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Health Affairs Web First: Assessing Health And Health Care Perceptions In sub-Saharan Africa


February 27th, 2015

A large share of Western aid to developing countries goes to sub-Saharan Africa, a region where spending on health care is around $100 per person in 2005 price-adjusted terms. This region, which experienced large gains in life expectancy in the years following World War II, suffered health-related setbacks in the closing years of the twentieth century as a result of the HIV/AIDS epidemic.

The authors of a February 25 Health Affairs Web First study used data from the Gallup Organization’s 2012 World Poll to investigate health and health care perceptions in sub-Saharan Africa compared to other regions of the world. The poll found that sub-Saharan Africans’ overall evaluation of their well-being was lower than that of any other population in the world. Additionally, only 42.4 percent of residents in that region were satisfied with the availability of high-quality health care in their community, also the lowest level in the world. Even so, when sub-Saharan Africans were asked to name the issues that should be the highest priorities for their government, health care was not seen as the most pressing issue.

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What Happens When A Retail Pharmacy Decides To Stop Selling Cigarettes?


February 26th, 2015

Editor’s note: This post is part of a series stemming from the Third Annual Health Law Year in P/Review event held at Harvard Law School on Friday, January 30, 2015. The conference brought together leading experts to review major developments in health law over the previous year, and preview what is to come. A full agenda and links to video recordings of the panels are here.

The sale of cigarettes and tobacco products at retailers with pharmacies has received considerable attention over the past year. The national debate reignited in February 2014, when CVS/pharmacy announced that we would quit the sale of cigarettes and tobacco products in our 7,800 pharmacies nationwide. In September 2014, we announced we were officially tobacco free — one month earlier than planned. This was met with kudos from the media, public health officials, and even the President of the United States.

But one question that did not receive anywhere near that level of attention was whether or not our actions would make a difference in the prevalence of smoking and, ultimately, in the public health.

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How Menu Labeling Could Spark Change Beyond The Menu Board


February 24th, 2015

If there’s one thing we’ve learned about catalyzing changes that prevent illness in the first place, it’s that passage of a single policy can be like lighting a match — illuminating the way towards strategies with greater impact and igniting the energy of leaders. The success of a menu labeling might be the match needed to inspire further policy change to shift the trend of increased diet-related chronic disease in the United States.

In November, the Food and Drug Administration released the final rule guiding calorie labeling of menu items at chain food service establishments with 20 or more outlets nationally. The rule will apply to fast-food and sit-down restaurants, supermarkets, convenience stores and movie theaters, and will take effect on December 1, 2015.

Once implemented, calorie counts will be posted for all items (including alcoholic drinks) on menus and menu-boards, and on display tags for salad bars, bakery items, and soda dispensers. A companion rule requiring calorie labeling for vending machines will take effect one year later.

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Indirect Effects From Menu Labeling Can Improve The Public’s Health


February 24th, 2015

Just this past November, the U.S. Food and Drug Administration (FDA) released sweeping final rules requiring that calorie information be posted on menus, menu boards, and vending machines. The regulations expand the proposed rule to include a wide variety of food outlets with more than 20 locations: quick service and table service restaurants, grocery stores and superstores, movie theaters, amusement parks, ice cream shops, takeout and delivery, vending machines, and even alcoholic beverages.

In the press release for the final rule, FDA Commissioner Margaret Hamburg stated, “making calorie information available on chain restaurant menus and vending machines is an important step for public health that will help consumers make informed choices for themselves and their families.”

Although the scientific evidence linking menu labeling to consumers’ purchasing behavior is weak, indirect effects may contribute more to incremental gains in public health. We highlight a few in the following blog post.

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Putting Humpty Dumpty Together Again: Consolidating Regulatory Authority Over Food Safety


February 23rd, 2015

The fragmented nature of regulatory authority over food in the United States is well known. More than a dozen federal agencies are responsible for the safety of the nation’s food supply. The Food and Drug Administration (FDA) and the Department of Agriculture (USDA) have the lion’s share of responsibility, together overseeing over 80 percent of the nation’s food safety.

Generally, the USDA regulates meat, and the FDA regulates everything else, but overlaps, exceptions, gaps, and therefore examples of resulting absurdities abound: the FDA regulates frozen pizza, unless it has pepperoni. The FDA regulates seafood, unless it’s catfish. The USDA has jurisdiction over packaged open-face meat sandwiches, but if the sandwiches are closed, authority shifts to the FDA.

This division in regulatory authority is neither planned nor rational. It is instead a historical accident, originating in the early twentieth century. When the Pure Food and Drug Act and Meat Inspection Act were passed on the same day in 1906, both targeting the adulteration of the food supply, their oversight was assigned to different departments within the USDA. The fissure widened when the FDA was moved out of the USDA in 1940. This divided regulatory framework is not the only reason for the fragmentation of regulatory authority over food in the US, but it is a main driver.

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In Regulating E-Cigarettes, No Easy Fix For The FDA


February 20th, 2015

Sometime in the next few months, the Food and Drug Administration (FDA) is expected to issue the so-called deeming regulations, which will open the door to the federal regulation of e-cigarettes. In considering whether to issue the regulations, which were first published for notice and comment rulemaking last April, the FDA faces a formidable challenge: it must decide whether and how to regulate in the midst of scientific uncertainty and limited statutory flexibility.

By subjecting e-cigarettes to its regulatory regime, the FDA risks retarding the growth of what may prove to be a powerful new tool for harm reduction. But by failing to act, the agency risks undermining decades of progress in tobacco control. In either case, the public health impact is apt to be significant.

It is a victory that was made possible, in large measure, by a constellation of state and federal regulatory interventions: laws regulating the marketing and sale of cigarettes, barring sales to youth, banning indoor smoking, and taxing cigarette sales have all played a role in reducing rates of smoking.

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An Era Of Precision Medicine And Rapid Learning


February 20th, 2015

At a recent White House event, President Obama presented his proposals for a Precision Medicine Initiative. The key elements include a national research system where 1 million or more volunteers can share their (privacy protected) electronic health records, genetics, and other data, and a national cancer initiative. The proposals will be developed in more detail based on meetings led by the National Institutes of Health (NIH) Director Francis Collins.

If national health policy adopts these proposals, much about today’s medical care system—including biomedical science, medical education, diagnostics, treatment options, comparative effectiveness research, quality metrics, payment systems, the role of patients, the personalization of medical care and prevention, and an understanding of the roles of environment, nutrition, culture, and many other factors—may greatly change.

The Obama administration proposes a highly collaborative, non-partisan public-private process. These proposals bring the era of “big data” to the center of the heath policy arena (see the July 2014 Health Affairs theme issue, “Using Big Data To Transform Care”). Many in the health system may want to take part in developing the proposals and being part of the implementation.

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Vaccinating Against Iron-Deficiency Anemia: A New Technology For Maternal And Child Health


February 19th, 2015

When we think of killer diseases of global health importance, iron-deficiency anemia (IDA) is not something that immediately comes to mind. Yet the December 2014 publication of leading causes of death by the Global Burden of Disease Study 2013 reveals that IDA kills an estimated 183,400 people annually. To put this number in perspective, in the year 2013, IDA killed more people worldwide than ovarian cancer. In terms of years of life lost, IDA ranked higher than cervical cancer.

The fact that we compared IDA to two other well-known threats to the health of women is no accident. Because women of child-bearing age have low underlying iron reserves, they are at great risk of becoming deficient in iron and progressing to IDA. Pregnant women are especially vulnerable to IDA because of the high iron demands of the growing fetus. Growing children represent another important group who develop IDA.

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Oregon Bridges The Gap Between Health Care And Community-Based Health


February 12th, 2015

It is now commonly accepted that to achieve health, the U.S. health system must address the social determinants of health. While the integration of health care with social services and public health is happening relatively infrequently across the country, one bright spot can be found in Oregon, where an innovative Medicaid health system model, referred to as the coordinated care model, is showing early signs of success in bridging the gap between the community and the health care system.

Under Oregon Governor John Kitzhaber’s leadership, newly created coordinated care organizations (CCOs)—partnerships between physical, behavioral, and oral health providers—have over the past two years adopted Oregon’s coordinated care model, which was created as the foundation for Oregon’s health system reform efforts to ensure care is coordinated, performance is measured, positive outcomes are rewarded, and that there is a shared responsibility for health, sustainable rate of growth, and transparency in price and quality—all with the goal of promoting positive health outcomes.

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What Ebola Teaches Us About Public Health In America


February 9th, 2015

Editor’s note: This post is part of a series stemming from the Third Annual Health Law Year in P/Review event held at Harvard Law School on Friday, January 30, 2015. The conference brought together leading experts to review major developments in health law over the previous year, and preview what is to come. A full agenda and links to video recordings of the panels are here.

2014 saw an epidemic of Ebola in Sierra Leone, Guinea, and Liberia, and an epidemic of fear in the US. Neither epidemic covered public health in glory. For Science, Ebola was the “breakdown of the year;” the Association of Schools and Programs of Public Health called it “the most important public health story” of the year; Politfact labeled it the political “lie of the year,” and Time magazine named “the Ebola fighters” its “Person of the Year.” All of these characterizations contain some truth.

Response to the epidemic in Africa relied heavily on volunteer organizations, especially Christian charity groups like Samaritan’s Purse and SIM (Serving In Mission), and medical NGOs, most notably Doctors Without Borders (MSF). It was MSF that called out the World Health Organization (WHO) for its failure to recognize the epidemic, and then its inability to respond to it. Their International Health Regulations, it turned out, were much more like guidelines than any form of law, and the WHO had no capacity to effectively respond to a new epidemic.

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After The Worst In Liberia And Sierra Leone


February 9th, 2015

From January 19-27, we traveled to Liberia and Sierra Leone to engage with national leaders, health workers, citizens, non-governmental organization (NGO) implementers, international organizations, and United States, United Kingdom (UK), and other officials, including the African Union (AU), Chinese, and Cuban medical delegations. It was a moment of hope and nervous adjustment, as Ebola cases dropped suddenly and unexpectedly in Liberia, followed by reductions in Sierra Leone and Guinea.

We listened to the reflections of those who lived through and led the mobilization to roll back the unprecedented Ebola emergency, as it raged in the second half of 2014. We sought to understand the latest phase, as complicated efforts have begun to move beyond an emergency response and seek to achieve “zero” Ebola infections in 2015 — while safeguarding against new outbreaks. We discussed briefly early plans for long-term recovery. Across these different phases and concerns, we had a special interest in examining the US contribution.

The visit generated countless conversations with diverse experts who were remarkably gracious, insightful, and candid in their remarks. In this post we share select major impressions we carried home. These opinions are, of course, ours, and ours alone.

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New Narrative Matters: How Access, Knowledge, And Attitudes Shaped My Sister’s Care


February 6th, 2015

Health Affairs‘ February Narrative Matters essay features a woman who helps her sister get the care she needs when a tooth infection turns into a health emergency. Elizabeth Piatt’s article is freely available to all readers, or you can listen to the podcast.

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How The Ebola Crisis Could Help Save 75,000 Patients


February 4th, 2015

It has taken an epidemic in West Africa to expose a troubling issue for U.S. hospitals and health policy: the short shrift given infection prevention.

In a thoughtful December Health Affairs Blog post, Dr. Leonard Mermel, an epidemiologist and infection control specialist, noted that over a three-month period his hospital’s work on Ebola preparedness “significantly strained our ability to manage other infection control challenges.”

That is a red flag for health care policymakers. As hospitals focus on Ebola preparations, we can’t lose sight of the fact that more than 700,000 Americans contract health care associated infections (HAIs) each year. About 75,000 people die from HAIs, such as Clostridium difficile (C. diff), Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE).

This is more than 10 times the number of patients who have died from Ebola across the globe.

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Request For Abstracts: Health Affairs Food And Health Theme Issue


February 4th, 2015

Health Affairs is planning a theme issue on food and health in November 2015. The issue will present work that explores the relationship between the food we consume and our wellbeing on the individual, societal, and global levels. Articles will address causes and consequences of dietary excess and insufficiency, analyze policies and programs aimed at influencing these, and explore the roles of public policy, industry, and stakeholder groups in the context of dietary behavior.

We invite all interested authors to submit abstracts for consideration for this issue.

The issue will consider the implications of global food production and distribution for the health of consumers and food workers, environmental quality, and food prices, among other things. It will also examine actions taken from the community level upward to address increasingly universal concerns about food-related illness. Several papers will provide broad overviews of key issues, but we are particularly interested in empirical analyses of specific policies, programs, and practices aimed at influencing dietary behavior and clarifying our thinking about food’s role in health.

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Beyond Wellness ROI Part II: The Case Study Of A Major Self-Funded Employer


January 30th, 2015

In a recent post, we agreed with Goetzel et al. about the advisability of moving away from a preoccupation with the return-on-investment (ROI) of wellness programs and toward the more systemic, iterative view required to make progress toward workplace “cultures of health.”

At the same time, we acknowledged Lewis et al. and others for helping to usher in a new and needed scrutiny of the fairness and effectiveness of employment-based wellness programs. But, we also cited peer-reviewed evidence that counters Lewis et al.’s conclusion that there are no conditions under which employer wellness programs, and by extension employer efforts to manage their core health-related value/sustainability challenge, can achieve a return-on-investment (ROI) ratio of better than 1-to-1 savings to cost.

Lewis et al. have added their voice to the scrutiny increasingly applied to employer use of outcome-triggered incentives or penalties to promote employee behavior change in the context of health-contingent programs under financial provisions in the Affordable Care Act. The momentum fueling these developments could soon extend far beyond wellness programs.

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Moving Beyond Wellness ROI Toward Employment-Based Cultures Of Health: Part I


January 26th, 2015

With their recent post declaring that employment-based wellness initiatives “increase rather than decrease employer spending on health care with no net health benefit,” Al Lewis and coauthors are continuing to exert a clarifying presence in a field with a history of unsubstantiated claims and suspect methods. This conclusion is not supported by the work with which we and others have been associated and is thus not one with which we agree.

Nevertheless, Lewis et al. are to be acknowledged for fueling the need for a sharper focus on the core challenge at hand for employers: how best to improve the value of their health care investment—that is, how to manage health care costs while improving employee health and productivity—in ways that are sustainable. Incremental, inconsistent and, at times, maddeningly slow progress has been made. Employment-based wellness has been at the forefront, even as the need for quality improvement continues.

Moreover leading employers with well-developed management and measurement approaches have moved well beyond calculating the return on investment of individual wellness efforts and are demonstrating the more comprehensive value of building “cultures of health.”

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Additional Requirements For Charitable Hospitals: Final Rules On Community Health Needs Assessments And Financial Assistance


January 23rd, 2015

On December 29, the Department of the Treasury and the Internal Revenue Service released long-awaited final regulations implementing Affordable Care Act provisions that impose additional obligations on charitable hospital organizations covered by §501(c)(3) of the Internal Revenue Code.  Published in the Federal Register on December 31 2014, the regulations are massive, consolidating a series of prior proposals into a single final body of regulatory law.  The regulations affect more than 80 percent of U.S. hospitals, both the 60 percent that operate as private nonprofit entities and the 23 percent that operate as governmental units.

Because state and local governments typically condition their own sales, property, and corporate income tax exemptions for nonprofit entities to a hospital’s §501(c)(3) status, the final regulations carry broad and deep implications from both a policy and financial perspective.  According to the Congressional Budget Office the 2002 the national value of the federal tax exemption exceeded $12 billion, a figure that undoubtedly has risen considerably.

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Last Year Was A Wild One For Health Law — What’s On The Docket For 2015?


January 22nd, 2015

Everywhere we look, we see the tremendous impact of new legal developments—whether regulatory or statutory, federal or state—on health and health care. These topics range from insurance to intellectual property to religion to professionalism to civil rights. They remain among the most important questions facing Americans today.

This post is the first in a series that will stem from the Third Annual Health Law Year in P/Review event to be held at Harvard Law School on Friday, January 30, 2015. The conference, which is free and open to the public, brings together leading experts to review major developments in health law over the previous year, and preview what is to come.

The event is sponsored by the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School and the New England Journal of Medicine, and co-sponsored by Health Affairs, The Hastings Center, and the Center for Bioethics at Harvard Medical School. Below, we will highlight a few themes that have emerged so far. The conference’s speakers will author a series of posts that follow on more specific topics.

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How Community Health Workers Can Reinvent Health Care Delivery In The US


January 16th, 2015

As health policy, research and practice are becoming increasingly focused on improving the health of populations and addressing social determinants of health, Community Health Workers (CHWs) may be just what the doctor ordered. As part of the public health workforce with ties to the local community, CHWs can now be reimbursed by Medicaid for providing preventive services if recommended by a physician or other licensed practitioner.

This groundbreaking CMS regulatory change, along with policy support from the Affordable Care Act, holds the promise of bridging the gap between mainstream health care and community health through expanding the CHW profession and its impact on clinical care. Much like other disruptive changes in health care, however, fulfilling this potential will require a new way of thinking among state policymakers and the health care system at large.

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Reconsidering Pauly And Coauthors’ ‘Economic Framework For Preventive Care Advice’


January 12th, 2015

In the November issue of Health Affairs, Mark Pauly and coauthors criticize the lack of cost-effectiveness considerations in the Affordable Care Act (ACA), which mandates that health plans include preventive care free at the point of use. The bodies critiqued, the Advisory Committee on Immunization Practices (ACIP) and the U.S. Preventive Services Task Force, convene health experts to develop recommendations for immunizations and other preventive services.

According to the authors, the task entrusted to these bodies by the ACA, of offering sound advice on preventive care without considering its cost-effectiveness, is “impossible to do well.” They propose instead an “economic framework” under which only services with “substantial external benefits” (e.g. a vaccination for contagious disease) would be mandated for coverage. We believe this position is misguided.

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