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The 2014 GME Residency Match Results: Is There Really A “GME Squeeze”?


April 24th, 2014
by Edward Salsberg

Each spring thousands of seniors at medical and osteopathic schools and other physicians apply for positions in graduate medical education (GME) training programs; simultaneously, thousands of training programs rank their preferred candidates. Based on the preferences of the medical student/physician applicants and the training programs, the two are matched by a sophisticated computer program. Since GME is a prerequisite to becoming licensed and practicing medicine in the US, this is a critical juncture in the education – training pipeline and provides a spotlight on the future physician workforce.

There are two matching systems: one administered by the National Residency Match Program (NRMP) for allopathic training positions, accredited by the Accreditation Council for Graduate Medical Education (ACGME), that matches medical doctors (MDs), doctors of osteopathic medicine (DOs) and graduates of schools outside of the US, known as international medical school graduates (IMGs); and one for GME programs accredited by the American Osteopathic Association (AOA) that is limited to DOs. The following are among the highlights of the results of this year’s matches.

First year positions (PGY 1 positions) for entrants into GME reached an all-time high and the number continues to grow. This year, a record 26,678 first year positions were offered by the NRMP and an additional 2,988 first year positions were offered in the AOA sponsored match, for a total of 29,666 positions offered in 2014. (See Note 1) This represents an overall increase of 2.2 percent from 2013. (See Note 2) However, some of the NRMP increase may reflect the “all in” policy instituted by the NRMP effective in 2013. (See Note 3)

Entry level GME positions far outnumber the number of US medical and osteopathic graduates seeking a residency position. Despite a lot of rhetoric and fear that new US graduates are facing a lack of training slots, overall, there were about 22,300 US MD and DO seniors competing for the 29,666 first year positions.

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(Only) Evidence-Based After-Hospital Care: Where Should the Savings Go?


April 24th, 2014
by Joanne Lynn

Medicare 2014 has achieved the main goal of Medicare 1965: Access to medical treatment for older Americans. That, and advances in medicine, public health, and technology, have led to long lives and better health. Nevertheless, the system designed for the priorities of 1965 does not match the needs of 2014, and beyond.

What very old and frail people need — whether to ease the fears of a 90 year old woman living alone in a second-floor walk-up apartment or the burdens on the family of an 85- year old slowly drifting into the haze of dementia — goes without Medicare coverage. Addressing those needs and correcting course to change habits of overtreatment and cost inflation for older people living with multiple chronic conditions is a historic opportunity — to build Medicare 2030.

With what we know today, we could actually right-size the medical services, generate the savings, and re-design the delivery system to ensure reliability and supportive services. And more: we could pay for all or most of that vastly improved system with the savings we achieve from optimizing medical care.

But will the nation pursue that reinvestment? Will policymakers insist upon it? Will the public demand it? To do so would mean major changes in how we operate health care.

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Implementing Health Reform: Federal SHOP Procedures And Other ACA Guidance


April 24th, 2014
by Timothy Jost

With open enrollment completed and regulations largely in place for 2014 and 2015, implementation efforts at the federal level have quieted down. The Centers for Medicare and Medicaid Services, however, continue to issue technical guidance both to clarify outstanding 2014 issues and to clear the way for 2015. Much of this guidance appears at the CMS REGTAP website.

On April 22, 2014, CMS updated at REGTAP a series of slides, published initially on April 1, 2014, describing their proposed enrollment and payment process for the 2015 federally facilitated SHOP (FF-SHOP), which will begin to offer employee choice and premium aggregation in 2015. These slides expand on information previously provided in the 2015 federal exchange letter to issuers regarding the federal SHOP. CMS states that it intends to update the procedures set out in the slides with formal guidance before QHP certification begins in May.

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Travels In Hyperreality: What If Bipartisan ACA Fixes Were Possible?


April 23rd, 2014
by Billy Wynne

Since enactment of the Affordable Care Act in March 2010, a strange, relatively unnoticed phenomenon has occurred: Congress has passed bipartisan changes to it. These amendments were generally to such esoteric components of the law that they dodged the political block-aid that otherwise surrounds it.

But what would happen if things were different? If Congress could act to change the ACA in a meaningful way, what would it do? Here we briefly review the previous sub rosa changes to launch into a broader examination of macro ACA reforms that have a fighting chance of enactment in the not too distant future.

Tinkering. Most recently, in the Medicare “doc fix” in March, both parties acted to repeal the section of the ACA that capped deductibles for small group health plans. That legislation also delayed, again, implementation of the ACA’s Medicaid cuts to disproportionate share hospitals.

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Return Of The Repressed: Spending Growth Is Back, But What To Do?


April 21st, 2014
by Rob Cunningham

The sheer magnitude of the Affordable Care Act and its implementation seems to have briefly preempted the attention of the health policy community, distracting it from its perennial and inescapable preoccupation with spending growth. Everyone knew, of course, that when the dust settled, access and insurance market reforms would set off in ever starker relief the menace of the spending dragon. But in the meantime, an eerie 4-year lull in growth seemed to dull the edge of the problem.

There was research suggesting that structural changes, some in anticipation of payment and delivery system reforms encouraged by the ACA, might continue to restrain growth as the health economy joined a recovery from recession. This hopeful scenario got a boost as the lull outlasted a return to improved GDP growth. Flagging growth in pharmaceutical spending and unexpectedly low premiums in many state and federal insurance exchanges were other favorable straws in the wind. Could a generation-long growth trend averaging nearly two-and-a-half points above GDP finally be at an end? Some saw cause for cautious optimism.

This month, however, the Michigan-based Altarum Institute released an analysis based on government data that showed health spending growth began to surge last October, when it reached a 5-percent annual rate, and has continued to accelerate to a 6.7 percent pace in February, 2.4 percent above GDP and a 7-year high. Growth over the fourth quarter of 2013 was 5.6 percent, a 10-year high.

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Implementing Health Reform: The Latest Affordable Care Act Coverage Numbers (Updated)


April 18th, 2014
by Timothy Jost

On February 17, 2014, the White House announced that 8 million Americans have signed up for private health insurance coverage through the health insurance marketplaces, or exchanges. This significantly exceeds the White House’s original goal of 7 million enrollees. It is far more than the Congressional Budget Office’s recent projections of 6 million.

The number of actual enrollees will be smaller than this number. The CBO’s projections are for the average number of those actually enrolled in coverage over the course of a calendar year. To calculate the average number of enrollees, one must subtract from the 8 million the number of individuals who fail to pay their premiums and thus are never actually enrolled in coverage, as well as those who will drop coverage at some later point during the year. To that reduced number, then, must be added back the number who become newly covered through special enrollment periods during the remainder of the year. In the end, 6 to 7 million average enrollees is probably a reasonable estimate.

This does not, however, exhaust the number of Americans who are now covered under the Affordable Care Act. The fact sheet states that 3 million young adults are covered under their parents’ plans because of the ACA. This number is probably high, but it is clear that the ACA has dramatically increased coverage of Americans between the age of 19 and 25 — the age group most likely to lack health insurance prior to the ACA (and still).

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Development Assistance For Global Health: Is The Funding Revolution Over?


April 17th, 2014
by Jennifer Kates

In many ways, the last twenty years have been somewhat of a “revolution” in global health, as marked by rising attention, growing funding, and the creation of new, large scale initiatives to address global health challenges in low and middle income countries.  Indeed, the 1990s brought a steady increase in global concern about health, largely centered on the HIV epidemic and due to civil society organizing to draw attention to the growing crisis, leading to the creation of the Millennium Development Goals, and soon thereafter, the GAVI Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and the U.S. President’s Emergency Plan for AIDS Relief, and other efforts.

A key driver of increased funding has been donors – governments and multilateral agencies, non-governmental organizations (NGOs), and foundations.  And tracking their funding has become one of the critical measures of the global health response.

A new analysis from Dieleman et al., published as a Health Affairs Web First on April 8, provides a needed contribution to the literature on donor funding for health, including an understanding not just of where donor funding is going but of the relationship between aid, burden, and income.

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Four Years Into A Commercial ACO For CalPERS: Substantial Savings And Lessons Learned


April 17th, 2014
 
by Glenn Melnick and Lois Green

Editor’s note: In addition to Glenn Melnick, this post is coauthored by Lois Green.

Background: In a very short period of time, Accountable Care Organizations (ACOs) have become an important and widespread part of the US health care landscape. A recent Health Affairs Blog post estimates the total number of public (Medicare) and private ACOs at more than 600 nationally, covering more than 18 million insured population. Despite their rapid and widespread adoption, relatively little is known about how ACOs actually work and how successful they have been. This is due in part to their relative “newness,” as many reported ACOs are just getting up and running. Others have been operational for short periods of time and have yet to produce meaningful or long-term sustainable results.

This Health Affairs Blog post helps fill some of this void by reporting on the operational experiences of one of the oldest (4+ years) and largest commercial ACOs in the nation. A previous Health Affairs Blog post reported on its initial planning and start-up phase, and a subsequent Health Affairs article reported on its early financial results.

In 2007, Blue Shield of California, along with provider and employer partner organizations, began exploring development of one of the first ACO-like programs in the country to serve Commercial patients. It launched in 2010 and, as reported below, has been generating savings to consumers throughout the period. Located in the competitive Sacramento market of northern California, the ACO is an example of an innovative shared savings model involving a large insurer—Blue Shield of California; a purchaser—the California Public Employees Retirement System (CalPERS); a physician group—Hill Physicians Medical Group (HPMG); and a hospital system—Dignity Health. The population served approximately 42,000 CalPERS employees and their families covered by Blue Shield.

In this Health Affairs Blog interview, senior executives from each of the partnership organizations, all of whom have operational responsibilities and oversight of this ground-breaking Commercial ACO, discuss key operational aspects of the ACO and its implementation. They discuss evolution of the culture, governance and essential “partnership” relationships an ACO requires to survive and thrive. In addition, they detail specific operational initiatives designed to coordinate and manage care, and report on how these initiatives have fared over the four-year period since the ACO’s launch. Empirical results show success in many areas, with challenges in some others. Of particular note has been overall cost of health care (COHC) savings reported at gross savings of more than $105 million, with net savings of $95 million to CalPERS members, since 2010. Finally, the partners illuminate the ACO’s future directions and offer lessons for other organizations considering development of an ACO delivery system for the Commercial market.

The interview was supported by funding from the California HealthCare Foundation.

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We’ll Need A Bigger Boat: Reimagining The Hospital-Physician Partnership


April 17th, 2014
 
by Francis J. Crosson and John Combes

Editor’s note: In addition to Francis J. Crosson, this post is coauthored by John Combes.

Change is underway in the delivery and financing of American health care, and it is manifested in the evolving relationship of hospitals and physicians across the U.S. These developments are most striking in California, but are appearing in various forms in almost all states. Physicians and hospitals are being both “pushed” and “pulled” together in new ways by a variety of market forces, including the development of Accountable Care Organizations (ACOs) for both Medicare and commercially insured patients, increased direct employment of physicians by hospitals, the emergence of new payment mechanisms such as global payments, and, in general, by the need for physicians, physician groups and hospitals to deliver greater “value.”

All of this presents the opportunity to redesign care to be more coordinated, efficient, patient-driven, and effective. These integration forces could lead to the kind of organizations envisioned 15 years ago in the Institute of Medicine report “Crossing the Quality Chasm”, resulting in the Triple Aim of better health, better patient care experiences and outcomes, and improved affordability — driven, in part, by new patient care models and payment methods including incentives for improving the value of health care services.

Many physicians are uncomfortable with the idea of physician-hospital integration for several reasons. The long tradition of “professional autonomy”– perhaps best described as “the need for physicians to be able to make appropriate and scientifically based patient-by-patient decisions in the best interest of those patients” — can raise fears among some physicians about becoming part of a larger practice or institution and losing that autonomy. Additionally, some physician groups have shown that they can develop a successful ACO without the need for hospital and insurance partners, preferring to manage the clinical and financial risk alone.

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Companies Must Approach Advanced Health Events As A Business Issue


April 16th, 2014
 
by J. Brent Pawlecki and Dan Morhaim

Editor’s note: In addition to J. Brent Pawlecki, this post is also coauthored by Dan Morhaim. For more on this topic, see the April issue of Health Affairs, which features a series of articles on Alzheimer’s disease.

In the corporate world, every company has a chief financial officer charged with ensuring that the organization meets all tax and accounting mandates and to report the data to officers of the company, shareholders, employees and the general public.

Yet, while organizations expend great effort addressing these matters, many miss another opportunity to protect their employees’ well-being by failing to talk about end-of-life care.  Most companies consider advanced illness to be a private matter. But in fact, this hands-off approach most assuredly affects the financial health of any organization – and the emotional well-being of its workforce.

Beyond its direct impact on individuals’ health and well-being, advanced illness can take a heavy economic toll, including its effects on productivity, health and benefits costs, employee potential and engagement.  According to the MetLife Mature Market Institute study, the total estimated cost to employers for all full-time employed caregivers is a staggering $33.6 billion.  The average cost per employee for caregiving responsibilities ranges from $2,100 to $2,400.

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Payment and Delivery Reform Case Study: Congestive Heart Failure


April 15th, 2014
by Darshak Sanghavi

Editor’s note: In addition to Darshak Sanghavi (photo and bio above), this post is coauthored by Meaghan George, a project manager at the Engelberg Center for Health Care Reform at the Brookings Institution. The post is adapted from a full-length case study, the first in a series of case studies made possible through the Engelberg Center’s Merkin Initiative on Physician Payment Reform and Clinical Leadership, a special project to develop clinician leadership of health care delivery, payment and financing reform. The case studies will be presented using a “MEDTalk” format featuring live story-telling and knowledge-sharing from patients, providers, and policymakers. The event series will kickoff on Wednesday, April 16 from 10 a.m. – Noon EST.

Introduction

Clinicians and hospitals across the nation struggle with providing and paying for optimal care for their congestive health failure (CHF) patients. However, there are opportunities to make care better. In fact, of the more than 10,000 pages in the Affordable Care Act (ACA) implementing regulations, the least talked about are the dozens of small experiments led by the Center for Medicare and Medicaid Innovation (CMMI) that test new ways to pay for medical services.

We use a case study approach to investigate and tell the story of what two academic medical centers, Duke University Health System (“Duke”) and University of Colorado Hospital (“Colorado”), are doing to innovate and improve CHF care while implementing alternative payment models offered by CMMI.

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Look At Consequences Of Rejecting Medicaid Expansion Leads First Quarter Health Affairs Blog Most-Read List


April 14th, 2014
by Tracy Gnadinger

Given their recent mention in Paul Krugman’s New York Times‘ column, it’s not surprising that Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhandler‘s discussion of the health and financial impacts of opting out of Medicaid expansion was the most-read Health Affairs Blog post from January 1 to March 31, 2014.

Next on the list was Robert York, Kenneth Kaufman, and Mark Grube‘s discussion of a regional study on the transformation from inpatient-centered care to an outpatient model focused on community-based care. This was followed by Susan Devore‘s commentary on changing health care trends and David Muhlestein‘s evaluation of accountable care organization growth.

Tim Jost is also listed four times for contributions to his Implementing Health Reform series on Medicaid asset rules, CMS letter to issuers, contraceptive coverage, and exchange and insurance market standards.

The full list appears below.

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The Case For Global Health Diplomacy


April 14th, 2014
by Bill Frist

At the end of February, I had the pleasure of speaking about global health diplomacy at the Nursing Leadership in Global Health Symposium at Vanderbilt University. Nurses are one of the specialties that we support in the Frist Global Health Leaders program facilitated by Hope Through Healing Hands, a nonprofit dedicated to advancing peace by supporting health care services and education in some of the world’s most vulnerable communities. Nurses, including the men and women I met at Vanderbilt, have an enormous opportunity to affect health and global health diplomacy. Indeed, everyone in the medical profession can play a crucial role in health diplomacy.

Global Health Diplomacy And Foreign Policy

For several years now I’ve been thinking about—and speaking about—global health diplomacy. The term started appearing around 2000 and has many definitions, representing the complexity of the issue itself. Diplomacy, at the simplest level, is a tool used in negotiating foreign policy. Health diplomacy is different, though. As a physician, the overall goal of health is clear: improve quality of life by improving health and meeting overall patient goals of care. As a diplomat and policymaker, the goal is more complicated.

Foreign policy, in general, is a dance—a negotiation of shared goals and identification of conflicts between nations, always with inherent tension. For example, what we want for the government of Afghanistan may not align with their complex political and cultural ideologies.

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Implementing Health Reform: Changing Focus, And Changing Leadership, At HHS (Updated)


April 11th, 2014
by Timothy Jost

With the March 31, 2014 deadline for applying for qualified health plan coverage through the health insurance exchanges behind us, and the April 15, 2014 deadline for completing those applications upon us, Affordable Care Act implementation has quieted considerably. The Centers for Medicare and Medicaid Services have been very active on the Medicare front, releasing in recent days their 2015 Medicare Advantage Rate Announcement and Call Letter and publishing data on Medicare payments to 880,000 Medicare providers. But on the exchange and insurance market reform side, CMS has only one major proposed rule pending at this time, the Exchange and Insurance Market Standards Rule proposed in March, and nothing pending for regulatory review at the Office of Management and Budget.

I am unaware of any major regulatory issuances expected in the immediate future from the Departments of Treasury or Labor, although Treasury does have a number of proposed rules on the table that have yet to be finalized dealing with issues such as minimum value of employer coverage or premium tax credit reporting requirements for exchanges.

On April 10, the media reported two major Health and Human Services developments. First, Secretary of Health and Human Services Kathleen Sebelius announced at a Senate Hearing that 7.5 million Americans have now signed up for health plans through the exchanges. Although opponents of the ACA continue to quibble about how many of these individuals have actually paid their premiums and how many were uninsured previously, the number far exceeds earlier estimates of how many would enroll in health insurance through the exchanges. A recently released Rand survey, which does not fully take into account the late surge that increased exchange enrollment by over 70 percent in the last month, indicates that in fact the ACA has made a significant dent in the number of uninsured in the United States.

The second announcement was of the resignation of Secretary Sebelius herself, and of the nomination of Sylvia Mathews Burwell as her replacement.

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Medicare Advantage Rolls On


April 11th, 2014
by Billy Wynne

Monday afternoon, the Centers for Medicare and Medicaid Services (CMS) released the final rates and other reimbursement policies for Medicare Advantage (MA) plans, referred to as the Final Call Letter. Once again, the Administration took pains to ameliorate planned cuts to MA, demonstrating the program’s increasing popularity with seniors and, by extension, its robust political strength.

For my money, we’ll look back at this year as the final hurdle the program jumped on its path to dominating the Medicare benefit for a generation to come. It’s already well on its way, covering 30 percent of Medicare beneficiaries and growing. So let’s take a quick tour of the MA program’s initially volatile history and the winning streak it’s been on of late, culminating with the breaks the Administration cut it this go round.

The history. First there was the growth and then precipitous decline of managed care in the 90s, a wave that the program – then called Medicare+Choice – rode alongside the commercial sector.

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Takeaways From The Aspen Institute’s Care Innovation Summit


April 10th, 2014
by Matthew Richardson

Back in February, The Aspen Institute and The Advisory Board Company sponsored the Care Innovation Summit in Washington, DC. With a keynote address from Secretary of Health and Human Services Kathleen Sebelius, the daylong summit featured some of the newest data and research on the rapidly evolving U.S. health care landscape.

Featured speakers such as Jeffrey Brenner of the Camden Coalition of Healthcare Providers and Claudia Grossmann of the Institute of Medicine in addition to others from State and Federal government, insurers, hospitals, and research institutions offered insights on higher-value care and improved health for individuals and populations.

Here are five most memorable takeaways:

1. Health Care Cost Inflation Has Slowed

Perhaps the most eye-catching data trend presented was the dramatic slowing of Medicare spending showcased by Patrick Conway, Director of CMMI (presentation available here). The collapse of annual per capita spending growth is important not only because it implies significant value changes are underway in the provision of ever more services by Medicare, but also because it can further mean many things to many people.

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What’s Past Is Prologue: Making The Case For PET Beta-Amyloid Imaging Coverage


April 9th, 2014
by Dora Hughes

Editor’s note: This post is published in conjunction with the April issue of Health Affairs, which features a series of articles on Alzheimer’s disease.

In September of 2013, CMS issued its final decision memo that concluded positron emission tomography- amyloid beta (PET Aβ) imaging is “not reasonable or necessary”, finding “insufficient evidence” that use of this diagnostic tool would improve health outcomes for patients with dementia or neurodegenerative disease. As such, PET Aβ imaging to help diagnose Alzheimer’s disease (AD) is not a covered service for Medicare beneficiaries except for those enrolled in CMS-approved clinical trials.

CMS’ final decision underscores the emerging new paradigm for coverage decision-making, requiring innovators not only to demonstrate to FDA’s satisfaction that their products are effective, but also to prove to CMS and other payors that their use will improve clinical outcomes. This paradigm will increase confidence in the value and health benefit of new technologies, although it will make the path to coverage more difficult and uncertain for diagnostic developers.

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Health Affairs Web First: Global Health Funding In 2013 Five Times Greater Than 1990


April 8th, 2014
by Tracy Gnadinger

Development assistance for health (DAH) to low- and middle-income countries provided by donors and international agencies are given in the form of grants, low-cost loans, and goods and services. Without this assistance, some of the poorest countries would be less able to supply basic health care.

A new study, being released today as a Web First by Health Affairs, tracked the flow of development assistance for health and estimated that in 2013 it reached $31.3 billion.

Looking at past growth patterns of these international transfers of funds for health, authors Joseph Dieleman, Casey Graves, Tara Templin, Elizabeth Johnson, Ranju Baral, Katherine Leach-Kemon, Anne Haakenstad, and Christopher Murray identified a steady 6.5 percent annualized growth rate between 1990 and 2000, which nearly doubled to 11.3 percent between 2001 and 2010 with the burgeoning of many public-private partnerships. Since 2011, however, annualized growth has dramatically dropped, to 1.1 percent, due, in part, to the effect of the global economic crisis.

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What The Affordable Care Act Means For Pregnant Inmates


April 4th, 2014
 
by Katy Kozhimannil and Rebecca Shlafer

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.

The Affordable Care Act (ACA) is anticipated to expand coverage to 44 million Americans. As John Iglehart noted in his introduction to the March issue of Health Affairs, expansion of Medicaid through the ACA will open an important door for a particularly vulnerable population – those who are cycling in and out of the criminal justice system.

Although Medicaid does not cover standard health care for inmates during incarceration, expansion of Medicaid to single and childless adults has meant that prisons and jails can start enrolling inmates (a substantial portion whom meet these criteria) so they are covered upon release.

The ACA also allows Medicaid to pay for inmates’ care for hospital stays longer than 24 hours. Such changes have important implications for a group of inmates that is not often the focus of health policy dialogue – incarcerated pregnant women.

A Particularly Vulnerable and Costly Group: Pregnant Prisoners

Nationwide, 75 percent of incarcerated women are of reproductive age, and about 6-10 percent of female prisoners are pregnant during their incarceration. Incarcerated women fare worse than incarcerated men, and their reproductive health care needs, including access to contraception and abortion services, often go unmet. Inmates who are pregnant face additional risks. Compared with similar women that are not incarcerated, pregnant inmates have more risk factors and worse birth outcomes, for both mothers and babies.

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Health Affairs Briefing Reminder: Long Reach Of Alzheimer’s Disease


April 4th, 2014
by Chris Fleming

Despite decades of effort, finding breakthrough treatments or a cure for Alzheimer’s has eluded researchers. In the April 2014 issue of Health AffairsThe Long Reach Of Alzheimer’s Disease, we explore the many subjects raised by the disease: the optimal care patients receive and the testing of new models, international comparisons of how the disease is treated, families’ end-of-life dilemmas, a new public-private research collaboration designed to produce improved treatments, and others.

Please join us on Wednesday, April 9, at W Hotel in Washington, DC, for a Health Affairs briefing where we will unveil the issue.  We are delighted to welcome Dr. Richard Hodes, director of the National Institute on Aging at the National Institutes of Health to deliver the Keynote. Read the full briefing agenda.

WHEN:
Wednesday, April 9, 2014
8:30 a.m. – 12:30 p.m.

WHERE:
W Hotel Washington
515 15th Street NW, Washington, DC (Metro Center)
Great Room, Lower Level

 REGISTER ONLINE

Follow live Tweets from the briefing @HA_Events, and join in the conversation with the hashtag #HA_Alzheimers.

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