the NFL and others are praising its ability to protect athletes and make the game safer. The NFL also celebrated a decrease in concussions in 2024.  

But the bottom line is that no piece of equipment can prevent head injury in football. We should try to better respond to injury for both youth and professional athletes alike instead.  

TIE contributor Katherine O’Malley wrote about this in Harvard Public Health Magazine last week ahead of the big game.  

You can read the full piece here. 

While any medication has risks, understanding and managing those risks is more important for some prescription medications than others. High-risk (or high-alert) medications (HRMs) are those that present extreme danger either due to patient characteristics (e.g., age, chronic disease, etc.) or misuse. As such, HRMs require prescribers and health systems to employ a number of practices and tools to evaluate and mitigate risk towards improving patient safety.

Given their prevalence, there is mounting interest about prescribing practices of HRMs and the implications for health care.

Recent Study

In a study published in JAMA Network Open, evaluators from Harvard University and Boston University compared HRM prescribing trends between traditional fee-for-service Medicare (TM) and Medicare Advantage (MA), which are privately managed plans for Medicare eligible individuals that are publicly funded through a capitated payment arrangement.

To complete their analysis, the authors compared over 13.7 million matched pairs of beneficiaries taken from samples spanning 2013-2018. The study relied on several sources to obtain data on the sample population, including the Medicare Master Beneficiary Summary file, Social Vulnerability Index, U.S. Office of Management and Budget, and the Medicare Part D Master Beneficiary Summary File.

For its primary measure, the study relies on the Healthcare Effectiveness Data and Information Set (HEDIS) and its Use of High-Risk Medications in Older Adults (DAE) metric. As a primary outcome, the authors considered the total number of HRMs that were prescribed to the qualified enrollees. As a secondary outcome, the authors looked at the proportion of older enrollees who had been prescribed at least 1 HRM per year. Other outcomes included the proportion of enrollees who had received 2 or more HRMs per year or the same HRM twice in the same year.

In addition to the primary variable of Medicare insurance type (i.e., enrollment in TM vs. MA), the study also examined a number of covariates. The researchers considered age, sex, race and ethnicity, dual-eligibility status, rurality, social vulnerability, eligibility for Medicare’s low-income subsidy, and a patient health indicator that factors the number of non-HRM medications.

The authors first used linear regressions to construct their primary model, and after accounting for covariates and other effects (fixed and random), they plotted the adjusted rate of unique HRM prescriptions. After the secondary outcomes were plotted similarly, sensitivity analyses were completed according to a range of criteria.

Ultimately, the study found that the rate of HRM use decreased in each year of the study period (2013-2018) – this was true for both TM and MA alike. Consistent with previously observed prescribing trends, HRM use in MA was significantly lower than in TM, but the gap between the two had narrowed. In the final year of the study period, the rate of HRM use in TM was still 56.9 HRMs (per 1000 beneficiaries) compared to 41.5 in MA. Similar patterns were observed in the analyses of the secondary outcome of the proportion of enrollees who had been prescribed at least 1 HRM per year. When compared with TM, MA performed better with a lower adjusted proportion of beneficiaries who had been prescribed at least 1 HRM (3.9%) versus 5.3% in TM. Relative to patient characteristics, the study observed higher rates of HRM use for certain population subgroups, including those who were female, American Indian or Alaska Native, or White.

Conclusion

The authors note several key limitations, including limiting analyses to only those medications identified by the DAE measure during the study period. The study was also unable to assess the extent that the HRM prescribing were clinically appropriate. The authors also explain that this work is limited by the use of MA as a single exposure and that only filled prescriptions were included in the analyses.

Despite these limitations, this study has implications for both medical practice and health care policy. As the study found that certain populations (female, American Indian or Alaska Native, and White individuals) received HRMs with greater frequency, there is a need to better understand how prescribers assess clinical presentation of these populations. The study’s findings also highlight how the mechanisms responsible for the overall decrease in HRM use in TM are not entirely known. The authors recommend that the Centers for Medicare & Medicaid Services explore additional avenues (e.g., tying HRM rates to reimbursement models) to narrow the gap between TM and MA relative to HRM rates.

Given their potential for harm, further research into HRM medication management strategies is an essential component of improving patient care and safety for older adults.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who support VA efforts to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

Read the full article here.

That progress is now in jeopardy with a new Trump administration that has voiced support for repeal of the Inflation Reduction Act’s protections. Doing so could also squash any hope for extending prescription drug price protections for a much larger portion of Americans: the privately insured.  

I wrote about that for Public Health Post. Read the full piece here.  

Research for this article was supported by Arnold Ventures.

A physical pendulum with mass m and center of mass (CM) moment of inertia I_cm pivoting at a point d from the CM has period T given by

$$T = 2\pi \sqrt{\frac{I_{\text{cm}} + md^2}{mgd}}$$

with g being the acceleration due to gravity. The last post showed that T has the same value on two circles centered on the pendulum’s CM, one with radius d and one with radius d’, where d’ = L – d and

$$L=\frac{I}{md}$$

Here I = I_cm+ md². The CM-centered circles of radius d and d’ are composed of isochronal points. That is, the period is the same no matter which point on these circles the pendulum is pivoted about.

This post explores T as a function of d (or d’) and some properties of d.

How T Behaves as d Varies

T as a function of d has a shape as shown in the figure below, where the horizontal and vertical axes represent d and T, respectively.

This suggests T approaches infinity as d approaches zero or infinity. This can be shown formally by taking limits, but it’s not hard to see informally by examining the expression for T.

As d approaches zero, the expression for T resembles (or behaves like) a constant times the inverse of the square root of d, which is asymptotic to the T-axis in the above plot and certainly goes to infinity. As d approaches infinity, the expression for T behaves like a constant times the square root of d, which also goes to infinity, as the graph shows.

This behavior of T as d approaches zero or infinity makes sense. As d approaches zero, the pendulum’s pivot point approaches its CM. There is no restoring torque at the CM, and the pendulum would not return from a displacement. Think of turning a disk of uniform density pinned at the center (its CM). If you give it a turn, it won’t turn back. That’s an infinite period.

As d approaches infinity, the situation resembles a simple pendulum, for which the period is proportional to the square root of its length (d), hence T also approaches infinity.

Moving away from these extremes, T strictly monotonically decreases to a minimum. This itself means that the minimum must be where d=d’. If this were not the case, then there would be two isochronal circles, centered on the CM, of minimum T, one of radius d and one of radius d’. This would imply that all pivot points a distance r from the CM such that d<r<d’ have larger periods, which contradicts the strict monotonicity of T from zero (or infinity) to the minimum.

Or, we could take the derivative of T with respect to d and set it to zero (steps omitted) to find that the minimum T is where

$$d^2 = \frac{I_{\text{cm}}}{m}$$

From the previous post, this is also the expression for dd’. That means that the minimum T is found where d and d’ coincide. This value of d is also the radius of gyration. By definition, this is the radius such that if all of m resided there, the moment of inertia would be the same as the object’s (here the pendulum), which has mass at locations other than the radius of gyration.

Plugging this into the expression for T given above, the minimum T (or, for convenience, T²) is

$$T_{\text{min}}^2=\frac{8{\pi }^2}{g}\sqrt{\frac{I_{\text{cm}}}{m}}$$

So, when d=0, d’=∞ we have two (degenerate) isochronal circles for which T is infinite. As d moves radially outward from the CM, d’ moves inward, and the circles they define are always composed of isochronal points. As this happens, T drops from infinity toward a unique minimum proportional to the quartic root of I_cm/m. The minimum is achieved when d=d’, at the radius of gyration, and the two isochronal circles become one (♥ cue violins ♥).

Where is the Minimum with Respect to the Pendulum?

Where is the d for which T is minimum with respect to the boundary of the pendulum? It’s never outside the boundary of the pendulum. I’ll show this mathematically, below, but it’s intuitive. Lengthening a simple pendulum, for which all the mass is at the end of the (assumed massless) support, increases its period. So, it stands to reason that a pivot point beyond the surface of a physical pendulum would have a larger period than a pivot point on its surface. Also, the definition of radius of gyration makes it pretty clear that it’s within the pendulum.

Let’s do it with math anyway. The pendulum’s CM rotational inertia is, by definition

$$I_{\text{cm}} = \int r^2 \, dm$$

where r is the perpendicular distance from the CM to a infinitesimal mass element dm. Replacing r with r_max, the largest distance from the CM to the boundary of the pendulum, we get the inequality

$$I_{\text{cm}} = \int r^2 \, dm \leq r_{\text{max}}^2 \int dm$$

Or, simply,

$$I_{\text{cm}} \leq r_{\text{max}}^2 \, m$$

Substituting this into the expression for the T-minimizing d above, d ≤ r_max. Equality is obtained only when all the pendulum’s mass is at a constant radius from the CM (an idealized hoop of zero width). Otherwise, the T-minimizing d is strictly within the pendulum’s boundary. For all practical purposes (assuming there are any), d < r_max. That is, not only is the T-minimizing d not outside the pendulum, it’s not even on the surface (apart from the idealized hoop). It’s somewhere strictly inside the pendulum. That means that both d and d’ are within the boundary of the pendulum for some range.

If the body of the pendulum includes the CM (true for convex shapes like a disk or triangle), then all possible values of T, from its maximum of infinity to its minimum at the d defined above are found at pivot points within it. For all such values of T, there are arcs* of one or two isochronal circles within the body of the pendulum — one when d’ is outside the pendulum’s boundary and two when it is inside, which, as noted above, it will be for some range. In fact, that range is when d’ is between the T-minimizing d (the radius of gyration) and r_max. 

If the body of the pendulum does not include the CM (as would be the case for some concave shapes like a uniform density banana or a washer), the maximum T for which a pivot point is inside the body of the pendulum is given by

$$T = 2\pi \sqrt{\frac{I_{\text{cm}} + m r_{\text{min}}^2}{m g r_{\text{min}}}}$$

where r_min is the distance from the CM to the point within the pendulum closest to it.​

Summary

• The period of a physical pendulum, T, varies with pivot point from infinity (at pivot points CM and infinity) to a minimum at the radius of gyration.
• ​A minimum achieving pivot point is always within the body of the pendulum.
• If the body of the pendulum includes the CM, then for all possible values of T, from its minimum to infinity, there are arcs of one or two isochronal circles within the body of the pendulum.​
• If the body of the pendulum does not include the CM, there are only isochronal circle arcs for T less then a finite maximum value, an expression for which we found.

* I’m talking arcs of circles and not necessarily full circles here because there may be some radial distances from the CM for which the body of the pendulum exists for only some angles. Think of a triangular-shaped pendulum as opposed to a disk-shape one. For the former, there are some CM-centered circles of radius less than the extent of the triangle that aren’t entirely within the triangle. For the latter, this is not true.

This post is about a topic in physics, which I suspect may not be of interest to many regular TIE readers. But, it could interest irregular (?) readers.

Why physics? It was my undergrad major, and I’m now helping my daughter through AP Physics. I’m finding myself going down some rabbit holes, exploring things I didn’t learn in college. Some aren’t in any textbook I have at my fingertips or online (so far as I can tell). This post is about one such thing. I used AI to check the math and logic. If you see a problem, please let me know.

What This Post Shows
Our starting point is a well-known property of a physical pendulum (also called a compound pendulum), the discovery of which is credited to Christian Huygens: you can pivot the pendulum from two different points and get the same period (they’re isochronal). Given one pivot point, Huygens and any other basic physics text that covers this topic, shows how to find “the” other isochronal pivot point.

What this post shows is that, in fact, there are an infinite number of isochronal points (hence the quotes around “the” in the previous sentence). Moreover, they all lie on two circles about the center of mass (CM).

The First Isochronal Circle
The derivation for the period of a physical pendulum can be found online or in many textbooks. The period T about pivot point P is given by

$$T = 2\pi \sqrt{\frac{I}{mgd}}$$

where I is the moment of inertia about the pivot point, m is the pendulum’s mass, g is the acceleration due to gravity, and d is the distance between P and the CM. From the parallel axis theorem

$$I = I_{\text{CM}} + m d^2$$

where the first term is the moment of inertia about the center of mass. Therefore,

$$T = 2\pi \sqrt{\frac{I_{\text{CM}} + m d^2}{m g d}}$$

which is constant for any distance d from the CM in any direction. Thus, there are infinite isochronal pivot points that lie on a circle of radius d centered on the CM. This is the first isochronal circle. Note that it is not an isochronal sphere. It is important that the pivot axes remain parallel because the moment of inertia of the center of mass is different for rotation about other (non-parallel) axes. Put another way, the moment of inertia is a tensor.​​

The Second Isochronal Circle
As discussed in many places but not shown in a simple way (that I’ve seen), there is a pivot point isochronal with P and not on the circle described above. It’s called the center of oscillation and we’ll label it point Q. The end of this post has a straightforward proof that the isochronal point Q is a distance L from P through the CM where

$$L = \frac{I}{md}$$

Define d’ = L – d as the distance between Q and the CM. The physical pendulum has a moment of inertia I’ about point Q. We can plug d’ and I’ into the equations provided in the section above (The First Isochronal Circle). The conclusion follows by the same argument as above that the period is a constant T for any point a distance d’ from the CM. We know it is T (the same period as in the previous section) because P and Q are isochronal pivot points. Thus there are an infinite isochronal pivot points that lie on a circle of radius d’ centered on the CM. This is the second isochronal circle.

Or, to sum up, Huygens and countless others open our eyes to the fact that there are two isochronal points, P and Q. What is also true is that there are two isochronal circles about the CM, one contains P, the other Q.

This is consistent with the obvious fact that the period of oscillation of a uniform density rod pivoting at one end is the same as that pivoting on the other end (an isochronal circle goes through both ends). Or, the period of oscillation is the same for any point of a circular disk of uniform density equidistant from the center (isochronal circles are concentric about the CM). These obvious facts are clear to us from symmetry.

What’s given above shows that the circular isochronal symmetry is there even for asymmetric (arbitrarily shaped, with non-uniform density) physical pendulums. This is not intuitive (not to me anyway). Yet, the only thing that isn’t fixed for all points relating to a given pendulum in the expression for T is the distance of the pivot point from the CM. With that, isochronal circularity is unavoidable.

Conclusion
Notice that d can be any positive distance, giving rise to a range of positive values for period T. So, by the above arguments, all isochronal pivot points lie on pairs of concentric circles centered about the CM. (There is a small technicality that for some (OK, an infinite number of) values of d, some isochronal points may not be within the body of the pendulum. That doesn’t mean they’re not isochronal with the other points on the circle(s) associated with d (or d’). It just means that actually getting the pendulum to pivot around such a point is challenging in practice. It’d take a massless, unbending support from that point to the pendulum’s CM — a modest engineering issue.)

Proof That the Center of Oscillation is Isochronal (Or Pivot Q Has the Same Period as Pivot P)
Above, I promised this proof. Skip it if you’re willing to trust Huygens and countless other physics texts, some of which state this without proof.

With all the terms as defined in the post, start with some preliminary stuff to get an expression of d’ in terms of d that will be useful later. Recall that

$$L = \frac{I}{m d},$$

By the parallel axis theorem, and as noted in the post

$$I=I_{\text{CM}}+m{d}^2$$

Therefore,

$$L = \frac{I_{\text{CM}} + m d^2}{m d}.$$

And, simplifying,

$$L = \frac{I_{\text{CM}}}{m d} + d.$$

Using this and the definition of d’ (= L – d) from the post, we have

$$d’ = \left(\frac{I_{\text{CM}}}{m d} + d\right) – d.$$

So that

$$d’ = \frac{I_{\text{CM}}}{m d}.$$

The period of the pendulum pivoting about point Q is given by

$$T’ = 2\pi \sqrt{\frac{I’}{m g d’}},$$

The job is to show T’=T. We will do so by plugging in for I’ and d’ and doing some algebra. Here we go. The only thing we can do with I’ is apply the parallel axis theorem.

$$I’ = I_{\text{CM}} + m d’^2.$$

Plug in the expression for d’ from above. (This is why we did that preliminary work.)

$$I’ = I_{\text{CM}} + m \left(\frac{I_{\text{CM}}}{m d}\right)^2.$$

Cancel m and plug this into the numerator of T’ and use the expression for d’ in the denominator too.

$$T’ = 2\pi \sqrt{\frac{I_{\text{CM}} + \frac{I_{\text{CM}}^2}{m d^2}}{m g \cdot \frac{I_{\text{CM}}}{m d}}}.$$

There’s lots to cancel to simplify. Go ahead and do that on a scrap of paper or in your head. You’ll get

$$T’ = 2\pi \sqrt{\frac{1 + \frac{I_{\text{CM}}}{m d^2}}{\frac{g}{d}}}.$$

Multiply numerator and denominator in the square root by md² to get

$$T = 2\pi \sqrt{\frac{I}{m g d}} = 2\pi \sqrt{\frac{I_{\text{CM}} + m d^2}{m g d}}.$$

Recognize, from the parallel axis theorem, that the numerator is just I and that this is the expression for T. So, T’ = T and we are done.

Historical addendum: HRET has owned HSR since its inception 60 years ago.

Meanwhile, underutilized EDs can lead to waste, particularly in a health system already short on providers. In response, some health systems reduce ED capacity as a cost-containment strategy. While the Department of Veteran Affairs (VA) has not adopted this practice, there has been a significant shift towards Veterans utilizing non-VA community ED care, carrying the risk that Veterans leave the VA system altogether. This has led to ballooning financial costs for the VA, and comes with potentially negative impacts on Veteran health.

New Research

A recent paper by the Partnered Evidence-based Policy Resource Center (PEPReC) evaluated the impact of VA ED physician capacity on Veteran utilization of community care (CC) EDs. Specifically, the authors assessed whether increased VA ED physician capacity would shift demand away from CC EDs and ultimately brings Veteran back in-house for care.

Study Methods and Limitations
The authors used VA Corporate Data Warehouse data from over 100 VA EDs between 2014 and 2019, enriching the data with socioeconomic indicators from the American Community Survey and Area Health Resources Files. The independent variable was ED physician capacity, measured  using the number of hours spent on patient encounters during an 8-hour clinic-day, while CC ED claims was the outcome variable​.

The study used an instrumental variables approach. The two instruments were the proportion of weekday federal holidays and emergency clinician full-time equivalents. The models adjusted for Veteran demographics, insurance coverage, socioeconomic factors, and ED wait times. Sensitivity analyses confirmed the findings were robust, and the instrumental variables were validated for relevance and strength.

Worth noting, the evaluation was limited by reliance on claims data and how ED capacity was assessed by the VA. The findings lacked differentiation between Veteran ED and urgent care usage and cannot speak to how specific resources were allocated in clinics (e.g. number of facility beds). Lastly, the study period ended in 2019 and does not encapsulate significant operational changes post-2020. Overall, the evaluation findings may not be generalizable beyond the VA system. ​

Findings
The study found that increasing VA ED physician capacity reduced the use of CC ED services. When the authors used the proportion of weekday federal holidays as an instrument, they found that adding one eight-hour clinician shift per 10,000 enrollees reduced CC ED claims by 61 claims per month per 10,000 enrollees. When they used emergency clinician full-time equivalents as the instrument, they found that adding one eight-hour clinician shift per 10,000 enrollees led to a reduction of 48 claims per month per 10,000 enrollees.

Said another way, using the holiday-based model, every 1% increase in VA ED capacity led to a 1.42% decline in CC ED claims. Similarly, using the emergency clinician full-time equivalents model, a 1% capacity increase led to a 1.13% decrease in CC ED claims.

Importantly, VA facilities with the lowest ED capacity had significantly higher CC ED claims. Conversely, VA facilities with the highest ED capacity had the lowest CC ED claims. In short, this means that adding an 8-hour clinic day to facilities with the lowest ED capacity had the most impact on Veteran CC ED use.

Conclusion
These findings confirmed that enhancing VA ED capacity could meaningfully curb CC ED reliance. Similarly, keeping more ED care in-house has potential to increase use of other VA services, as many ED encounters require follow up care. As policymakers consider various options to address VA challenges, expanding VA ED capacity provides a proven method to help reintegrate Veterans into the VA system.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who support VA efforts to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

Drug development is a long and expensive process, even for drugs that never make it to market (and most don’t). For the products that do, patents give manufacturers a market monopoly for a certain number of years, ensuring no biosimilars or generics are sold. These monopolies are considered foundational to drug innovation, being extremely lucrative and designed to reward companies who risk resources developing new drugs.

There’s evidence, however, that some drug manufacturers game the system by extending these exclusive windows of profit. Over the last twenty years, a few common tactics have emerged.

One is patent thickets, which create a dense network of overlapping patents for one drug and crowd out the market. Without making any actual changes, manufacturers patent different parts of a drug at different times, extending the overall life of their intellectual property. For instance, Humira has more than 130 distinct patents and about 90 percent of them were filed after the drug was already on the market, serving as a huge monopolistic barrier to competition.

Another tactic is evergreening, a delay strategy that involves making minor modifications to some aspect of an existing drug, and then patenting those changes. The manufacturer’s timeframe of exclusive control is now extended well beyond the original patent window. This is a popular approach, with a recent paper finding that for all patents approved between 2005 and 2015, more than three quarters of them were for existing drugs.

Finally, product hopping is a tactic where manufacturers slightly alter a drug and then switch their consumer base to the new version before competitors have a chance to create a generic for the original version. Thankfully, the Federal Trade Commission (FTC) and courts have cracked down on this over the last few years, so the prevalence of future product hopping is uncertain.

While drug manufacturers reap the rewards with these strategies, significant costs crop up for patients.

The most obvious is actual health care costs. Taken together, these tactics heavily delay generic (or biosimilar) entry, forcing patients to use more expensive brand name drugs. This is huge, as generics have reduced health care costs by trillions over the past decade.

Taxpayers also pay. First and foremost, they foot the bill for government agencies to investigate drug manufacturer patent abuses. Second, their taxes partially subsidize drug development costs – with some conflicting, but far reaching, impacts. Coupled with some of the highest prices in the world for prescription medications, taxpayers don’t just “pay twice” for drugs, they pay three, four, or five times.

Meanwhile, the more hidden cost is lost innovation.

For one, patent gaming deters generic drug development. Even the biggest companies feel this, with Boehringer Ingelheim laying off staff after failing to bring a Humira generic to market due to Humira’s patent thicket.

Additionally, patent gaming contributes to a  hostile environment for smaller biotech startups trying to enter the market. New companies face huge barriers when they’re starting out, and generic creation offers a way to generate revenue while they hope to develop the “next blockbuster.” Patent hurdles exacerbate those challenges, an unwelcome reality as biotech bankruptcies hit a 10-year peak last year.

Luckily, the government is increasingly aware of these issues and beginning to address them.

In the last year, the FTC challenged the validity of over 400 patents on weight loss drugs, inhalers, and other medical devices. The Food and Drug Administration and the United States Patent Office are also collaborating to streamline patent review and dispute processes.

Progress is slow though. The FTC’s patent challenges last year had limited success: Just 30% of challenges received legal responses, and only a handful of patents were removed. But the work is ramping up, and federal offices are laying the groundwork for stronger patent action in the future.

Legislatively, Congress is considering a law that would create stricter criteria for patent extensions that would result in deeper scrutiny of minor drug modifications. This would help federal agencies reduce patent gaming by denying patents that don’t offer the public meaningful innovation.

Congress could also increase payments for more cost-effective drugs to incentivize innovation. For instance, the funding emphasis could be placed on developing drugs that cure or prevent disease rather than indefinitely treat patients. Success here would save patients and insurers from having to pay the financial and medical costs of lifelong medication maintenance.

In short, the goal of future policy to tackle patent abuses should be to expand competition, increase the value of innovation, and lower drug costs. The government already has the tools to do those things. Encouraging innovation over profit-driven patent manipulation will lead to a more sustainable and equitable health care system.

Research for this piece was supported by Arnold Ventures.

The physician shortage impacts the Veterans Health Administration (VHA), too. In addition to the aforementioned stressors, VHA also contends with salary limitations, strict regulatory processes, and other constraints. As a result, VHA is always working to “hire faster and more competitively” with the ultimate goal of improving access to care for the Veterans it serves.

To further investigate VHA physician hiring, the Partnered Evidence-based Policy Resource Center (PEPReC) evaluated the relationship between physician base salary and the amount of time required to fill open positions. PEPReC evaluators found that base salary matters when it comes to hiring quickly. Detailed results can be found in a new PEPReC policy brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

In 2023, policy analysts at the Partnered Evidence-based Policy Resource Center (PEPReC) summarized the impact of the law after the first year of implementation. Now, in 2024, they wrote a follow up policy brief to compare implementation in Year Two. New implementation successes were observed, alongside continued challenges from the previous year. Read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

New Research 

In partnership with VHA’s Office of Integrated Veteran Care (formally, the Office of Veterans Access to Care), the Partnered Evidence‐based Policy Resource Center (PEPReC) responded to the MISSION Act’s mandate to measure and mitigate underservedness at each VAMC. PEPReC outlines this new evidence-based approach to modeling access to care in a commentary published in Health Services Research. In it, PEPReC explains how to identify underserved VAMCs by using the econometric principles of supply and demand. 

PEPReC defines underservedness as an imbalance between the supply of VHA care and the expected Veteran demand for VHA care. In the first year after the law’s passage, PEPReC developed a statistical model to measure underservedness in primary care. (PEPReC has similar methodology ready for implementation in specialty care as well but those models have not yet gone live.)  

Model and Variables 

The model is centered around new patient waiting times, but takes a step further by considering the various factors that can impact waiting times. These variables and their relationships to waiting times are explained by being assigned numerical weights. Some increase waiting times while others decrease waiting times; some impact waiting times a lot and others not so much. A larger weight indicates more influence over waiting times.  

The model includes 21 variables to comprehensively capture VHA supply of care and Veteran demand for VHA care. For example, on the supply side, PEPReC includes clinic capacity and clinic efficiency, measures of staffing and productivity, respectively. On the demand side, PEPReC includes the household median income in the area surrounding the VAMC, the percent of Veterans who also have private insurance, Veterans’ Nosos risk scores (a measure of how sick they are), and the percent of Veterans who are 65 or older. 

Scores and Facility Rankings 

The model estimates the relationship between the variables listed above and raw waiting time data and creates an underserved score for each VAMC. The higher a VAMC’s score, the more underserved they are. In other words, the higher a VAMC’s score, the more they may struggle to provide timely access to quality care for their Veterans. 

After running the model and producing underserved scores each year, VAMCs are ranked relative to each other.  

Impact 

The underserved scores for all VAMCs are shared with the Office of Integrated Veteran Care. From there, the VAMCs with the highest scores are notified of their underserved status and are required to submit action plans explaining how they plan to mitigate underservedness in the coming year. The most underserved VAMCs and their action plans are shared with Congress via an annual congressionally mandated report.   

Each year, the model is refined and the underserved scores are recalculated.  

Importantly, this novel approach to measuring access to care can be used beyond the MISSION Act. The model and scores allow VHA to systematically identify and address imbalances in the supply of and demand for VHA care through evidence‐based policy making and equitable resource allocation. For example, VHA can used the scores to guide mental health clinic operations forecasting, budget forecasting, and local clinic management.  

The approach can also be used by other health systems, too, helping Veterans and non-Veterans alike access the quality care they need. 

Understanding and managing access to care for any population is tricky, and the MISSION 401 models are just one way to tackle that complexity.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who support VA efforts to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

Organ donation in the US is far more efficient now than it was before the transnational network was put in place in the 1980s, but operational issues and negligence plague the system. The product of light regulation and little consequence, these grave operational errors mean life or death for patients waiting for an organ or tissue transplant. But there are better ways to hold the operational entities that run the network accountable. The question is: Will we finally flex our regulatory muscle?

Read the full piece here BU Today by Katherine O’Malley.

With rising temperatures and inconsistent regulations, it’s critical to address heat vulnerability through proactive, community-based strategies. Our new piece recently published in The Health Care Blog describes the need for stronger policy interventions, such as workplace protections, urban planning adjustments, and public health outreach, especially for high-risk communities. There’s a lot that can be done to keep people safer as climate change continues to make heat a leading health threat.  

Read the full article here. 

To support this congressional requirement, in collaboration with the VA Office of Human Resources and Administration, the Partnered Evidence-based Policy Resource Center (PEPReC) developed population-based workforce guidelines for Fiscal Year 2024 (FY24).

These guidelines offer a data-driven approach to help VAMCs evaluate both current and future staffing needs to ensure timely access to care for Veterans. PEPReC’s supply and demand models incorporate validated metrics, such as new patient clinic work rates and clinic time, to determine how VAMCs can meet preestablished wait time standards. The FY24 guidelines focus on primary care and eight specialty care services that are either high volume or related to military toxic exposure care. Qualitative evaluation was used to refine the guidelines.

For more details on the latest guidelines and workforce planning strategies, read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

More than 22 million Americans have asthma. For half of adults and almost 90% of children, it’s caused by allergies. These rates have grown since 1996, likely due to climate change.

To manage asthma, there are two main types of inhalers: controllers for daily maintenance and relievers for flare ups. Based on symptom severity, patients may use both kinds. Patients may also choose to treat their underlying allergies with immunotherapy, antihistamines, and/or by avoiding allergy triggers altogether.

But the expense of some of these asthma treatments puts them out of reach for many patients.

One study of nearly 130,000 participants found that allergic asthma patients have 39% greater annual total health care costs and 79% greater annual asthma-related health care costs than non-allergic asthma patients. They had significantly more pharmacy claims, outpatient visits, and emergency department visits. They also were more likely to have undergone skin and/or blood allergy testing.

All told, the authors calculated that allergic asthma patients paid over $1100 more per year than non-allergic asthma patients. But that didn’t even include the costs of over-the-counter treatments, like antihistamines and nasal sprays, or the costs of immunotherapy (and not just the medicine itself but also weekly copays travel expenses). Nor did their results indicate how well patients’ asthma was controlled, and health care costs are typically higher for patients with poorly controlled asthma.

Further, an investigation by a US Senate Committee found that asthma medications cost significantly more in the US than they do elsewhere. For example, AstraZeneca charges $645 in the US for an inhaler that only costs $49 in the United Kingdom. Similarly, Teva Pharmaceuticals charges $286 in the US for an inhaler that costs $9 in Germany.

To be fair, some drug companies are addressing these high prices.

For example, AstraZeneca and GSK are following the example of major insulin manufacturers and reducing their prices. While these companies are implementing $35 monthly price caps on inhalers, eligibility varies, and patients are still years away from actually seeing the benefits.

Some companies are authorizing generic options for their brand-name inhalers, too. For instance, GSK recently discontinued Flovent, a frequently prescribed maintenance inhaler, because they’re making a cheaper, generic version instead. (It’s worth noting that this abrupt change caused chaos for some patients who had to scramble to find a comparable prescription for the interim.)

Despite these positive changes, the overall system remains flawed. Consider patent protections and Food and Drug Administration-granted exclusivity protections.

With the goal of rewarding innovation, the US Patent and Trade Office allows drug companies to sell new medications for a set period of time without any competition, typically 20 years. The Food and Drug Administration may also give manufacturers a monopoly for different periods and reasons. However, because of these protections, over 50 patents were approved for brand-name inhalers from 1986 to 2020, with only three facing generic competition afterwards. What’s worse, some drug companies partake in unethical practices to extend their market control even longer.

There are ways to remedy this though. The Senate recently passed a bipartisan bill that could prevent product-hopping, one of those unethical practices where manufacturers stop producing a nearly expired product and start selling a new, very similar version, effectively restarting their patent protection. This has been common with Albuterol rescue inhalers, costing payers and patients billions of dollars. If signed into law, this bill could increase the speed at which generics hit the market, ultimately leading to lower prices for patients.

An even more significant change would be if the US moved towards value-based pricing, where prices are based on drug effectiveness and the quality of life improvements patients see. A variety of cost analyses can be utilized to determine fair prices, and this approach has been successful in Europe and Australia with inhalers.

Asthma treatment is expensive, full stop. But asthma sufferers shouldn’t have to worry about how to pay for it. It is possible to minimize costs, but federal policies will need to balance profitability, affordability, and innovation.

Research for this piece was supported by Arnold Ventures.

Half of adults and almost 90% of children with asthma have allergic asthma. Triggered by inhaling allergens such as pollen, dust mites, or pet dander, allergic asthma commonly produces respiratory symptoms like shortness of breath and chest tightness, as well as hives and nose irritation.

The impact of asthma on a person’s quality of life is significant. Asthma is actually one of the top reasons children miss school. In 2013, kids missed almost 14 million days because of asthma alone. (A more recent statistic is not available.) And a fifth of adults with asthma report that workplace exposures make their symptoms worse and negatively affect their productivity. These losses, coupled with related medical costs, make asthma one of the most expensive diseases in the US.

While many asthma cases aren’t preventable, the noted increase in allergic asthma rates is likely due in part to climate change.

First, global warming – due to an increase in greenhouse gases in the atmosphere caused by human activities – impacts the duration and intensity of allergy season.

Warmer temperatures confuse trees into releasing more pollen, and releasing it earlier than they normally do. Think January instead of March. In North America, there is currently almost 20% more pollen than there was in 1990. Historically cooler environments like Norway and Canada are feeling it, too, now that warmer temperatures can support more pollen-producing plants.

Second, global warming causes more frequent, extreme weather events, worsening air quality. For example, wildfires and floods often trigger asthma attacks because the former releases pollutants into the air and the latter promotes indoor mold growth. Even thunderstorms have an effect: Heavy rain and strong winds break up pollen grains into smaller pieces that can travel longer distances.

What’s worse, historically marginalized individuals are hit the hardest by climate change. The data show these populations are 52% more likely to live in areas with higher predicted asthma-related emergency room visits. Higher rates of asthma are also common in low-income households, and Black children are more than seven times as likely to die from asthma than their non-Hispanic White peers.

While daunting, there are ways to reduce the impact of climate change on allergic asthma.

For starters, providers could consider switching the inhalers they prescribe, choosing dry powder inhalers, instead of metered-dose inhalers. Metered-dose inhalers account for almost 90% of the US asthma medication market, prescribed to 144 million patients per year. Yet with every use, they release a greenhouse gas more powerful than carbon dioxide (the most significant contributor to the greenhouse effect) and produce the same amount of emissions as all of the homes in Milwaukee, Wisconsin.

Hospitals could also make environmentally friendly changes. After all, they are major greenhouse gas emitters. The health care system in the US is responsible for 8.5% of all of the country’s carbon emissions, regardless of industry, and 25% of the world’s health care-related emissions. One fix could be to improve energy efficiency in buildings and to substitute fuel powered emergency vehicles with electric ones. Some also recommend reducing single use plastics by switching to reusable isolation gowns, surgical supplies, linens, and other products.

But other sectors have a large role to play, too, and broader scale climate change reform from the federal government could have trickle-down effects.

For example, federal policies could limit how much Americans use fossil fuels. Policymakers could require that large corporations reduce their emissions and enforce a goal of carbon neutrality by 2050 (the year when the damage from climate change will be irreversible). More work can be done on the state and local levels, too, to create and prioritize renewable energy sources like solar, wind, and hydropower.

Asthma won’t ever be gone completely, but rates of allergic asthma could be reduced if global warming is. The health care system and policymakers must work together to protect respiratory health while it’s still possible.

TIE contributor, Elsa Pearson Sites, recently wrote about the Evidence Act and the strength of evidence checklist developed by the Partnered Evidence-based Policy Resource Center (PEPReC) and used by the Veterans Health Administration. Earlier this month, PEPReC published a new brief exploring how the checklist has changed since its inception, how it has been deployed, and how it might be used in the future.

For more, read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

It’s hard to not be familiar with the term “mindfulness;” it’s spreading across workplaces, classrooms, and friend groups. What’s trickier is knowing what it can and cannot do for one’s health. Although mounting evidence suggests it may have wide utility, there are still unknowns on how far benefits can go.

Academics have discovered over 30 definitions for this Buddhist concept in the literature, but mindfulness is typically defined as “the awareness that emerges through paying attention on purpose, in the present moment, and nonjudgmentally to the unfolding of experience moment by moment.”

Tracing back millennia in the Eastern world, this awareness can now be nurtured formally through instructor-led mindfulness programs or informally through self-guided personal practice.

The former method often spans months and is facilitated through group training sessions or daylong retreats. The most frequently cited, evidence-based program is Mindfulness-Based Stress Reduction (MBSR). Some of its common exercises include sitting meditation, Hatha yoga, and body scans.

The latter type of mindfulness is individualized, leaving room for a flexible setting and time commitment. Some individuals distinctly set aside time to sharpen this skill with apps like Calm or Healthy Minds, while others find moments to be mindful in their existing daily routine (e.g., while eating, washing the dishes, taking a walk, etc.).

One’s goals for engaging in the practice can also vary; some have a singular aim to achieve, others go into it with no expectations. Some mindfulness interventions have an intended purpose, others are more general.

While mindfulness can sometimes stir up uncomfortable, negative feelings from heightened awareness, these effects are usually mild and to be expected. Research has confirmed that mindfulness based programs are safe and do not come with serious adverse events.

In fact, it can be used to prevent some mental health issues and improve social-emotional skills.

Formal Mindfulness
There are numerous studies that focus on the efficacy of mindfulness programs.

A recent systematic review of randomized controlled trials found evidence that mindfulness based programs can reduce psychological distress for at least six months in a variety of settings. And programs specifically targeting stressed, anxious, or symptomatic adults were more effective at reducing depression and anxiety than generalized programs.

MBSR in particular has been widely cited in clinical literature to reduce symptoms and improve quality of life for healthy individuals and those with a variety of conditions such as post-traumatic stress disorder, multiple sclerosis, chronic pain disorders, and cancer.

By strengthening one’s ability to focus on one thing at time and make more conscious choices, MBSR also encourages self-compassion and promotes positive social behavior. This is precisely why it is sometimes offered by employers! It has been successfully used to improve workplace retention, culture, and productivity.

Informal Mindfulness
General mindfulness practices seemingly produce physical benefits. Research indicates mindfulness practices may reduce cortisol awakening responses, chronic pain, blood pressure, and cardiovascular disease. They may also slow weight gain in women with obesity and improve sleep disorders.

Gaps in Mindfulness Research
There are still plenty of things researchers remain unsure about when it comes to what mindfulness can or cannot do.

For example, it is unclear how mindfulness impacts long-term mental health, and whether any benefits are will last beyond the period of regular practice.

One study did discover potential long-term effects of MSBR on mental health, finding that participants who practiced more days and had higher levels of mindfulness two to five years post-program, had lower levels of anxiety. Though, there was a general decay of benefits after one to two years for those who did not keep up with the practice. While promising, the authors suggest the study should be interpreted with caution due to design limitations.

Another unknown is the difference in effectiveness based on setting. For instance, there’s a lot of room left to investigate nature-based mindfulness and how it compares to practices in more cultivated settings. Preliminarily, one systematic review hints that nature-based mindfulness is superior, and even saw stronger effects for individuals participating in natural outdoor environments (e.g., forest, wild nature) compared to urbanized outdoor environments (e.g., gardens, parks).

Additionally, there’s conflicting preliminary evidence on the neural changes that mindfulness can produce. Some studies have shown that mindfulness programs increase gray matter density in the brain, thus improving working memory capacity and slowing signs of aging. However, a recent review of 25 studies, found that while there are positive neural changes on attention and executive function, there were not significant results for working memory and long-term memory like previous studies had noted.

Some researchers have also expressed ethical concerns. For instance, one study claimed mindfulness programs lack qualified instructors, ethical delivery guidelines, and the capacity to screen for adverse events. To mitigate these concerns, researchers suggest that public health practitioners should establish regulatory bodies, standardized ethical guidelines, appropriate screening procedures, and adequate accreditation and licensing procedures.

Despite the uncertainty of how far the benefits can go, mindfulness remains promising and an inexpensive practice one can explore on one’s own with little to no reported harm.

The Evidence Act requires certain formal deliverables be submitted to the Office of Management and Budget on routine cadences. However, beyond the law’s formal requirements, VHA developed the strength of evidence checklist to strengthen the legislative and budget proposal processes. The goal is to ensure that VHA offices are using evidence to justify any changes they’re proposing to current law and/or budget lines. VHA considers this the Evidence Act “in action.”

The Partnered Evidence-based Policy Resource Center (PEPReC) spearheaded the checklist’s development and wrote a short policy brief about it. In the policy brief, PEPReC discusses the domains of evidence included in the checklist, how VHA uses it in the legislative and budget proposal process, and the routine improvements made in its early years.

Read the policy brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative, is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

As a gentle sleep aid, suppose your doctor recommends you take 200 milligrams of magnesium glycinate. Or, suppose you read a recommendation of just that in a newsletter from a well-known neuroscientist. Following this advice is not as simple as you might think.

First, let’s get straight that, putting aside how it is phrased, this is a perfectly reasonable recommendation. Recommended daily allowances of magnesium for anyone other than young kids is in the hundreds of mg; it is quite common that people do not reach these levels through diet; and servings of foods can include many dozens to about 100mg of magnesium. Daily magnesium supplementation up to a 350mg is considered safe for adults, perhaps higher in consultation with a health care provider.

OK, so what are the problems? In short, there two significant communication issues.

The first is that when someone makes such a recommendation (and the internet is full of them), they almost certainly do not mean what it sounds like they mean. When someone says to take “200mg of magnesium glycinate” they really mean “take 200mg of magnesium in the form of magnesium glycinate.” Or, to be even more precise, they mean “take 200mg of elemental magnesium, delivered as a constituent of the compound magnesium glycinate.”

How do I know they mean this? First, there’s what I wrote three paragraphs above. Recommended daily allowances of magnesium are in the hundreds of mg of magnesium not magnesium glycinate (or some other compound of magnesium). As I will explain below, the difference is large. Only by ignorance or sloppiness can one confuse one with the other.

Second, there are many studies that are clear on this point. They examine magnesium for sleep and discuss doses in the hundreds of mg of elemental magnesium, some taken as magnesium glycinate, others as some other magnesium compound (e.g., magnesium citrate, magnesium oxide).

This is an important distinction. Each magnesium glycinate molecule contains one magnesium atom and two glycine molecules (this is why it is also called magnesium biglycinate, the “bi” meaning two). So, the mass of a number of magnesium atoms is less than the same number of magnesium glycinate molecules, by about a factor of 7. Thus, if you follow the advice “take 200mg of magnesium glycinate” literally (meaning you buy and consume as directed a supplement that offers 200mg of the magnesium glycinate compound per serving), you will be taking less than 30mg of elemental magnesium (200/7 is not quite 30). Based on what I’ve already conveyed above, that’s not enough to do anything. You’re way under-dosing.

(If anything about the preceding paragraph is confusing, think of it this way: imagine a special cherry that has as its pit elemental magnesium. Suppose the pit has a mass of 1 (units irrelevant). The pit is surrounded by cherry fruit composed of biglycinate with a mass of 6. The total mass of a cherry, with pit, is 7. Suppose your doctor said you should eat a mass of 210 of these magnesium-pitted cherries (and to eat the pits too, not spit them out), but she really meant that you should eat 210 magnesium pits. If you follow her instructions, you’d eat 30 cherries (210/7 = 30). In doing so, you’d only get 30 mass units of magnesium (30 pits), a far cry from 210!)

OK, so we’re clear that everyone on the internet, in doctor’s offices, and everywhere else should stop saying “take 200mg of magnesium glycinate” and start saying “take 200mg of magnesium in the form of magnesium glycinate” (or something even clearer than that). Good.

Here’s communication issue number two: The supplement market is not adequately regulated. This allows manufacturers to put all kinds of confusing stuff on their labels. This includes:

• Not clearly indicating the mg of elemental magnesium, only writing the mg of the compound of which it is a constituent. So, even if you know you want 200mg of elemental magnesium, you’ve got to do some math to figure out how much of this some supplements deliver.
• Or, providing the mg of elemental magnesium but mislabeling it as that of the compound.
• Mixing compounds of magnesium — for example, some kind of blend of magnesium glycinate and magnesium oxide — and only providing the mg of this mix. That makes it even harder to figure out how much elemental magnesium is in it (perhaps impossible, because they usually don’t state the ratio of the mix).
• Sneaky “serving size” bullshit. When the front label says “500mg magnesium glycinate” in big print and “per serving” in small print and the back label says “4 capsules per serving,” that’s some sneaky bullshit. In addition to increasing the risk of taking the wrong dose, it’s another way it makes it very hard to shop, not just on price but also with an eye toward simplifying your pill burden. Nobody wants to take 4 capsules when they could take 2, say (all else equal).

There are undoubtedly other tricks and sources of confusion, but these are the ones I easily noticed. The best labels indicate the mg of elemental magnesium and the mg of the full compound of which it is a constituent, per serving. The very best labels consider one capsule a serving.

If all labels were written according to these two “Frakt best practices” magnesium shopping would be far less burdensome. And if all advice-givers were clear about what amount of elemental vs compound-bound magnesium they are talking about, that would reduce confusion.

The days and weeks after being in the hospital are a vulnerable period, sometimes followed by readmission. High hospital readmission rates in an area can be influenced by factors like socioeconomic status or lack of community support systems. Health system-related failures can also contribute to patient readmission. For instance, gaps in post-discharge care, poor home or nursing home care management, or receiving care at low-quality hospitals can all lead to higher 30-day readmission rates. Ongoing research highlights the importance of addressing social and health system disparities to lower readmission rates.

New research

Evaluators at the Partnered Evidence-based Policy Resource Center (PEPReC) and other partner institutions added to this body of literature in a recent paper by investigating the relationship between the local supply of post-discharge care options and hospital readmission rates for patients with acute myocardial infarction (i.e., heart attack), heart failure, or pneumonia.

Study Methods and Limitations

The authors consolidated data (2013-2019) from the Centers for Medicare and Medicaid Services, the American Hospital Association, the Census Bureau, and the Health Resources and Services Administration. Once condensed, the sample was generally reflective of American hospitals, with over 50,500 hospital-condition-years from over 3,000 unique hospitals included.

Controlling for hospital characteristics, patient demographics, and clinical factors, the authors used multivariable regression models to isolate the impact of local post-discharge care supply on hospital readmission rates. The authors conducted analyses with all three health conditions pooled together as well as with each condition individually.

There were some limitations to the study. For instance, the authors relied on secondary data and could not identify specific reasons why certain post-discharge care options generate more readmissions. Additionally, the data did not differentiate which readmissions were potentially preventable through improved quality of care.

Findings

From 2013 to 2019, the population-level availability of post-discharge care options varied greatly by county. When controlling for differences in hospital characteristics, patient demographics, and clinical factors, hospitals in areas with more primary care doctors and nursing home beds had lower readmission rates. Hospitals in areas with greater availability of palliative care and skilled nursing facility beds also had reduced readmissions, though only for individual conditions and not when the three conditions were pooled.

On the other end, hospitals in areas with more available home health agency services saw higher readmission rates for patients with heart failure. Similarly, when conditions are pooled or when analyzing only heart failure or pneumonia, areas with more nurse practitioners are found to have increased readmissions. The authors pointed out that home health agencies experience frequent staffing changes, and areas with higher levels of nurse staffing tend to have greater patient acuity, which may explain these findings.

The figure below represents the findings visually.

Conclusion

After reviewing their findings, the authors argued that improving continuity of care for patients post-discharge would improve patient outcomes. They also proposed that the federal system designed to fine hospitals for high readmissions rates should consider these local health system characteristics to more accurately assign penalties.

Returning to the hospital after recently being discharged isn’t an experience most people want. It’s costly and inefficient. This study speaks to the importance of the availability of post-discharge care services to prevent that experience, offering policymakers a better way forward.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who support VA efforts to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

PTSD is associated with comorbid mental health conditions, decreased functioning and quality of life, unemployment, greater health care costs, and difficulty reintegrating into civilian society. And although antidepressant therapies and trauma-focused psychotherapies may improve PTSD symptoms for some, relief can be elusive for others.

Because PTSD can be a chronic and debilitating condition, combining new treatments with existing treatments may be a valuable strategy. One promising new approach is utilizing service and/or emotional support dogs.

Multiple studies have shown that dogs have beneficial effects on one’s mental health, quality of life, and well-being, especially trained service dogs who can improve PTSD symptoms and social functioning in Veterans. While service dogs are able to perform various tasks specific to assisting a Veteran with PTSD, the sole function of an emotional support dog is to provide comfort (a distinction that disqualifies them from accessing public buildings under the Americans with Disabilities Act).

Studies have yet to assess the therapeutic and economic benefits of service dogs versus emotional support dogs for veterans with PTSD.

New Evidence:
In January 2023, evaluators from the Partnered Evidence-based Policy Resource Center (PEPReC) published a novel paper titled “Therapeutic and Economic Benefits of Service Dogs Versus Emotional Support Dogs for Veterans With PTSD” in Psychiatric Services, a journal of the American Psychiatric Association. Authors studied whether providing a service dog versus an emotional support dog to Veterans diagnosed with PTSD improved overall functioning and quality of life over time. Additionally, they assessed PTSD symptoms, suicidal behavior and ideation, depression, sleep quality, anger, and economic outcomes

Methods:
Authors conducted a randomized clinical trial recruiting 181 Veterans diagnosed with PTSD from three Department of Veterans Affairs (VA) medical centers. The Veterans randomly received either a trained service dog or emotional support dog and were followed for 18 months.

Throughout the study, participants were assessed, either by phone or in person, for several therapeutic outcome measures, including health-related quality of life. They received questionnaires at screening, baseline, before pairing, and at a variety of points post-pairing.

Authors used a linear mixed repeated-measures model to determine changes over time between the service dog and emotional support dog groups. They also used panel models to examine whether treatment assignment was associated with VA health care utilization and costs, with analyses controlled for follow-up time. Work productivity and sensitivity analyses were also conducted.

Findings:
The authors found that both groups appeared to benefit from having a service or emotional support dog, but there were no significant differences in improved functioning or quality of life between the two. Service dogs did not appear to be superior to emotional support dogs in terms of costs, health care utilization, employment, or productivity outcomes. Though, those in the service dog group had a greater reduction in PTSD symptoms, better anti-depressant adherence, and tended to have a reduction in suicidal behavior and ideation compared with those paired with an emotional support dog.

Conclusion:

This study had several limitations. For example, participants were unable to be blind to dog type and there was no control group (i.e., Veterans with no dog) included because that would have created ethical and analytical challenges. The study results may not be generalizable to other populations (e.g., non-Veterans) either.

This study suggests that pairing Veterans with PTSD with service or emotional support dogs can complement existing evidence-based treatments, increase levels of treatment engagement, and reduce PTSD symptoms. Future work should examine the mechanisms by which a service or emotional support dog has an impact on patient functioning, such as by directly reducing PTSD symptoms or by improving treatment engagement or adherence.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

Thanks in part to support from the National Institute for Healthcare Management, that’s the topic of this week’s Healthcare Triage.

Getting enough, good quality sleep every night is important. Yet, hundreds of Americans struggle to get ample rest regularly, despite all efforts. We know sleep deprivation is generally bad for our health, yet research shows it can be harnessed to help heal depression.

About one in three adults report not getting enough sleep, and an estimated 50 to 70 million face chronic sleep disorders. This can lead to sleep deprivation, from either not enough sleep or poor-quality sleep.

The amount of sleep we need changes with age, and we know the consequences of not getting enough. Reaching any point of sleep deprivation can impact daily life, leading to mood changes, difficulty concentrating, and memory issues. Severe and chronic cases can harm connectivity and blood flow in the brain, and result in conditions like heart disease, high blood pressure, and stroke.

The use of sleep aides is at an all-time high, often involving experimenting with different methods to finally get some rest. For those already experiencing sleep deprivation, a recent study found that taking a creatine supplement can improve cognitive performance and energy levels as a way to mitigate the effects of prolonged sleeplessness. This can be useful for those who can’t avoid irregular sleep, such as night shift workers.

Despite the battle for quality sleep and reprieve, some people with depression can actually benefit from sleep deprivation.

Sleep Deprived on Purpose 

Wake therapy intentionally uses sleep deprivation to temporarily treat depression. This is because, for some, being in a sleepless state for a prolonged period can boost mood, increase mental and physical stamina, and enhance creativity. What distinguishes wake therapy from other treatments for depression is that it works fast; antidepressants, for example, can take weeks to kick-in.

Triple chronotherapy is one type of wake therapy that uses a combination of one total night of sleep deprivation (33-36 hours), followed by three nights of sleep phase advance (sleep between 6pm and 1am on day one, 8pm and 3am on day two, and 10pm and 5am on day three), accompanied by 30-minute sessions of bright light therapy each morning. This therapy is often given in conjunction with other treatments, like medicine.

It’s been found effective in preventing some from relapsing into depression and shows promise in treating acutely suicidal patients. Despite these findings though, research is still limited and the effects remain short-term.

Manipulating sleep for treatment is tricky since sleep patterns differ for everyone. Our circadian rhythms, or internal clocks, are not consistent and can vary based on genetics, age, sex, exposure to light, and time zone. Because of these complications and other risks, any form of wake therapy should be done under the supervision of a clinician.

Sleep deprivation as a tool for healing isn’t new. Native American communities have long practiced using different forms of deprivation, including lack of sleep, food, or comfort, to access altered states of consciousness. There seems to be something about entering a delirious state of mind that can change the way we process information, and sleep deprivation can be one way to get there. It’s believed that while being in this hypnotic-like state, under the guidance of an elder or shaman, healing of a “lost soul” – otherwise believed to be depression – is possible.

So, does this mean that some of us should purposefully become sleep deprived? Definitely not, as evidence points to the importance of sleep for health and well-being, in general. As for sleep deprivation (wake therapy) to address depression, it is wise to work closely with an experienced practitioner. At the very least, while more research is needed to understand how sleep deprivation can both be avoided and used to address specific conditions, it has shown promise across different communities.

The United States’ health care spending has grown recently to nearly $5 trillion a year, and some of this spending is due to unnecessary testing.

Unnecessary testing isn’t always the result of an overzealous provider or a worried patient though. It can also occur because of fragmentation and miscommunication between providers and health care systems. Without an ability to connect, fragmentation can increase the risk of adverse health outcomes.

The most common way to connect disparate providers and health systems is through health information exchanges, also known as electronic medical record interfaces. These platforms enable providers to communicate and see prior testing, imaging, and other medical encounters. But, in practice, does provider access to these interfaces actually reduce duplicate testing for Veterans?

Recent Study

Evaluators at the Partnered Evidence-based Policy Resource Center set out to answer that question in a study published in JMIR Medical Informatics. The authors sought to estimate the impact of provider usage of the Joint Longitudinal Viewer (JLV) on the ordering of duplicate imaging across the Department of Veterans Affairs (VA) and the Department of Defense (DoD).

The JLV is a joint electronic health system utilized by both VA and DoD and allows providers across both enterprises read-only access to their patients’ health records from the other enterprise. For this study, authors examined data from fiscal year 2018 and conducted a retrospective cross-sectional analysis.

Authors looked at 892 unique medical encounters involving recently separated Veterans with at least one primary care visit at VA within 90 days of an imaging study at DoD. There were a number of exclusionary criteria, such as Veterans who had a primary care visit as part of a compensation and benefits screening or those diagnosed with cancer which may require frequent testing to monitor their illness.

To estimate the relationship between use of the JLV during the primary care visit and duplicate imaging, authors used a logistic regression model. The model controlled for potential confounders, including Veteran age and sex and provider imaging rate in the past six months. To test the results of the model for robustness, evaluators used 2-stage ordinary least squares models and other specifications.

Findings and Limitations

Overall, authors found that JLV use by VA providers increased since fiscal year 2015 when the system was first introduced. Monthly queries in JLV grew to over 1.4 million by 2018.

During this year of peak JLV use, for providers in the study cohort, use of the system was associated with a significant reduction in the likelihood of ordering duplicate imaging. VA providers who did not use the JLV ordered duplicate imaging 11.2% of the time, compared to 6.1% of the time for JLV users.

Additionally, evaluators found differences in duplicate image ordering between providers with historical JLV use and those without. VA primary care providers with a history of using the JLV at least once in the six months before the study period were five percentage points less likely than their counterparts to order duplicate imaging.

However, the authors also acknowledged some study limitations.

First, they only examined primary care visits within 90 days of imaging, so it’s possible that duplicate imaging still occurred, either outside this window or in non-primary care settings.

Secondly, authors noted that they could not delineate between necessary or unnecessary duplicate testing due to data source limitations. Put simply, some seemingly duplicative imaging may have in fact been necessary for monitoring disease. Though authors tried to mitigate this by excluding Veterans with cancer, other conditions may also necessitate frequent testing.

Lastly, authors noted that the results lost robustness with adjustments to the definition of a provider with historical JLV use. According to authors, this suggested “heterogeneity of JLV benefits by frequency of use.”

Takeaway

Study findings suggest that using the JLV and similar longitudinal health information exchanges may reduce duplicate imaging and, therefore, patient burden and unnecessary spending. More research is necessary to understand how electronic medical record features could impact other testing and care in the future.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who support VA efforts to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

Special thanks to the NIHCM for supporting this special series on the costs of prescription drugs.

Organ transplantation is a measure of incredible scientific achievement. It began in earnest in the 1950s, with Dr. Joseph Murray performing the world’s first human kidney transplant in Boston. (He later went on to win the Nobel Prize for his work.) The world’s first kidney-pancreas, liver, and heart transplants followed in the late 1960s, along with breakthroughs in immunosuppression in the 1970s, necessary for successful transplantation.

Governing laws

As science advanced, more patients became eligible for transplants, and more donors became available to provide them. But the system matching one to the other was piecemeal.

For decades, a small and scattered group of local transplant hospitals managed organ procurement and transplantation themselves. A national, connected network didn’t exist.

That all changed in 1984 with the passage of the National Organ Transplant Act. The landmark law created today’s Organ Procurement and Transplantation Network (the network), a national matching system that fixed a fragmented, inefficient operation.

With the creation of the network, geographically diverse hospitals could communicate with others in the network, making transplantation quicker and more efficient. It also allowed for cross-country transplantation instead of limiting a donated organ to its immediate locale.

Notably, the law also stipulated that only one private organization would be contracted to run the entire network. The United Network for Organ Sharing (UNOS) won that federal contract in 1986 and has run the network ever since.

While delegating network operations to one organization seemed efficient at first, UNOS has garnered some valid criticism during its 40-year reign, including complaints about its antiquated technology and operational failures resulting in discarded organs.

A new law passed in 2023 addressed this by breaking up UNOS’ monopoly over the network and allowing the federal government to contract with multiple organizations at once to run it. These contract changes are still in the works.

Registry

The network uses a national registry to match deceased and living donors to recipients. This registry contains important details about both parties, including blood type, body size, and demographics.

When an organ becomes available, algorithms use all of those details to generate a list of eligible recipients, ranked by a composite score. Importantly, recipients aren’t simply ranked based on when they got on the waiting list. Instead, the registry is a “dynamic, ever-changing pool of information.” The organ is then offered to the top eligible recipient on the list and, if declined by the patient’s surgical team, is offered to the next person. (An organ may be declined due to a size mismatch or the recipient being temporarily unsuitable for transplant, among other reasons.)

Procurement and Transplantation

While UNOS oversees the entire national transplantation network, much of the work is coordinated by local organ procurement organizations.

Once a local organ procurement organization learns that an organ is available in its catchment area, it coordinates procurement from the donor and arranges transportation via ambulance, private courier service, or even commercial flight.

While most organs are delivered successfully, some organs are delayed in transit, lose viability, and have to be thrown away. Some just get lost, too.

Once received by the recipient’s surgical team, they work against the clock to transplant the organ. Through special preservation methods, organs can survive outside of the body for varying amounts of time. For example, kidneys can last up to 48 hours, while hearts and lungs can only survive four to six hours.

After surgery, the recipient maintains a lifelong regimen of immunosuppressant drugs and other treatments to prevent their body from rejecting the new organ. The network tracks outcome measures for successful transplantation, including recipient mortality and the transplant organ’s survival and functionality.

Organ donation has seen truly amazing innovation in the last 75 years. The United States’ network alone has saved hundreds of thousands of lives. Even though it is undergoing an operational makeover to improve efficiency and transparency, the network has proven its value and made good on Congress’ 1984 promise to streamline organ donation.

0:00 Intro

0:22 A Brief History of Opioids

8:13 Opioid Science

16:14 Opioid Addiction Treatment

22:26 The Opioid Crisis Continues

31:34 Deaths of Despair

37:49 What Can We Do About Opioids?

Be sure to check out our podcast!    • Podcast   Other Healthcare Triage Links: 1. Support the channel on Patreon: http://vid.io/xqXr 2. Check out our Facebook page: http://goo.gl/LnOq5z 3. We still have merchandise available at http://www.hctmerch.com 4. Aaron’s book “The Bad Food Bible: How and Why to Eat Sinfully” is available wherever books are sold, such as Amazon: http://amzn.to/2hGvhKw Credits: Aaron Carroll — Writer Tiffany Doherty — Writer and Script Editor John Green — Executive Producer Stan Muller — Director, Producer Mark Olsen – Art Director, Producer

The Veterans Health Administration (VHA), serving over nine million Veterans, is becoming more ethnically and racially diverse. In addition, VHA enrollees tend to have a higher number of comorbidities and higher risk for severe COVID-19 illness compared to the general US population. Previous work found that minoritized Veterans were disproportionately affected by excess mortality during the COVID-19 pandemic, but that work did not account for Veterans’ underlying health status such as group-level differences in comorbidity burden.

New Research:

In the study, “Racial and ethnic disparities in excess mortality among US Veterans during the COVID-19 pandemic,” researchers examined how the pandemic may have disproportionately affected Veterans from different racial and ethnic backgrounds. To understand the impact on minoritized communities, researchers expanded on existing work, using a longer time period and a previously validated approach to identify excess mortality attributable to the COVID-19 pandemic. Excess mortality refers to the number of deaths for a specific time (i.e., pandemic) that is above what would be expected based on historical averages.

Methods:

Researchers queried nationwide data from VHA’s Corporate Data Warehouse for Veteran demographics (e.g., race/ethnicity, age) and other characteristics that were previously associated with mortality risk (e.g., service-connected disabilities, major comorbidities). A validated mortality risk prediction model was leveraged to estimate the expected mortality among Veterans, using five years of pre-pandemic data and controlling for disease burden. Once established, the model was then used to generate predicted Veteran mortality for the pandemic period (March to December 2020) specifically, along with estimating excess mortality for each race/ethnicity group.

Findings:

To populate the mortality risk prediction model, the researchers analyzed data from about 9.3 million unique Veterans seeking care at VHA between 2016 and 2020, excluding those with missing race/ethnicity or county information.

For the pandemic period, March to December 2020, they observed monthly enrollment of 7.8 million Veterans and 261,523 Veteran deaths. Overall, Veterans’ mortality rates were 16% above normal during the pandemic period, equating to 42,348 excess deaths.

Excess mortality rates increased significantly for particular racial and ethnic groups as well. Native American, Black, and Hispanic Veterans faced significantly higher excess mortality rates (40%, 32%, and 26%, respectively), compared to the lowest calculated excess mortality rate in non-Hispanic White Veterans (17%). However, these disparities in VHA were smaller than what is seen in the general US population.

Conclusion:

The study’s findings reflect the broader societal inequities exacerbated by the pandemic. To address these issues in VHA, it is essential to expand health care services in underserved areas and increase funding for Veteran-specific programs that improve access to care. Expanding VHA’s telehealth services, which have successfully reached minority Veterans in remote or rural areas, is one effective strategy to ensure timely medical attention.

Implementing targeted interventions, such as community outreach and culturally competent care, could also help reduce disparities and improve health outcomes for minority Veterans. Provider training programs on cultural competency have been shown to enhance patient-provider interactions and care quality.

During the COVID-19 pandemic, VHA observed racial and ethnic disparities in excess mortality, with minoritized Veterans dying at higher rates compared to White Veterans. While progress has been made in addressing structural racism within VHA, further improvements in care quality, delivery, and access are needed, especially for communities of color.

“The COVID-19 pandemic produced a perfect storm for elder abuse that reverberates today, as both older adults and perpetrators experienced social isolation, stress, and health problems. One survey of community-based caregivers shows that, post-COVID, they are drinking more alcohol, feeling significantly more socially isolated and lonely, and are more worried about their finances than before the pandemic (Makaroun et al., 2021).”

Read the whole piece here, beginning on page 27.

VHA leverages its extensive health education and training program to prepare physicians to enter the field in service of this mission. Interestingly, a recent evaluation by the Partnered Evidence-based Policy Resource Center (PEPReC) found that increasing the size of medical training programs at a VHA medical center was associated with a small decrease in facility productivity and a small increase in staff turnover. However, increasing the size of the programs was also associated with a decrease in the time needed to fill vacant positions.

PEPReC published a brief detailing the impact of VHA physician training programs on facility-level productivity, turnover rates, and time to fill vacancies. For more, read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

But the sale of Our Lady of Fatima Hospital and Roger Williams Medical Center doesn’t fit into the nice, clean “mergers and acquisitions are bad” box. It’s neither an excellent decision nor a terrible decision for Rhode Island. What it is is complicated.

Read the full piece here.

Research for this article was supported by Arnold Ventures.

Recognizing the need, the Partnered Evidence-based Policy Resource Center (PEPReC) published a policy brief that delves into the significance of clinic efficiency. This brief also highlights PEPReC’s pilot program aimed at improving clinic efficiency. By collaborating with various VHA facility leaders at select facilities, the pilot program focused on facilitating transparency by reporting and sharing validated data. Read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

• Limiting media consumption, especially political content
• Setting boundaries on where and when you have political discussions
• Establishing policy to limit sensitive discussions in the workplace
• Getting involved with issues that matter to you

Read the whole piece here.

Sponsored by: Department of Public Health Sciences, University of Virginia School of Medicine
Submission deadline for abstracts: Monday 17 July 2024

Health Services Research (HSR) and the Department of Public Health Sciences, University of Virginia School of Medicine are partnering to publish a Special Issue on The Role of Health Services Research in Cancer Prevention and Control. The special issue will be edited by Kevin Schulman, MD, Roger Anderson, PhD, Xin Hu, PhD, and Asal Pilehvari, PhD.

Paradigm shifts in cancer screening such as mammography, colonoscopy, and Pap smears have been pivotal in detecting cancers at earlier and more treatable stages. Treatments including targeted therapies, immunotherapies, and precision medicine have prolonged disease-free intervals, improved overall survival, and enhanced quality of life for survivors. Interventions in the delivery and quality of palliative care and hospice utilization have improved the end-of-life experience. Health services research has contributed significantly to evaluating the effectiveness, accessibility, and implementation strategies of these screening programs, treatments, and interventions, guiding their integration into clinical practice.

Nonetheless, challenges persist in ensuring equitable access to high-quality cancer care for all. Disparities in cancer outcomes based on factors including socioeconomic status, sex, gender identification, race, ethnicity, disability, comoribidities, care delivery system, health policy, and geographical location remain a concern. Addressing these disparities and further improving cancer prevention and control strategies requires a comprehensive application of health services research.

Health services research can contribute to understanding how integrating innovative approaches of technology such as artificial intelligence (AI), predictive analytics, big data analytics, and evidence synthesis methodologies can improve informed decision-making across the cancer care continuum. Health services research can also inform policy innovations that promote access to care, and patient-centered care approaches. All present opportunities to further enhance cancer prevention and control and improve patient outcomes.

This special issue will include empirical studies that illuminate the application of health services research throughout the cancer care continuum, from prevention and early detection to treatment, survivorship, and end-of-life care. Examples of topic areas of interest include but are not limited to:

• Evaluation of cancer care quality indicators, cancer care utilization and economic outcomes, and/or organizational structures or designs associated with efficiency and effectiveness of cancer care delivery.
• Evaluation of the use of cutting-edge technologies, including AI and machine learning:
  • to evaluate and/or quantify cancer care quality, utilization, and outcomes; or
  • as a clinical application to improve personalized treatment decision, cancer care quality and utilization in real-world-applications, such as risk stratification, pattern recognition, or improved diagnostic accuracy.
• Generation of data-driven recommendations to address the access, cost or quality of cancer care for key stakeholders across the cancer control continuum, from prevention to end-of-life care, including but not limited to insurance companies, professional societies, health care providers, governments, patients and caregivers.

HSR is issuing a call for abstracts to invite paper submissions for this special issue. The deadline for initial submission of abstracts is 17 July 2024.  Abstracts may not exceed 300 words and must be formatted as indicated in the HSR Author Instructions (Section 2.4.2.2, keywords not necessary).

Abstracts will be evaluated by a multidisciplinary review panel. Evaluation criteria include:

• Quality, rigor, and originality
• Relevance to the special issue theme
• Clarity of writing and presentation.

Authors of abstracts that most closely match the criteria will be invited in August to submit full manuscripts in November 2024.

Invited manuscripts must follow the Author Instructions and undergo the same HSR peer review process as regular issue manuscripts. However, due to the strict timeline for publishing the special issue, the review and revision process will follow an expedited timeline. Authors must be prompt in returning revisions. Invited articles will be published online on acceptance. Some accepted articles might not be selected for the special issue but will be published in a regular issue.

The expected publication date for the special issue is March 2026.

To submit an abstract for consideration, please email it with the corresponding author’s contact information to hsr@aha.org. Include “Special Issue HSR in Cancer” in the email subject line.

Key dates for authors

Submission deadline for abstracts: 17 July 2024

Full manuscript invitation: 12 August 2024

Full manuscript deadline: 15 November 2024

Special issue publication date: March 2026

Questions? Please email Kelly Teagle at hsr@aha.org.

SHIP is a federal program that provides funding to states to counsel Medicare beneficiaries on coverage choices, eligibility, and costs. It’s overseen by the Administration for Community Living (ACL), which provides grants to states that are then often distributed to local organizations providing services through paid and volunteer counselors.

The ACL produces public reports that focus on state-level contact metrics within SHIP but do not include more granular information. To date, we haven’t known whether SHIP sites are located efficiently (i.e., in areas with high concentrations of Medicare beneficiaries) or equitably serve both low- and high-income beneficiaries. This data would help identify potential unmet needs for services, an effort that is required by the Medicare Improvements for Patients and Providers Act.

New Research

In a study published in the American Journal of Managed Care, evaluators from Boston University School of Public Health identified areas where in-person SHIP service expansion might be beneficial.

Using 27 state directories of SHIP sites (totaling over 1,500 sites) and population socioeconomic conditions, authors examined whether SHIP sites were disproportionately located in higher-income communities. SHIP sites were mapped to Zip Code Tabulation Areas (ZCTA), which allow for geographic analysis of zip codes.

To understand the characteristics of areas where SHIP counseling was more or less likely to be available, four types of geographical areas were compared:

1. ZCTAs with SHIP services;
2. ZCTAs without SHIP services but located in a county with SHIP services;
3. ZCTAs located in a county without SHIP services but where an adjacent county had SHIP services; and
4. ZCTAs located in a county without SHIP services and where no adjacent counties had SHIP services.

Linear regressions and t-tests were then used to evaluate whether SHIP counseling sites were disproportionately located in communities with higher incomes and/or fewer Medicare beneficiaries.

Findings

More than half of the ZCTAs included (63%) had a SHIP site within the ZCTA or surrounding county, a quarter (24%) only had a SHIP site in an adjacent county, and the remaining 13% did not have a SHIP within or in an adjacent county.

The authors also found that a disproportionate number of Medicare-aged eligible adults live in localities without a nearby SHIP site. Median household income and educational attainment were also lower in areas without in-person SHIP services.

Access to SHIP services may be affected by the availability of volunteer counselors, non-English services, education, and transportation options. This is especially true for beneficiaries living in low-income neighborhoods, which are more likely to be in rural areas and have more non-English speakers.

These findings only indicate associations between SHIP sites and the areas within which they’re located. The size of ZCTAs and counties also vary, so a SHIP site could be in the same county as an individual but still require a long drive to reach these services.

Conclusion

This study suggests that there may be inequities in where in-person SHIP services are located and potential unmet needs for service expansion. Although telephone counseling is always an option, access to in-person services is important for dually eligible individuals with complex health needs, those with hearing loss, limited English proficiency, or who need a caregiver or companion to help understand the information provided.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who support VA efforts to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

“When drugs receive accelerated approval, they go to market and companies immediately start profiting. The Office of the Inspector General found that Medicare and Medicaid spent over $18 billion in three years on drugs with accelerated approval but incomplete confirmatory clinical trials.”

Read the whole piece here.

Research for this article was supported by Arnold Ventures.

When the MISSION Act passed in 2018, one section of the law required the Veterans Health Administration (VHA) to conduct a two-year medical scribes pilot. The goal was to determine how medical scribes impact VHA clinic function. The pilot was implemented in emergency departments and cardiology and orthopedics clinics.

The Partnered Evidence-based Policy Resource Center (PEPReC) evaluated the pilot and, in 2023, published a policy brief on its findings. Read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

On The Health Care Blog, I write about how telehealth may inadvertently increase the risk of antibiotic overuse, contributing to antimicrobial resistance. Studies show higher antibiotic prescription rates during virtual consultations than during in-person visits, raising concerns about the quality of diagnoses and the influence of patient satisfaction on prescribing rates. This is a call for insurers, providers, and patients to work together to ensure antibiotics are prescribed and used responsibly.

Read my full piece here.

Oil pulling – swishing an unrefined oil in your mouth for 10-20 minutes to “pull” bacteria from the mouth has recently gained popularity on TikTok. It’s not a new concept though. Articles report that oil pulling first showed up in Ayurvedic medicine thousands of years ago.

Ayurvedic medicine is a traditional medicine practice that focuses on balance and natural remedies. It’s still practiced around the world, but the evidence for it is scattered and inconclusive. This is in part because many Ayurvedic practices claim to unilaterally cure dozens of ailments. Oil pulling, for instance, is said to cure 30 diseases.

Regardless of effectiveness, oil pulling has enjoyed cyclical popularity in modern times.

Anecdotally, oil pulling was first re-popularized in the 1990s during a presentation by Dr. Fedor Karach, although no record of him or the presentation can be found despite still being regularly cited. Oil pulling made its rounds again in the mid-2010s, popularized by celebrities like Gwyneth Paltrow and Shailene Woodley. At the time, how-to’s usually focused on swishing unspecific oils for arbitrary amounts of time.

Today, on TikTok, oil pulling is a commercial endeavor and Guru Nanda’s branded mouthwashes are the leading attraction. As opposed to ten years ago, the general sense now is that it’s better to buy a pre-made product. To date, just one internet storefront has sold over 1.7 million bottles of Guru Nanda’s oil pulling mouthwashes.

Just as in the past, modern claims of what oil pulling achieves are all over the place. Guru Nanda’s CEO has made an effort to clarify what their mouthwashes can do, but the company still benefits from the many misconceptions. TikTok sellers make claims of teeth strengthening and whitening and body “detoxification.” Plus, pitches for Guru Nanda products often show grotesque recreations of what was “pulled” from the person’s gums after use.

This is all likely an overrepresentation of what oil pulling actually does. But what is that exactly?

It’s hard to tell.

A lot of the research on oil pulling is low quality and hard to reproduce. Very small sample sizes plague existing studies, and large meta-analyses have a hard time determining statistical significance of any result. No articles demonstrate that oil pulling strengthens, whitens, or detoxifies teeth or the body.

At best, some studies show oil pulling may be associated with a decrease in counts of certain bacteria related to tooth decay. It’s also possible that some oils like coconut or sesame are more effective than others.

But even if oil pulling does something, it’s not very user friendly. For one, users must swish for 10-20 minutes; this can lead to jaw strain and is quite time-consuming. Plus, users must spit the oil out in the trash rather than the sink – oil clogs drains.

To make matters worse, oil pulling research doesn’t stand against research on traditional antiseptic, teeth whitening, or fluoride-based mouthwashes.

In a review of 28 systematic reviews and 18 meta-analyses on mouthwash, all found it inhibited and reduced plaque and gingivitis. There was no consensus on what mouthwash was best, but some did have distinct benefits over others, like strengthening teeth (fluoride) or eliminating more microorganisms (antiseptic and prescription).

Regarding usability, standard mouthwashes only need to be swished for 30-60 seconds to be effective, and they can be spit right into the sink. Plus, standard mouthwashes are the same no matter where you buy them. (The number of counterfeit Guru Nanda products have soared, creating a potentially dangerous market for consumers.)

Consumers want what’s best for their health, and sellers on TikTok are ready to take advantage of that. All that we know and don’t know about oil pulling tells us that rinsing with standard mouthwash takes less effort, costs less, and is more effective. Regardless of the product, all consumers deserve concrete evidence that it actually works, and oil pulling just doesn’t meet the mark.

There are 67 million Americans currently on Medicare. Ninety percent of them are over 65 and the country’s population is aging quickly. By 2040, it’s estimated that 80 million Americans will be over 65. That’s an extra 13 million people on Medicare’s rolls.

It’s simple math: More recipients means more spending. But the catch is Medicare is already spending a lot of money and how fast it’s spending is alarming.

This presents an access to care problem not only for aging adults and their families, but also for our health care system to successfully serve those patients. While there are home-based primary care and community programs that reach homebound individuals with dementia, the demand for them far outstrips supply.

There’s incentive, then, to better understand what factors contribute to becoming homebound for people living with dementia beyond well-established contributors like age or socioeconomic status.

Recent Study

Collaborators from the Icahn School of Medicine at Mount Sinai, Johns Hopkins University School of Medicine, Johns Hopkins University School of Nursing, and Boston University School of Public Health published a study investigating factors that contribute to someone newly diagnosed with dementia becoming homebound.

Authors followed a cohort of 939 individuals aged 65 or older newly diagnosed with dementia in the National Health and Aging Trends Study (NHATS) from 2011 to 2018. Participants were classified as either homebound (never or rarely leaving home) or nonhomebound based on self and proxy reporting.

Investigators performed two different analyses to examine factors contributing to becoming homebound in individuals with dementia. First, they used chi-square and Student t tests to investigate differences between those who were homebound and nonhomebound when initially diagnosed with dementia. Those participants were followed for a median of four years after initial participation to identify changes in homebound status over time.

Authors also used a Fine-Gray subdistribution hazard model to identify factors contributing to becoming homebound over time among those who were nonhomebound when they initially received their dementia diagnosis.

Findings

Authors found that about 20 percent of this nationally representative sample were homebound at the time of dementia diagnosis. Additionally, these homebound individuals were more likely to be Hispanic, have Medicaid and lower income, and have more chronic conditions and depression than nonhomebound individuals.

Those who were homebound from the start were also more likely to need more assistance with activities of daily living (e.g., eating, dressing) and receive more hours of care from a caregiver per week. This group was more likely than nonhomebound individuals to receive paid help, live in an assisted living facility, and live in a metropolitan area.

When looking at the individuals who were nonhomebound at the time of dementia diagnosis, between eight to 11 percent became homebound in any given year of follow-up between 2011 to 2018. Authors found that individuals living in an assisted living facility and Hispanic ethnicity were more likely to become homebound.

Conclusion

Investigators acknowledged several limitations of this study. First, homebound status can be fluid, and annual, brief assessments may fail to capture that fluidity. Additionally, the National Health and Aging Trends Study definition of dementia is not equivalent to a clinical assessment, so some cohort participants may instead have had more transient cognitive impairment.

The study’s findings demonstrate that most individuals newly diagnosed with dementia are nonhomebound but may become homebound over time, and this risk is elevated among those residing in an assisted living facility or being of Hispanic descent. These findings underscore the need to examine if and how assisted living facilities meet the needs of those who are newly diagnosed with dementia. Additionally, further research is needed to identify the preferences of different groups and their options for culturally sensitive care.

In general, identifying contributing factors to becoming homebound for individuals newly diagnosed with dementia is an important first step for preventing or reducing this phenomenon.

In 2020, over 260,000 immigrants with undergraduate health care degrees such as nursing were underemployed. How might this untapped group of health professionals have buoyed the workforce during the COVID-19 pandemic if they’d been licensed in the U.S.?

Read the whole piece here.

Research for this article was supported by Arnold Ventures.

The Partnered Evidence-based Policy Resource Center (PEPReC) published a policy brief on the qualitative research of one of PEPReC’s doctoral students, examining the roles of and relationship between VHA urgent care clinics and VHA emergency departments. Read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

The Partnered Evidence-based Policy Resource Center (PEPReC) published a policy brief exploring whether RCI is associated with changes in the proportion of VHA specialty care referrals completed by community providers (rather than VHA providers) and changes to mean appointment waiting times for VHA and community providers. Read the full brief here.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

The challenges are even greater for those receiving home- and community-based long-term supports and services. Understanding the relative benefits of self-directed services compared to other paid home- and community-based personal care services in rural areas is of particular interest to Veterans Health Administration (VHA) as nearly three million Veterans aged 65 years and older live in rural areas.

An example of a self-directed program, the Veteran Directed Care (VDC) program helps isolated, aging Veterans and their caregivers develop a spending plan and hire people of their choosing (including family members or neighbors) or purchase equipment or home modifications to ensure the Veteran can live independently at home. Home-based workers or paid family members provide assistance with daily activities (e.g., eating, grooming, getting dressed).

New Evidence:
In January 2022, evaluators from the Partnered Evidence-based Policy Resource Center (PEPReC) published a paper titled “Fewer Potentially Avoidable Health Care Events in Rural Veterans with Self-Directed Care versus Other Personal Care Services” in the Journal of the American Geriatrics Society. The objective was to understand whether rural and urban Veterans used less VHA-paid community or in-house nursing home, acute, or emergency department (ED) care following enrollment in VDC, compared to recipients of other VHA-paid personal care services.

Methods:
This retrospective observational study included over 37,000 Veterans receiving VHA-paid home- and community-based long-term care services in fiscal year 2017. Using VHA administrative data on health status and health care use, evaluators compared the differences in outcomes from pre- to post-enrollment in the VDC program and other VHA-paid personal care services programs for Veterans living in rural and urban areas. The baseline period was 12 months prior to service initiation and the outcome period was 12 months after service initiation.

They used logistic regression models stratified by location (rural/urban) to estimate the relationships between VDC receipt and utilization of VHA-paid community or in-house hospital, nursing home, and ED services. Sensitivity analyses also matched Veterans on several covariates (e.g., age, dementia, comorbidities, etc.).

Findings:
The authors found that both rural and urban VDC recipients had fewer VHA-paid community and in-house nursing home admissions, compared to recipients of other VHA-paid personal care services. Rural VDC enrollees had fewer VHA-paid community and in-house acute care admissions and VHA-paid community and in-house ED visits, unlike urban VDC enrollees who had no significant changes in admissions or ED visits before and after service initiation.

In terms of demographics, VDC recipients were younger, had a higher VHA priority status (significant health issues and/or disabilities; high financial need), and were more likely to have sustained a spinal cord injury compared to recipients of other VHA-paid personal care services programs.

Conclusion:

This study had a few limitations. For example, the data did not include non-VHA paid (e.g., paid for out of pocket or by private insurance) long-term care services and evaluators did not compare administrative costs between the VDC program and other VHA-paid personal care services programs. The study was also unable to determine the degree to which improved health outcomes were due to the VDC program or the presence of a strong family caregiver.

This study suggests that the VDC program is an appropriate and beneficial care option for Veterans with multiple chronic conditions and/or cognitive impairment and may be particularly beneficial for Veterans living in rural areas. It also has the potential to reduce use of VHA-paid community and in-house health care more than other VHA-paid personal care services. Future studies should continue to explore the degree to which non-VHA paid care and nursing home admissions change among VDC recipients.

PEPReC, within the Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative (QUERI), is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who support VA efforts to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

The Partnered Evidence-based Policy Resource Center (PEPReC) published a policy brief summarizing the results of their recent STORM evaluation. They found that, for high-risk Veterans, a mandated case review with STORM was associated with a decreased probability of mortality. They also describe the effectiveness of how STORM can be used as a risk mitigation intervention, suggesting the potential of predictive analytic tools to improve patient outcomes. Read the full brief here.

PEPReC, within Veterans Health Administration and funded in large part by the Quality Enhancement Research Initiative, is a team of health economists, health services and public health researchers, statistical programmers, and policy analysts who engage policymakers to improve Veterans’ lives through evidence-driven innovations using advanced quantitative methods.

Many PCPs don’t feel comfortable assessing cognition. A 2020 survey conducted by the Alzheimer’s Association found that 40% of PCPs are “never” or “only sometimes” comfortable diagnosing Alzheimer’s disease and other dementias and relaying those diagnoses to patients. In the same survey, almost all PCPs said they wait for their patients to bring up cognitive concerns rather than proactively discussing them.

Read the whole piece here.

Research for this article was supported by Arnold Ventures.

Thank to the Commonwealth Fund for supporting the production of this video.

Sponsored by: Department of Public Health Sciences, University of Virginia School of Medicine
Submission deadline for abstracts: Monday 17 June 2024

Health Services Research (HSR) and the Department of Public Health Sciences, University of Virginia School of Medicine are partnering to publish a Special Issue on The Role of Health Services Research in Cancer Prevention and Control. The special issue will be edited by Kevin Schulman, MD, Roger Anderson, PhD, Xin Hu, PhD, and Asal Pilehvari, PhD.

Paradigm shifts in cancer screening such as mammography, colonoscopy, and Pap smears have been pivotal in detecting cancers at earlier and more treatable stages. Treatments including targeted therapies, immunotherapies, and precision medicine have prolonged disease-free intervals, improved overall survival, and enhanced quality of life for survivors. Interventions in the delivery and quality of palliative care and hospice utilization have improved the end-of-life experience. Health services research has contributed significantly to evaluating the effectiveness, accessibility, and implementation strategies of these screening programs, treatments, and interventions, guiding their integration into clinical practice.

Nonetheless, challenges persist in ensuring equitable access to high-quality cancer care for all. Disparities in cancer outcomes based on factors including socioeconomic status, sex, gender identification, race, ethnicity, disability, comoribidities, care delivery system, health policy, and geographical location remain a concern. Addressing these disparities and further improving cancer prevention and control strategies requires a comprehensive application of health services research.

Health services research can contribute to understanding how integrating innovative approaches of technology such as artificial intelligence (AI), predictive analytics, big data analytics, and evidence synthesis methodologies can improve informed decision-making across the cancer care continuum. Health services research can also inform policy innovations that promote access to care, and patient-centered care approaches. All present opportunities to further enhance cancer prevention and control and improve patient outcomes.

This special issue will include empirical studies that illuminate the application of health services research throughout the cancer care continuum, from prevention and early detection to treatment, survivorship, and end-of-life care. Examples of topic areas of interest include but are not limited to:

• Evaluation of cancer care quality indicators, cancer care utilization and economic outcomes, and/or organizational structures or designs associated with efficiency and effectiveness of cancer care delivery.
• Evaluation of the use of cutting-edge technologies, including AI and machine learning:
  • to evaluate and/or quantify cancer care quality, utilization, and outcomes; or
  • as a clinical application to improve personalized treatment decision, cancer care quality and utilization in real-world-applications, such as risk stratification, pattern recognition, or improved diagnostic accuracy.
• Generation of data-driven recommendations to address the access, cost or quality of cancer care for key stakeholders across the cancer control continuum, from prevention to end-of-life care, including but not limited to insurance companies, professional societies, health care providers, governments, patients and caregivers.

HSR is issuing a call for abstracts to invite paper submissions for this special issue. The deadline for initial submission of abstracts is 17 June 2024.  Abstracts may not exceed 300 words and must be formatted as indicated in the HSR Author Instructions (Section 2.4.2.2, keywords not necessary).

Abstracts will be evaluated by a multidisciplinary review panel. Evaluation criteria include:

• Quality, rigor, and originality
• Relevance to the special issue theme
• Clarity of writing and presentation.

Authors of abstracts that most closely match the criteria will be invited in August to submit full manuscripts in November 2024.

Invited manuscripts must follow the Author Instructions and undergo the same HSR peer review process as regular issue manuscripts. However, due to the strict timeline for publishing the special issue, the review and revision process will follow an expedited timeline. Authors must be prompt in returning revisions. Invited articles will be published online on acceptance. Some accepted articles might not be selected for the special issue but will be published in a regular issue.

The expected publication date for the special issue is March 2026.

To submit an abstract for consideration, please email it with the corresponding author’s contact information to hsr@aha.org. Include “Special Issue HSR in Cancer” in the email subject line.

Key dates for authors

Submission deadline for abstracts: 17 June 2024

Full manuscript invitation: 1 August 2024

Full manuscript deadline: 1 November 2024

Special issue publication date: March 2026

Questions? Please email Kelly Teagle at hsr@aha.org.