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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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Nine Questions About My New Medical Home

March 17th, 2014
by Matthew Anderson

Sometime in the past five years — it’s hard for me to say exactly when — I suddenly found myself living in a new home. I must admit I am still a bit disoriented by how this happened. But it did. People keep telling me that everything will be ok but I am not entirely sure.

For example, in my old home we had occasional family meetings; things are different now. We now have weekly (and monthly) meetings. The many new administrators ask us to complete personality surveys. Once we had to figure out what items we should take from a sinking yacht in the South Pacific (hint: the $100 bill will be useful). Another time we had to decide if we were a “Wow” or a “Thinker.” We are asked to figure out how we can do a better job for them. I guess, like all forms of therapy you don’t get better unless you change.

Despite all these meetings there are a series of things I still don’t understand. I am afraid to raise my hand at the meetings and give the impression I’m a bad sport so I have written my questions down. Please, please don’t think I am a Luddite who wants to go back to the old home. In fact, what I dislike most about the new home is precisely the way — even in its differences — it resembles the old home.

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Ethical Dilemmas In Prison And Jail Health Care

March 10th, 2014
by Nancy Dubler

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.

Prison and jail health care, despite occasional pockets of inspiration, provided by programs affiliated with academic institutions, is an arena of endless ethical conflict in which health care providers must negotiate relentlessly with prison officials to provide necessary and decent care.  The “right to health care” articulated by the Supreme Court pre-ordained these ongoing tensions.  The court reasoned that to place persons in prison or jail, where they could not secure their own care, and then to fail to provide that care, could result in precisely the pain and suffering prohibited by the Eighth Amendment to the Constitution.

Good reasoning was followed by a deeply flawed articulation of the “right” that defines the medical care entitlement as care provided to inmates without “deliberate indifference to their serious medical needs.” By forging a standard which was, and remains, unique in medicine and health care delivery — designed to avoid intruding on state malpractice litigation regarding adequacy of practice and standards of care — the court guaranteed that dispute would surround delivery.  That first framing, which did not establish a right to “standard of care” or to care delivered according to a “community standard,” set the stage for endless ethical and legal conflict.

The Eighth Amendment’s deliberate indifference standard, forbidding cruel and unusual punishment, presents a relatively demanding standard for proving liabil­ity.  The Eighth Amendment, as interpreted by the federal courts, does not render prison officials or staff liable in federal cases for malpractice or accidents, nor does it resolve inter-professional disputes — or patient-professional disputes — about the best choice of treatment. It does require, however, that sufficient resources be made available to implement three basic rights: the right to access to care, the right to care that is ordered, and the right to a professional medical judgment.

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HA Web First: Improved Prescribing And Reimbursement Practices In China

February 26th, 2014
by Tracy Gnadinger

Pay-for-performance—reimbursing health care providers based on the results they achieved with their patients as a way to improve quality and efficiency—has become a major component of health reforms in the United States, the United Kingdom, and other affluent countries. Although the approach has also become popular in the developing world, there has been little evaluation of its impact. A new study, released today as a Web First by Health Affairs, examines the effects of pay-for-performance, combined with capitation, in China’s largely rural Ningxia Province.

Between 2009 and 2012, authors Winnie Yip, Timothy Powell-Jackson, Wen Chen, Min Hu, Eduardo Fe, Mu Hu, Weiyan Jian, Ming Lu, Wei Han, and William C. Hsiao, in collaboration with the provincial government, conducted a matched-pair, cluster-randomized experiment to review that province’s primary care providers’ antibiotic prescribing practices, health spending, and several other factors. They found a near-15 percent reduction in antibiotic prescriptions and a small decline in total spending per visit to community clinics.

The authors note that the success of this experiment has motivated the government of Ningxia Province to expand this intervention to the entire province. “From a policy perspective, our study offers several additional valuable lessons,” they conclude. “Provider patterns of overprescribing and inappropriate prescribing cannot be changed overnight; nor can patient demand, for which antibiotics are synonymous with quality care. Provider payment reform probably needs to be accompanied by training for providers and health education for patients.”

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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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A Cure For Physician Shortage: Lessons From Indonesia

February 2nd, 2014
by Christian Suharlim

Recent literature has shown the growing mismatch between health care demand and supply. Insurance expansion under ACA, demographic changes, and population growth will require 30,000 more primary care physicians (PCPs) in 2025. Despite the growing need for PCPs, only less than 25 percent of newly qualified doctors go into primary care, and just 4.8 percent move into rural areas. This worsening shortage is expected to extend PCP wait time and increase the number of preventable ER admission and hospitalization.

An efficient solution to overcome this problem is by improving care capacity using an integrated care model, sharing the care between physicians and non-physician clinicians (NPCs) including nurses, physician assistants, and certified nurse-midwives. Although a partial implementation of this model has improved efficiency and quality of Kaiser Permanente, Clinica Family Health Services, and Group Health Olympia, these institutions have yet to fully shift the point of care to non-physicians, which is important in improving primary care capacity. This article will elaborate how Indonesia’s Jampersal program shifts maternal services point of care to non-physicians and improves maternal primary care capacity.

Indonesia is a developing country with scarce physician resources, 0.2 physicians per one person (as opposed to 2.4 per one person in the US). Despite having the lowest physician ratio in ASEAN countries, the Indonesian government tries to improve the number of attended deliveries by providing universal and free maternity care benefit (Jampersal) in 2011. Practicing as a physician in Indonesia, I expected a significantly higher number of maternity care patients following the implementation of this program, but that was not the case.

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Maryland’s Bold Experiment In Reversing Fee-For-Service Incentives

January 28th, 2014
by Robert Murray

Fee-for-service (FFS) medicine encourages inappropriate volume growth, but a new experiment in Maryland seeks to turn the incentives upside down. The state, in a Model approved this month by the Centers for Medicare and Medicaid Services (CMS), will transform its hospital rate-setting system from a focus on controlling per-case cost toward population health and the total cost of hospital care per capita.

As the nation’s only all-payer hospital payment system, Maryland affords CMS a unique opportunity to demonstrate that a hospital payment system with properly designed and broadly applicable incentives can generate significant efficiencies.

Since 1977, Maryland’s Health Services Cost Review Commission (HSCRC) has established the rates paid to Maryland acute-care hospitals by both public and private payers. For nearly four decades, Maryland has shown significantly lower per-case cost growth than the rest of the nation, while reimbursing hospitals for uncompensated care and preventing cost-shifting from public to private payers. The Maryland system has rested on FFS financial incentives, however, and has therefore encouraged hospitals to boost volumes while controlling unit costs.

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Maryland’s Triple Aim Roadmap

January 28th, 2014
by Carmela Coyle

In January, the State of Maryland and the Centers for Medicare and Medicaid Services (CMS) signed a historic agreement that, for the first time on a statewide level, provides the framework of a system that can deliver on the elusive Triple Aim of health care — reducing costs, enhancing quality and patient experience, and improving health.

The parameters of the agreement include principles upon which all stakeholders agree. The most important being that quality, not quantity, is what matters. The incentives are no longer to treat conditions, but to treat each person as a whole.

This agreement builds on Maryland’s legacy as a health care pioneer. More than 35 years ago, the state signed its first deal with the federal government to regulate hospital prices through a statewide commission — an “all-payer” system that helped control costs and ensured parity for those in need of care by ensuring that everyone pays the same price for the same service at the same hospital. Now, the state is once again forging a new way forward.

If it is successful, many believe that Maryland’s system could serve as a model for the nation. CMS will work closely with Maryland’s hospitals to ensure that the aggressive quality and financial metrics outlined in the agreement are met. The federal agency is doing so with the firm belief that there truly is a way to deliver better health care and reduce costs for all, and that Maryland’s plan may be the roadmap.

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The Need For A Smart Approach To Big Health Care Data

January 27th, 2014

Today, academic medicine and health policy research resemble the automobile industry of the early 20th century — a large number of small shops developing unique products at high cost with no one achieving significant economies of scale or scope. Academics, medical centers, and innovators often work independently or in small groups, with unconnected health datasets that provide incomplete pictures of the health statuses and health care practices of Americans.

Health care data needs a “Henry Ford” moment to move from a realm of unconnected and unwieldy data to a world of connected and matched data with a common support for licensing, legal, and computing infrastructure. Physicians, researchers, and policymakers should be able to access linked databases of medical records, claims, vital statistics, surveys, and other demographic data. To do this, the health care community must bring disparate health data together, maintaining the highest standards of security to protect confidential and sensitive data, and deal with the myriad legal issues associated with data acquisition, licensing, record matching, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Just as the Model-T revolutionized car production and, by extension, transit, the creation of smart health data enclaves will revolutionize care delivery, health policy, and health care research. We propose to facilitate these enclaves through a governance structure know as a digital rights manager (DRM). The concept of a DRM is common in the entertainment (The American Society of Composers, Authors and Publishers or ASCAP would be an example) and legal industries.  If successful, DRMs would be a vital component of a data-enhanced health care industry.

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Primum Non Nocere: Congress’s Inadequate Medicare Physician Payment Fix

January 24th, 2014
by Jeff Goldsmith

Editor’s note: You can read other perspectives on the Medicare physician payment reform pending in Congress in Health Affairs and Health Affairs Blog (here, here and here).

Partisan gridlock in Washington regarding health policy has been so pervasive and bitter that any bipartisan co-operation on any important health issue should be applauded by a frustrated public. That is why the emerging bipartisan compromise regarding the fifteen-year long policy embarrassment known as the Sustainable Growth Rate (SGR) problem needs to be taken seriously. Remarkably similar solutions — a new hybrid physician “value-based” payment methodology — have emerged from three of the four key committees in Congress, and seemingly the only stumbling block is finding the $115-120 billion to pay for it. Moreover, key physician interest groups, including the American Medical Association, appear to have signed off on this approach.

This makes it all the more troubling that the approach taken is unsound health policy that will damage practicing physicians in diverse settings: private practice, medical school practice plans, and hospital employment. This is because the proposed legislation casts in concrete an almost laughably complex and expensive clinical record-keeping regime, while preserving the very volume-enhancing features of fee-for-service payment that caused the SGR problem in the first place. The cure is actually worse, and potentially more expensive, that the disease we have now.

The SGR fix would basically freeze or severely limit future physician fee updates for Medicare Part B (a serious problem for primary care), while permitting physicians to earn modest “value-based” bonuses if they can document quality measure attainment, cost reductions, participation in alternative payment schemes, practice enhancement activities, or meaningful use of EHRs.

Physicians who meet all these standards could expect to supplement their existing Part B fee by about 4 percent in 2016, going to 10 percent in 2020, with the aggregate bonuses subtracted from the pool of total Part B physician payments to preserve budget neutrality. Non-compliant physicians would see corresponding reductions in their updates. There are sensible opt-outs for physicians who can report in groups, virtual or real, as well as for physicians who participate in as yet unspecified “advanced payment models” (APMs).

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Examination Of Health Information Technology’s Disappointing Impact Leads Health Affairs 2013 Top-Fifteen List

January 21st, 2014
by Chris Fleming

Years after promises of large gains from health information technology, evidence of the impact of health IT on efficiency and safety remain mixed, Arthur Kellermann and Spencer Jones report in the most-read Health Affairs article of 2013. Achieving health IT’s original promise will require standardized systems that are easier to use and more interoperable, and that provide patients with more control over their health information; providers must re-engineer care systems as well, Kellermann and Jones write. To celebrate the New Year, Health Affairs is making this piece and all the articles on the journal’s 2013 most-read list freely available to all readers for one week.

Second on the 2013 top-fifteen list is a report on 2011 health spending by analysts at the Centers for Medicare and Medicaid Services Office of the Actuary. Every year, Health Affairs publishes a retrospective analysis of National Health Expenditures by the CMS analysts, as well as their health spending projections for the coming decade. In the latest installment in this series, the analysts reported on 2012 health spending in our January 2014 issue and discussed their findings at a Washington DC briefing.

In the third most-read Health Affairs article of 2013, Linda Green and coauthors caution against projecting primary care physician shortages based on simple patient-physician ratios. They argue that increasingly popular strategies — such as the use of teams and nonphysicians, and better information technology and data-sharing — can potentially eliminate projected physician shortages.

The top fifteen articles for 2013 also include studies addressing the impact of states’ opting out of Medicaid expansion, the cost-shifting effects of some workplace wellness programs, and several other topics. The full list appears below. The list is based on online viewing statistics and covers all articles published in 2013.

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Review Of Accountable Care Organization Landscape Leads 2013 Health Affairs Blog Top Fifteen

January 17th, 2014
by Chris Fleming and Tracy Gnadinger

David Muhlestein’s comprehensive look at the growth of Accountable Care Organizations leads the list of most-read Health Affairs Blog posts for 2013. Muhlestein, Director of Research at Leavitt Partners, followed up this post later in the year with a discussion of why ACO growth was slowing.

Next on the top-fifteen list is a post by Tim Jost on exemptions from the Affordable Care Act’s individual mandate. Several posts in Jost’s extensive “Implementing Health Reform” series made the most-read list. Jost teaches law at Washington and Lee University and is a Health Affairs Contributing Editor.

Number three on our list is a post by Robert York, Kenneth Kaufman, and Mark Grube of Kaufman Hall on what declining inpatient utilization rates tell us about how health care is changing. At number four: an analysis of who will remain uninsured after the Affordable Care Act is implemented by Rachel Nardin, chief of neurology at Cambridge Health Alliance, and coauthors Leah Zallman, Danny McCormick, Steffie Woolhandler, and David Himmelstein,

The full list is below. (You can also review the 2013 most-read list for our sister publication, GrantWatch Blog.)

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The Seeds of a Solution to the Problems of Emergency Medicine

January 3rd, 2014
by Mona Sarfaty

As one of the principal authors of the original Emergency Medical Treatment and Active Labor Act (EMTALA), I want to make clear that our efforts as the advisors to Senator Kennedy’s Committee in 1985 were squarely focused on the responsibility of hospital emergency departments (EDs) to provide access to emergency care within their communities. Representative Stark in the House of Representatives agreed unequivocally with Senator Kennedy about this point and together they helped enact the “anti-dumping” bill with bipartisan support. Nevertheless, it took years of additional work before EMTALA began to make a real impact. Access problems may have changed since EMTALA barred “dumping,” but inadequate access to care remains a problem.

The intent of EMTALA was never to make EDs a major provider of outpatient care. However, as documented in the December issue of Health Affairs, EDs now provide a significant percentage of all acute care visits for the uninsured. Many of the people who rely on EDs as a source of outpatient care lack access to the bedrock foundation of a rational health system—a primary care home. Some have no regular source of care, some do not know where to go for a medication refill, and some feel they have no other way to find reassurance or safety when panicked about their wellbeing. In particular, finding urgent mental healthcare remains a significant challenge for many. But, thirty years after the passage of EMTALA, the nation is slowly moving to address the access problem. The seeds of a solution are scattered around the country. They must grow and spread if they are to coalesce into a full-blown remedy.

What follows are some key elements necessary to continue improving access to primary healthcare while assuring that investments in emergency care are appropriately utilized.

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New Health Affairs: Issues Facing The Health Care Workforce

November 4th, 2013
by Chris Fleming

The November issue of Health Affairs, released today, discusses how the US health care workforce can respond to the Affordable Care Act’s expanded coverage and new models of care, as well as to an aging population. Some notable studies in the issue are described below, and the issue will be discussed at a Washington DC briefing on Thursday, November 14.

The aging population’s implications for specialty care and primary care.A study by Timothy Dall of IHS Inc. and coauthors forecasts future demand for health care services and providers based on projected demographics and other predictive changes, including the expected effects of expanded health insurance coverage under the Affordable Care Act. The authors project that demand for adult primary care services will grow by roughly 14 percent between 2013 and 2015, and demand for certain specialty care services will grow even faster at a high of 31 percent growth for vascular surgery. Cardiology (20 percent) and neurological surgery, radiology, and general surgery (each 18 percent) round out the list of the top five.

Dall and coauthors caution that failure to address the inadequate number and inappropriate mix of specialty care providers will further contribute to long wait times, reduce access to care, and decrease patients’ quality of life.

Diabetes patients in patient-centered medical homes are well served by nonphysicians and physicians alike. In this first study to compare the effectiveness of physician assistants (PA) and nurse practitioners (NP) roles to physician-only care for patients with chronic disease, Christine Everett of Duke University and coauthors found that patient outcomes were generally the same in thirteen comparisons. In four comparisons, PA and NP care was found to be superior; in three, the physician-only outcomes were higher.

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Narrative Matters: A Safety Net Tale Of Ticking Clocks And Tricky Diagnoses

August 27th, 2013
by Chris Fleming

In a time-crunched clinic, physician Maria Maldonado and her resident battle the clock to uncover a potentially fatal diagnosis. Maldonado tells this story in her August 2013 Health Affairs Narrative Matters essay. The essay is freely available in full to all readers; you can also listen to Maldonado read it by visiting iTunes or the free Narrative Matters archive.

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The First-Year Pioneer ACO Results: Predictable Bumps In The Road

July 25th, 2013
by Debra Ness and William Kramer

It’s not often that progress comes in straight lines. To tackle complex problems, we test and innovate and then try out our new ideas, and then continuously reconsider, revise and adapt them over time. Few problems are more complex and vexing than figuring out how to make our health care system work for those it has been failing for so long: the most complex, high-risk, high-cost patients and their families.

So getting mixed results from the first year of testing Pioneer Accountable Care Organizations (ACOs) was to be expected. In fact, for those of us with experience working with our health care system and a dose of realism in our perspectives, it was all but inevitable.

But we see more potential good than bad, and reason for hope, in the outcomes the Centers for Medicare and Medicaid Services reported for the first year of this grand experiment.

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Analysis Of Post-ACA Uninsured Leads Health Affairs Blog June Top Ten

July 11th, 2013
by Chris Fleming

Who will be left uninsured under the Affordable Care Act? That’s the question addressed by Rachel Nardin and coauthors in the most-read Health Affairs Blog post for June.

Next on last month’s top-ten list: Joanne Pohl and coauthors’ look at the relative numbers of physicians and nurse practitioners choosing primary care specialties. The list also features Christine Cassel’s discussion of her priorities as she assumes the leadership of the National Quality Forum, and Robert Berenson’s proposals for improving quality measurement. Additionally, the top ten includes three posts in Tim Jost’s series on implementing the Affordable Care Act, as well as posts on lessons from early ACA Medicaid expansions, the growth of accountable care organizations, and health information technology for the accountable care era.

The full list appears below:

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New Health Affairs Issue Examines The States And Medicaid Expansion

July 8th, 2013
by Chris Fleming

With nearly half the states planning to expand Medicaid eligibility in 2014, Health AffairsJuly issue includes several articles that reflect, in the words of founding editor John Iglehart, “various cross currents of federalism.”

Medicaid, as seen in this issue, says Iglehart, “is not the uniform national health program envisioned by Democrats, but one that reflects the heterogeneity of the United States and the Republican imperative for decentralized policy making.”

This variety issue also addresses health care workforce concerns, an increase in e-prescribing by providers responding to a federal incentive program, and the lessons for state legislatures when school immunization exemption laws are relaxed.

Selected content in the issue is supported by a grant from Blue Shield of California Foundation.

Noteworthy articles include:

Existing Medicaid Beneficiaries May Be Denied Preventative Care. The Affordable Care Act promotes access to preventive care as outlined by the US Preventive Services Task Force. However, because the law treats new and existing Medicaid beneficiaries differently, the two groups may not be eligible for the same preventive services. A study by Sara Wilensky and Elizabeth Gray of the George Washington University reviewed Medicaid policies across the country between June and November 2012. They found that most states do not offer existing beneficiaries all the services rated “A” and “B” by the US Preventive Services. In contrast, states expanding their Medicaid eligibility must offer these benefits to new participants without cost sharing.

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The Latest Data On Primary Care Nurse Practitioners And Physicians: Can We Afford To Waste Our Workforce?

June 18th, 2013

If primary care is the foundation of the evolving health care system in this country, and if access to primary care for all is the goal, then nurse practitioners will be increasingly crucial to achieving these aims. Let’s face it, in our current system, there just aren’t enough primary care providers to meet the nation’s need while containing costs and focusing on quality outcomes. With an estimated 30 million more people who will be covered and require access to full primary care based on the Patient Protection Affordable Care Act (ACA) numbers, we will need additional providers functioning to their fullest preparation.

2013 National Resident Matching Program Data

The 2013 National Resident Matching Program (NRMP) released in March is not good news for primary care. Although matching rates were up overall, the primary care numbers are still very low given the national need. According to the American Academy of Family Physicians (AAFP, 2013), only an additional 92 U.S. graduate medical students were matched to primary care specialties compared to a year ago. That translates to 39 more family medicine resident positions filled, 14 more internal medicine positions, 3 more pediatric and 36 pediatric/internal medicine positions filled, compared to 2012. The bottom line is 1,916 U.S. medical school grads were matched to primary care residency programs, with a total of 3,715 primary care matches when international graduates are included (AAFP,2013; NRMP, 2013) .

Primary Care Nurse Practitioner 2012 Graduation Rates

At the same time, the 2012 nurse practitioner (NP) graduation rates announced recently by the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties (AACN/NONPF 2013) showed a continued increase in primary care. Primary care NP graduates include those prepared as pediatric, family, adult, gerontological, adult/gerontological, and women’s health NPs. They numbered 11,764 in 2012 compared to 9,708 in 2011, an increase of 18.6 percent or 2,228 NPs.

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A Life-Course Approach to Vaccination Can Drive Healthy Aging

May 22nd, 2013

As life spans increase and birth-rates decrease, the world’s population is aging. From 2000 to 2025, the over-60 demographic segment will double from 600 million to almost 1.2 billion. By 2050, it will nearly double again, surpassing two billion and accounting for an incredible 22% of the total global population. A society this “old” has never before existed, and it is a social, ethical, and economic imperative to keep older adults healthy and engaged. It is timely for the global public health community to re-align its thinking, policies and activities to this new demographic reality.

Organizations at national and global levels have begun to pursue initiatives to promote healthy aging, and these efforts are going to intensify in the coming years. Thus far, the progress has been admirable, with the World Health Organization, the United Nations, the Organisation for Economic Co-operation and Development, and others taking leadership roles. Yet, despite many promising developments, the potential of “life-course immunization,” which stresses the administration of vaccines throughout all stages of life – including for adults – to prevent disease and promote health, has been largely overlooked, especially among adults.

This is a missed opportunity. There is a growing body of research and data to show that immunizations against some of the more specific age-related health challenges – such as pneumococcal disease, herpes zoster, and others – are economically feasible investments that can create large public health benefits.

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