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Origins In Oregon: The Alternative Payment Methodology Project

April 14th, 2014

Editor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. The authors of this post are part of the team evaluating the Oregon model.

How the country pays for health care is currently at odds with its vision of how health care should be delivered. Traditional fee-for-service health care payments are linked to the volume of visits, rather than the quality of patient-centered care.

To unlink payment from the volume of services provided and begin aligning it with value, Oregon recently launched the Alternative Payment Methodology (APM) demonstration project, where participating community health centers (CHCs)—aka federally qualified health centers—no longer earn revenue based on the number of individual patient seen. Instead, community health centers will receive a monthly payment based on the size and composition of their patient population, shifting the paradigm from the number of doctor visits to the provision of high-quality, team-based, patient-centered care.

APM is being piloted at three Oregon Community Health Centers: Virginia Garcia Memorial Health Center, Mosaic Medical, and OHSU Family Medicine at Richmond. The clinics are receiving technical assistance from the Oregon Primary Care Association (OPCA) and other community, regional and national partners.

With funding from the Robert Wood Johnson Foundation, a team of researchers from Oregon Health and Science University and OCHIN, one of the nation’s largest health information networks, is investigating the impact of APM on the delivery of primary care in safety-net populations. In addition to regular posts like this one, the research team will also share lessons learned and perspectives from key stakeholders on Frontiers of Health Care.

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Health Reform And Criminal Justice: Advancing New Opportunities

April 1st, 2014
by Chris Fleming

Community Oriented Correctional Health Services (COCHS) and Health Affairs invite you to join thought leaders from public safety, health care, philanthropy, and all levels of government to further explore the intersection of health reform and criminal justice. As implementation of the Affordable Care Act continues, it is time to take stock of how far we have come in addressing the needs of the jail population through policy and planning, and to set our direction for the future.

This national event will take place on Thursday, April 3, from 8:00 a.m. to 4:00 p.m., at the Columbus Club in Union Station, Washington, D.C. It is being organized with support from the Robert Wood Johnson Foundation, the Jacob & Valeria Langeloth Foundation, and Public Welfare Foundation. Registration for in-person attendance is closed, but a live webcast is available.

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Mental Illness In America’s Jails And Prisons: Toward A Public Safety/Public Health Model

April 1st, 2014
by Dean Aufderheide

Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health. 

Mental Illness in America’s Jails and Prisons

The United States continues to have one of the highest incarceration rates in the world, with 5 percent of the world population, but nearly 25 percent of the world’s prisoners.  Inmates are spending more time behind bars as states adopt “truth in sentencing laws,” which requires inmates to serve 85 percent of their sentence behind bars.

In 2012, about 1 in every 35 adults in the United States, or 2.9 percent of adult residents, was on probation or parole or incarcerated in prison or jail, the same rate observed in 1997.  If recent incarceration rates remain unchanged, an estimated 1 out of every 20 persons will spend time behind bars during their lifetime; and many of those caught in the net that is cast to catch the criminal offender will be suffering with mental illness.

Nearly a decade ago, I wrote an article with Patrick Brown titled “Crisis in Corrections: The Mentally Ill in America’s Prisons.”  It was about the alarming growth in the number of mentally ill individuals behind bars.  Since then, it has been shown that about 20 percent of prison inmates have a serious mental illness, 30 to 60 percent have substance abuse problems and, when including broad-based mental illnesses, the percentages increase significantly. For example, 50 percent of males and 75 percent of female inmates in state prisons, and 75 percent of females and 63 percent of male inmates in jails, will experience a mental health problem requiring mental health services in any given year.

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Embarking On A New Journey With Health Affairs

March 31st, 2014
by Alan Weil

I am delighted to be taking on the role of editor-in-chief of Health Affairs. This is a dynamic time in all aspects of health and health care: insurance coverage expansions, delivery system changes, and growing attention to population health.  Building upon thirty-three years of peer-reviewed scholarship, Health Affairs will continue to serve as the nation’s primary resource for the health policy community.

My goals for Health Affairs coalesce around a single theme: broadening the reach of the journal.

Health Affairs is strong in the core health policy community, but our scholarship is relevant to myriad actors in the one-sixth of the United States economy represented by health care.  My goal is to broaden our engagement with the worlds of law, finance, design, and many others.

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A March Madness Health Wonk Review

March 27th, 2014
by Chris Fleming

Welcome to the “March Madness” edition of the Health Wonk Review. The NCAA college basketball tournament seemed like a natural theme for a health care policy blog post: huge amounts of money floating around in ways that only sometimes correlate with performance, and head-to-head match-ups that can yield results no one expected (though in the tournament those unexpected results produce quicker and more certain changes than is often the case in health care).

We considered illustrating each blog post with pictures of a college basketball team from the author’s home state celebrating a championship, but we thought better of that after seeing this cautionary tale. So let’s get to the great collection of posts from our Wonkers.

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HA Web First: New Medicaid Recipients Healthier Than Pre-ACA Enrollees

March 26th, 2014
by Tracy Gnadinger

The Affordable Care Act (ACA) gives states the option of expanding Medicaid coverage to individuals and families with incomes of up to 138 percent of the federal poverty level. A new study, being released today as a Web First by Health Affairs, used simulation methods to compare nondisabled adults enrolled in Medicaid before the ACA with newly eligible adults and those previously eligible but not enrolled in the program.

According to the study’s analysis, both the newly eligible and those not previously enrolled were healthier than the pre-ACA Medicaid enrollees. Authors Steven Hill, Salam Abdus, Julie Hudson, and Thomas Selden found that the pattern of results was similar for physical and mental health. They also determined that in states not expanding Medicaid under the ACA, adults in the income range for the law’s Medicaid expansion were healthier than pre-ACA enrollees.

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Health Information Exchange In NYC Jails: Early Policy Challenges

March 20th, 2014
by Michelle Martelle

Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health. For more on jails and health information technology in particular, see here, here, and here.

New York City has the second largest jail system in the United States, with an average daily census of approximately 12,000 and 80,000 annual admissions. It is well documented that the population that cycles in and out of US jails each year is statistically sicker than the general population and therefore would benefit from greater care coordination between correctional and community settings. The Department of Health and Mental Hygiene’s Bureau of Correctional Health Services (CHS) is responsible for the care delivered in all 12 NYC jail facilities. The mission of CHS is to provide a community standard of care based on three core frameworks; patient safety, population health and human rights.

As part of this mission, CHS implemented a full electronic health record (EHR) system starting in 2008, completing the implementation of the final facility in 2011. One of the most promising features of EHRs is the ability to share information electronically to facilitate care coordination, referred to as Health Information Exchange (HIE).  Preliminary research of the use of HIE in community based settings is encouraging, with the use of HIE in the Emergency Department resulting in 30 percent fewer admissions and use in ambulatory settings resulting in 56 percent fewer readmissions within 30 days of hospital discharge. (Results pending review; presented 11/14/13 at NYeC Digital Health Conference by Center for Healthcare Informatics and Policy (CHiP).) In the hopes of realizing the full benefits of its EHR system, CHS recently launched an HIE pilot in its women’s facility.

The goals of integrating HIE into jail-based health care are to inform the care patients receive while incarcerated and to coordinate care upon release.  Currently, CHS has access to two external sources of information: BHIX, a Regional Health Information Organization (RHIO) that recently merged with Healthix and now includes patient data from some major hospital systems and community providers in parts of Brooklyn, Queens and Long Island; and PSYCKES, a Medicaid claims-based data warehouse that includes claims information (both medical and mental health) on patients who have had a substance abuse or mental health diagnosis and/or substance abuse or mental health treatment within the last five years.

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The New Nutrition Facts Panel: Public Health Improvement Or Distraction?

March 19th, 2014
by Brian Elbel

Last month, the United States Food and Drug Administration announced long awaited proposed changes to the Nutrition Facts Panel (NFP), the nutrition information found on the back of packaged foods and beverages. The NFP is required to be on all packaged foods, with significant regulations on what is presented and how the information can be presented. Initially mandated in the first Bush Administration, the NFP offers a clear and consistent manner of presenting nutrition information—at least for those with the time and nutrition knowledge to benefit from the information.

The key questions behind the proposed changes are: will they be successful in altering consumer behavior, how might they be improved, and what overall role might they play in obesity prevention?

The NFP is clearly a source from which those already motivated and knowledgeable can easily access information and a base on which to build future approaches to addressing obesity. Put differently, this information will only work if people actively, directly choose to turn the package over, engage in information, and push past the many impulses pulling them towards the less healthy foods. The compelling nature of unhealthy foods means that individuals have to be particularly motivated, or the nutrition information has to be particularly compelling.

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Neighborhood Grocery Stores Combat Obesity, Improve Food Perceptions

March 12th, 2014
by Yael Lehmann

The Cummins et al article “New Neighborhood Grocery Store Increased Awareness of Food Access but Did Not Alter Dietary Habits or Obesity,” published in the February issue of Health Affairs, generated considerable media attention, with headlines claiming that grocery stores do not contribute to healthy diets or reductions in obesity.  However, the study offered no conclusive proof showing that access to grocery stores is not a part of the solution to preventing obesity.  In fact, the study showed clear signs of promise that the intervention was working in key aspects during the short time the researchers collected data.  Within just a few months after the new supermarket opened, for example, researchers documented significant improvement in residents’ perceptions about the choice and quality of fresh fruits and vegetables, along with improvements in their perception of healthy food accessibility.

The subject of the study, the Fresh Grocer in North Philadelphia, is a beautiful store with a bountiful fresh produce section. The supermarket, which is now thriving in one of the poorest neighborhoods in the country, was built from the ground up after a 15-year hiatus in which the surrounding community had no grocery store. Its opening has revitalized a historic African-American owned shopping plaza and reinvigorated the local neighborhood’s retail economy.

Has the store reduced the rate of obesity among local residents? This is a crucial question, but one that cannot be adequately deduced from the present study. All we know from this study’s findings is that obesity rates did not change significantly during the first six to nine months after the store’s opening – not surprising, given the many decades of gradual changes in eating habits that have led to the obesity epidemic.

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How Will California’s Penal System Respond To The ‘Perfect Storm’?

March 7th, 2014
by Jonathan Simon

Editor’s note: In addition to Jonathan Simon (photo and bio above), this post is coauthored by Daniel Mistak, a graduate student in Jurisprudence and Social Policy at the University of California, Berkeley. He previously earned his juris doctorate from University of California, Berkeley, School of Law. Prior to law school he attained a master’s degree in philosophy, with a focus in bio-ethics, and a master’s degree in genetics and cell biology. This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health.

California’s system of incarceration is in the midst of sweeping changes. Recent shifts in state and federal law, motivated and bolstered by Supreme Court decisions, have created a perfect storm for institutional change. But as with any storm, it can be difficult to predict what can be done to prepare and what will be left when the clouds clear.

What caused this perfect storm in California? In 2011, the Supreme Court found in Brown v. Plata that California’s prisons could not meet the mental and physical health needs of the inmates because of prison overcrowding. To avoid violating the VIII Amendment’s prohibition on cruel and unusual punishment, the Court mandated that California prisons decrease their over-crowded prison populations to 137.5 percent of their design capacity within two years. Governor Jerry Brown signed into law Assembly Bill 109 (‘Realignment’) to facilitate this transition.

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New Health Policy Brief: Geographic Variation In Medicare Spending

March 6th, 2014
by Tracy Gnadinger

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation describes geographic variation in Medicare spending. Data from the Centers for Medicare and Medicaid Services (CMS) show that in 2012 Medicare spent an average of $9,503 nationally per beneficiary, ranging from $15,957 in Miami, Florida, to $6,569 in Grand Junction, Colorado.

This brief looks at the factors that may be driving these variations, including the amount Medicare pays for services, the health status of beneficiaries, the types of services provided to a region’s population, and whether the local spending patterns are consistent with the spending on patients with private insurance.

As policy makers continue to find ways to improve quality in health care and eliminate unnecessary spending, a better understanding of geographic variation in Medicare spending has the potential to help achieve the so-called Triple Aim: better health, better health care, and lower costs.

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Empathy: The First Step To Improving Health Outcomes

February 25th, 2014
by Aubrey Hill

Health care providers across the country are diagnosing, prescribing, and bandaging, but for many patients, that may not be enough to improve health.

Health care providers have a unique opportunity to improve patient health outcomes by practicing empathy for their patients and complex life circumstances. Empathy is defined as, “the ability to understand and share the feelings of another,” and studies have shown that empathy is an important skill for health care providers and is significantly associated with improved clinical outcomes.

Social Determinants of Health

Social and environmental factors (also known as social determinants of health) have a larger impact on health than medical intervention. Social determinants of health such as income, education, food and housing access, and racial and ethnic inequality affect the health of a person from birth to death, and can be difficult to understand and control for within a health care visit. Due to a lack of social resources, patients are unable to fully comply with treatment plans, follow provider instructions, return for a follow-up visit, and ultimately, experience good health outcomes. A few specific examples include: problems accessing care without insurance, finding funds to cover needed services or prescriptions, securing transportation to get to and from appointments on time, or speaking the same language as a health care provider.

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Jeffrey Brenner On GrantWatch: The Future For Population Health

February 21st, 2014
by Tracy Gnadinger

In a recent GrantWatch Blog post, Jeffrey Brenner raises the question, “What if Thomas Edison had to write grant proposals to invent the light bulb?” Brenner is a MacArthur fellow, medical director of the Urban Health Institute, and executive director and founder of the Camden Coalition of Healthcare Providers.

Brenner uses the Edison analogy to look at current grant funding and population health.

Since 1945 the National Institutes of Health (NIH), a federal government agency that funds medical research, has spent $547 billion dollars to cure disease and push the frontiers of medical knowledge. This spending has been supplemented by funding from private foundations. Sadly, despite all of this spending we have little understanding of how to deliver better care at lower cost to every American. At best, in the field of population health, we have a few light bulbs that stay lit for an hour or two, but we lack even basic knowledge to drive this field forward.

With 85 million baby boomers in the midst of retiring and a health care system that consumes 18 percent of our economy, it is not a small problem. We do not understand the fundamental drivers of health care utilization; the basic rules for designing and implementing effective interventions; the best ways to use data to plan, implement, manage, and evaluate interventions; nor how to train staff to run and lead these interventions. Why the lack of progress?

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A Call For A Deeper, Cross-Sector Examination Of The Hunger-Health Link

February 18th, 2014
by Sharon Feuer Gruber

Evidence continues to build that hunger should be approached in some measure as a public health issue, and Hilary Seligman of the University of California, San Francisco and co-authors contribute to this trove of research in the January Health Affairs journal article “Exhaustion of Food Budgets at Month’s End and Hospital Admissions for Hypoglycemia.” Hunger-relief organizations across the country can attest to the long-observed pattern of a rise in demand for food distribution at the end of the month. In fact, meal providers and food pantries tailor their decisions about purchasing, staffing, and program design around the uptick in client need as the month comes to a close. Seligman et al correlate this surge in demand with an increase in hospitalization among low-income individuals the fourth week of the month (a 27 percent increase in hospitalization among low-income individuals for hypoglycemia, according to their study). These findings suggest the profound need to devise food policies and programs with public health in mind.

However, to effectively address hunger as a public health issue in particular, hunger-relief organizations, community health organizations, universities, government, and others must take a collective impact approach. This cross-sector approach to complex, systemic social issues fosters coordination among such groups so they can have a greater positive impact than if they were to operate independent of one another; it is being turned to with increasing frequency to create large-scale social change. Policy can encourage a collective impact approach; it is already happening in the case of hospitals, which under Section 3025 of the Affordable Care Act, are penalized a portion of their Medicare reimbursement if they have a higher than expected rate of acute care readmissions within 30 days of discharge. (See 42 CFR part 412P.)

New community and regional partnerships are beginning to develop in part because of this incentive. The Atlanta Community Food Bank, for example, which distributed 21.8 percent more food and grocery items this past fiscal year than the last, is in early discussions with the Atlanta Regional Commission, the city health department, regional hospitals, and universities. Together they aim to confront the need for better health education and sustained access to nutritious food among low-income individuals discharged from hospitals for chronic, diet-related disease like diabetes, congestive heart failure, and associated complications. This is precisely the type of alliance that could help address the issues laid out in “Exhaustion of Food Budgets…” Policymakers need to build on this kind of ingenuity taking place in the field – especially if those in the field are expected to do more with less. That will certainly be the case, as the recently enacted Farm Bill imposes $8.6 billion in cuts to SNAP over the next 10 years, increasing demand on hunger-relief organizations even further.

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Health Affairs “Community Development And Health” November 2014 Theme Issue: Announcement

February 18th, 2014
by Chris Fleming

Health Affairs plans to publish an issue on the topic of “Community Development and Health” in November 2014. Details on the upcoming issue are available here. The deadline for submissions is June 1, 2014.

Papers will be competitively reviewed by editors, and, for those that are selected for external review, outside experts. We will make publication decisions based on these selection processes.

If you are interested in submitting a paper, please review our submissions procedures and guidelines. Contact senior deputy editor Sarah Dine ( or executive editor Don Metz ( with any questions.

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The PRIDE Initiative: Building The Capacity And Scalability Of Integrated Managed Care Plans

February 13th, 2014

As health care costs have increased, the challenges of managing complex chronic conditions, compounded by frailty, disability, mental illness, poverty, or limited education, have become more pressing. Correspondingly, individuals, families, and government entities alike are increasingly frustrated with the current health care system. Even people like me – a seasoned health services researcher working in a large integrated delivery system – find it difficult to assemble and coordinate an array of medical and long-term services and supports (LTSS) to meet our family members’ preferences and needs.

Coordinating services for my own mother – an upbeat 94-year old with considerable financial resources but advancing dementia, frailty, blindness, and a variety of health and LTSS needs – requires more of my time and that of other family members.  People with similar needs but fewer resources often face far more daunting problems in trying to understand diverse Medicare and Medicaid benefits, access appropriate services, and navigate among multiple health and LTSS providers that rarely communicate with each other.

Below I describe the early work of the PRIDE consortium, a small group of seven high potential health care organizations (CareSource, OH; Commonwealth Care Alliance, MA; iCare, WI; Health Plan of San Mateo, CA; Together4Health, IL; UCare, MN; and VNSNY CHOICE , NY) that aim to provide access to genuinely integrated medical and behavioral health and LTSS for people dually eligible for Medicare and Medicaid. The backdrop for PRIDE (Promoting Integrated Care for Dual Eligibles) is the new federal-state effort to align the Medicare and Medicaid programs and enroll high-needs, high-cost dually eligible beneficiaries in integrated health care entities that will offer better coordinated, more consumer-centric and lower-cost care. At the federal level, the Centers for Medicare & Medicaid Services (CMS) is the chief honcho for efforts to harmonize the workings of Medicare and Medicaid, test innovative payment and service delivery models, and reduce expenditures.

In 2011, CMS awarded contracts of up to $1 million to each of fifteen states to design coordinated care demonstrations involving capitation arrangements or fee for service entities.  Additionally, eleven states (plus those that received the $1 million planning awards) submitted proposals to participate in CMS’s “financial alignment initiative,” intended to improve alignment between Medicare and Medicaid policies affecting care for dual eligibles.  By September 2013, CMS had signed Memorandums of Understanding (MOU’s) with seven states to pursue coordinated care demonstrations, while others’ MOU’s were in the pipeline.

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Encouraging Nonprofit Hospitals To Invest In Community Building: The Role Of IRS ‘Safe Harbors’

February 11th, 2014

Hospitals as public health actors. A notable development in public health policy is the growing emphasis on community health improvement as part of the community benefit activities required of nonprofit hospitals that seek federal tax exempt status under §501(c)(3) of the Internal Revenue Code. Key industry leaders, such as the Catholic Health Association, have sought to increase the role of hospitals as public health actors. A report by the Hilltop Institute recognizes the potential link between hospitals’ community benefit expenditure activities and community health and describes states that have sought to involve hospitals in health planning to improve public health.

Two important policy developments have breathed further life into the effort to emphasize public health investments as part of a community benefit strategy. This post reviews these policy advances and proposes that the Internal Revenue Service (IRS) establish “safe harbors” describing in advance certain evidence-based investments by nonprofit hospitals in their communities that will automatically count as required community benefit activities.

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The Changing Health Care World: Trends To Watch In 2014

February 10th, 2014
by Susan DeVore

While today’s news is bombarding us with headlines about, the Affordable Care Act isn’t just about insurance coverage. The legislation is also about transforming the way health care is provided. Consequently, it has ushered in new competitors, services and business practices, which are in turn generating substantial industry shifts that affect all players along healthcare’s value chain. Following are some of the top trends that our alliance is preparing for in 2014:

Chronic Care, Everywhere. It’s no secret that providers are moving quickly to implement accountable care organizations (ACOs). Recently, the Premier healthcare alliance released a survey of hospital executives projecting that ACO participation will nearly double in 2014. As providers work to improve their way to shared savings payments, look for a more intensive focus on the biggest health care consumers: those with multiple chronic conditions.

Since each chronic condition increases costs by a factor of three, managing this population is the sweet spot for the ACO, and the deepest pool from which to pull savings. To do it, an increasing number of providers will deploy Ambulatory Intensive Care Units (A-ICUs) or patient centered medical homes as part of their ACO, which will be charged with better managing chronic conditions exclusively within a clinically integrated, financially accountable primary care practice. As part of the approach, providers will develop care pathways for better managing chronic conditions and behavioral health needs, with an eye toward lowering hospital utilization, including inpatient bed days, length of stay, admissions, readmissions, and ED visits.

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GrantWatch: Zip Code Overrides DNA When It Comes to Health

February 4th, 2014
by Tracy Gnadinger

This month on GrantWatch Blog, Anne Warhover, president and CEO of the Colorado Health Foundation, expands on the recommendations released last month from the Robert Wood Johnson Foundation (RWJF)’s Commission to Build a Healthier America (of which Warhover was a commissioner). For more on the report, see the Health Affairs Blog post.

In “Zip Code Overrides DNA Code When It Comes to a Healthy Community,” Warhover looks at the impact of a person’s environment on health.

Everyone wants to live a long and healthy life. Yet one-fifth of all Americans live in environments that compromise their health—where there are no sidewalks or trails for people to walk and bike; where there are no playgrounds or parks for children to play; where crime and violence discourage not only outdoor activity, but also social interaction; and where communities lack affordable access to fresh fruits and vegetables.

In fact, when it comes to your health, your zip code matters more than genes, writes Warhover. The recommendations of the RWJF Commission raises awareness of this issue and suggests new priorities that include “investments in our youngest children, encouraging leaders in different sectors to work together to create communities where healthy decisions are possible, and broadening the mission of health care providers beyond treatment.”

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New Health Affairs Issue: Successes And Missing Links In Connected Health

February 3rd, 2014
by Chris Fleming

Health Affairs’ February issue focuses on the current evidence and future potential of connected health — encompassing telemedicine, telehealth, and mHealth. The importance of connected health is sure to grow as more Americans gain access to health care and new, team-based models seek to provide better quality care in more efficient ways. The issue offers a variety of articles that explore what can entice hospitals, health systems, and individual providers to embrace telehealth, as well as the policy solutions that can better facilitate adoption across the health care system:

Want to increase telehealth adoption among U.S. hospitals? Look to state legislatures. Julia Adler-Milstein of the University of Michigan School of Information and co-authors emphasize that state policies are influential. According to their findings, states that wish to encourage the use of telehealth should promote private payer reimbursement and relax licensure requirements.

Overall, Adler-Milstein and coauthors found that 42 percent of US hospitals had adopted telehealth by late 2012, with significant variation across the country: Alaska was the highest with 75 percent, and Rhode Island had minimal adoption.

Market forces and individual hospital features also influence telehealth adoption rates. Factors that positively influence adoption rates include serving as a teaching hospital, being part of a larger system, having greater technological capacity, and higher rurality. Factors negatively affecting adoption include high population density, being for-profit, and operating in a less competitive market.

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