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Recent Health Policy Briefs: Mental Health Parity And ICD-10 Update

April 3rd, 2014
by Tracy Gnadinger

The latest Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation examines the issue of mental health parity. The push to make coverage for mental health treatment equal to that of physical health has been on legislative to-do lists for some time, both in Congress and in state houses. This brief looks […]

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Responding To ‘The Hidden Curriculum’: Don’t Forget About The Patient

April 3rd, 2014
by Rob Lott

Narrative Matters readers might remember Joshua Liao’s moving essay about the dangers of the Hidden Curriculum. Liao, a resident physician at Brigham and Women’s Hospital, wrote about the consequences of making a serious mistake as a medical student on an obstetrics rotation. He read the essay for the Narrative Matters podcast and it’s a great listen.

Liao’s essay, penned with Eric Thomas and Sigall Bell, also generated some compelling responses. It inspired Tim Lahey to write about his experience leading the curriculum redesign at Dartmouth’s Geisel School of Medicine. And when the Washington Post ran an excerpt of Liao’s essay last week, it led Franca Posner to remind readers about “one missing piece of this puzzle”: the patient’s perspective.

Posner was once in a similar situation, but it was she on the hospital bed: “I was that woman 20 years ago, only I was almost 40 and had a 5-year-old child and five miscarriages in my reproductive history,” Posner wrote in a letter to the editor published in the Post’s Health and Science section on March 31.

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The Health Workforce: A Critical Component Of The Health Care Infrastructure

March 24th, 2014
by Edward Salsberg

Editor’s note: This is the first in a periodic series of Health Affairs Blog posts on health workforce issues by Edward Salsberg. Mr. Salsberg has spent over 30 years studying the health workforce, including nearly 20 years establishing and directing three centers dedicated to workforce data collection, analysis and research. The first center, at the University at Albany, was focused on state health workforce data collection and issues. The second, at the Association of American Medical Colleges, was focused on the physician workforce across the nation. The third, the National Center for Health Workforce Analysis, was authorized by the Affordable Care Act. Mr. Salsberg has now joined the faculty at George Washington University where they are establishing a new Center for Health Workforce Research and Policy.

In the post below, Mr. Salsberg provides an overview of workforce issues. Future posts will discuss more specific health workforce questions and developments.

It could be argued that the health workforce — the people who provide direct patient care, as well as the staff that support caregivers and health care institutions — is the most significant component of the infrastructure of the health care system. Yet as a nation we have invested very little in collecting and analyzing health workforce data or in supporting the necessary research to inform effective public and private decision making. The results of this lack of investment are surpluses and shortages, significant mal-distribution, and less efficient and effective care than would be possible with better intelligence on our workforce needs.

For many health care professions, it takes years to build education and training capacity to increase, supply, or to change curriculum and modify the profession’s skill set. For these professions, we need to not only assess today’s needs but to project our future needs.

What the nation needs is a system to provide data, research findings, and information to thousands of individual stakeholders. This includes individuals considering a health career; colleges, universities and training programs that will educate and prepare them; the health organizations who will employ them; policy makers who need to decide what, if any, programs and policies to support; and the private sector that needs to decide whether to invest in workforce development. The responsibility for assuring an adequate supply and a well prepared health workforce is shared between the public and private sectors at both the national and the state and local level. Regardless of who is making the decisions related to health professions education and training capacity and health professions preparation, accurate and timely data is extremely important to support informed decisions.

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New Health Policy Brief: Transitioning To ICD-10

March 20th, 2014
by Tracy Gnadinger

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation looks at an important change expected in the American health system later this year: the transition to the ICD-10 coding system by all health providers for diagnoses and inpatient procedures. ICD stands for the International Classification of Diseases, which is maintained by the World Health Organization. The ICD system, which began in the nineteenth century, is periodically revised to incorporate changes in the practice of medicine.

While the most current version, ICD-10, has been used in most countries since its initial adoption in 1990, the United States has until now limited its use to the coding and classification of mortality data from death certificates. This brief examines the debates that have accompanied the broad conversion in this country to ICD-10, set to take place on October 1, 2014.

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The Dangers Of Quality Improvement Overload: Insights From The Field

March 7th, 2014

Editor’s note: This post is also co-authored by Ksenia O Gorbenko, Catherine van de Ruit, and Charles Bosk of the University of Pennsylvania.

Quality improvement (QI) and patient safety initiatives are created with the laudable goal of saving lives and reducing “preventable harms” to patients. As the number of QI interventions continues to rise, and as hospitals become increasingly subject to financial pressures and penalties for hospital-acquired conditions (HACs), we believe it is important to consider the impact of the pressure to improve everything at once on hospitals and their staff.

We argue that a strategy that capitalizes on “small wins” is most effective. This approach allows for the creation of steady momentum by first convincing workers they can improve, and then picking some easily obtainable objectives to provide evidence of improvement.

National Quality Improvement Initiatives

Our qualitative team is participating in two large ongoing national quality improvement initiatives, funded by the Agency for Healthcare Research and Quality (AHRQ). Each initiative targets a single HAC and its reduction in participating hospitals. We have visited hospital sites across six states in order to understand why QI initiatives achieve their goals in some settings but not others. To date, we have conducted over 150 interviews with hospital workers ranging from frontline staff in operating rooms and intensive care units to hospital administrators and executive leadership. In interviews for this ethnographic research, one of our interviewees warned us about unrealistic expectations for change, “you cannot go from imperfect to perfect. It’s a slow process.”

While there is much to learn about how to achieve sustainable QI in the environment of patient care, one thing is certain from the growing wisdom of ethnographic studies of QI: buy-in from frontline providers is essential for creating meaningful change. Front-line providers often bristle at expectations from those they believe have little understanding of the demands of their daily work. Requiring health care providers to improve on all mandated measures at once—in an atmosphere of reduced reimbursements and frequent staff shortages—is a goal that risks burnout, discouragement, and apathy – all signs of initiative fatigue.

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Exhibit Of The Month: Virtual Visits On The Rise

February 27th, 2014
by Rob Lott

At Health Affairs Blog, we’re excited to introduce a new regular feature. Each month, Health Affairs editors will review all the tables, charts, graphs and maps that have run in the latest print edition of the journal. After deliberating in a dark, but smoke-free, backroom, we’ll emerge to crown the most compelling, creative or surprising exhibit as our Exhibit of the Month!  Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

This exhibit shows how, within the Kaiser Permanente Northern California system, the number of virtual physician visits grew from 4.1 million in 2008 to 10.5 million in 2013.

According to Pearl, “In 2008 KPNC implemented an impatient  and ambulatory care electronic health record system for its 3.4 million members and developed a suite of patient-friendly Internet, mobile, and video tools.”  Among these tools is a system that allows patients to send secure e-mail messages to their primary care physician.  KPNC physicians are now expected to respond within 24 hours of receiving the message.  This system builds on the 10-15 minute physician telephone visits that KPNC has offered patients for more than a decade.

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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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Doctors Without State Borders: Practicing Across State Lines

February 18th, 2014
by Robert Kocher

Note: In addition to Robert Kocher (photo and bio above), this post is authored, by Topher Spiro, Vice President, Health Policy, Center for American Progress ; Emily Oshima Lee, Policy Analyst, Center for American Progress; Gabriel Scheffler, Yale Law School student and former Ford Foundation Law Fellow at the Center for American Progress with the Health Policy Team; Stephen Shortell, Blue Cross of California Distinguished Professor of Health Policy and Management and Professor of Organization Behavior at the School of Public Health and Haas School of Business at the University of California-Berkeley; David Cutler, Otto Eckstein Professor of Applied Economics in the Faculty of Arts and Sciences at Harvard University; and Ezekiel Emanuel, senior fellow at the Center for American Progress and Vice Provost for Global Initiatives and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania.

In the United States, a tangled web of federal and state regulations controls physician licensing. Although federal standards govern medical training and testing, each state has its own licensing board, and doctors must procure a license for every state in which they practice medicine (with some limited exceptions for physicians from bordering states, for consultations, and during emergencies).

This bifurcated system makes it difficult for physicians to care for patients in other states, and in particular impedes the practice of telemedicine. The status quo creates excessive administrative burdens and like contributes to worse health outcomes, higher costs, and reduced access to health care.

We believe that, short of the federal government implementing a single national licensing scheme, states should adopt mutual recognition agreements in which they honor each other’s physician licenses. To encourage states to adopt such a system, we suggest that the federal Center for Medicare and Medicaid Innovation (CMMI) create an Innovation Model to pilot the use of telemedicine to provide access to underserved communities by offering funding to states that sign mutual recognition agreements.

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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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Can Online Learning Solve The Global Health Care Capacity Crisis?

January 31st, 2014
by Kunmi Sobowale

Health care systems cannot be supported by the efforts of a few. But in many low- and middle-income countries worldwide, one medical specialist may be responsible for the health of millions. In Vietnam, where I work, there is one psychiatrist for 300,000 people. For many people in need, health care is simply unavailable. The inability to provide care, particularly in rural areas, results in increased morbidity and mortality. More community health workers (CHWs) are necessary to provide care where treatment is unavailable.

CHWs are lay people or non-professional health personnel who provide focused health care in local communities. CHWs work with health ministries, non-governmental organizations (NGOs), international organizations, and many other groups. From malaria to mental health, studies find that CHW interventions improve health and are cost-effective.

Despite their merits, many CHWs are employed as temporary workers. After projects end or funding runs out, many CHWs no longer work in a health care capacity. Whether CHWs retain the skills (e.g., data collection) and knowledge (nutrition counseling) they have gained is unknown. Even with long-term projects, education and career advancement may be unavailable, which are important reasons for attrition among CHWs. Poor retention leads to poorer health outcomes for populations served, higher program costs, and threatens program sustainability.

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The Hidden Curriculum: Changing The Water In Which We Swim

January 31st, 2014
by Tim Lahey

Editor’s Note: This post is a response to Joshua Liao, Eric Thomas, and Sigall Bell’s essay, “Speaking Up About The Dangers Of The Hidden Curriculum,” published under Narrative Matters in the January issue of Health Affairs.

As the lights in the auditorium go down, just before I flick on my microphone, I remember what media critic Marshall McLuhan once said about culture: We live “in an electric information environment that is quite as imperceptible to us as water is to fish.”

As a leader of my institution’s curriculum redesign effort, I often speak with departments and even the whole faculty about our plans for the new curriculum. These experiences have made me acutely aware of how well McLuhan’s quote applies to what has been called the “hidden curriculum” in medical education. Medical education, and the culture of medicine in which it occurs, influence personal identity and perception so pervasively that it can be a challenge to talk clearly about how to change the hidden curriculum.

Liao and colleagues overcome that challenge in the January issue of Health Affairs, making an eloquent call for better dialogue about how the hidden curriculum can undermine patient safety. They point out, rightly, that, “The difference between what we say we do and what we actually do as doctors and teachers can be stark.” Such verbal disconnects can undermine the culture of patient safety, a dilemma fixed first through awareness and then through the courage to speak up.

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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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Cracking The Code On Health Care Costs: What The States Can Do

January 7th, 2014
by Raymond Scheppach and John Thomasian

State governments have a unique opportunity to transform the current health care system into one that provides higher-quality care at lower costs. The State Health Care Cost Containment Commission was created to identify how states might use their authorities and policy levers to guide this transformation. The members of the Commission, consisting of two former governors and high-level executives from major national health plans, all shared the same conviction: state governments were much more likely to succeed in lowering the growth rate of health care costs than any federal action in the next few decades. Moreover, the states are well positioned to accelerate the current trend toward integrated, coordinated care organizations that are held accountable for meeting cost management and quality goals.

The goal envisioned by the Commission is straightforward but ambitious: Replace the nation’s reliance on fragmented, fee-for-service care with comprehensive, coordinated care using payment models that hold organizations accountable for cost control and quality gains. Achieving this will take time. There is inertia in the current system and few incentives for changing it. However, the states are in a strong position to achieve meaningful reforms and create the needed incentives with the support of payers, providers, insurers, and consumers. As the nation’s “laboratories of democracy,” states can serve as a proving ground for new approaches that raise the efficiency and value of health care.

The Commission’s report, “Cracking The Code On Health Care Costs,” will be released tomorrow at the National Press Club.

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Health Care Preparedness Funding: Are We Inviting Disaster?

December 31st, 2013
by Dan Hanfling

Editor’s note: This post expands on the theme of the December issue of Health Affairs, The Future of Emergency Medicine: Challenges And Opportunities.

Disasters always make the big headlines. In large part, this is because they can take away lives in an instant. They also make for big news because in some way, shape or form, we identify with those who suffer, if only to think – “at least it wasn’t me”.

In 2013, there were plenty of tragedies that caught our attention. The massive F5 tornado that destroyed Moore, OK. The cowardly bombings of the Boston Marathon followed two days later by the West, TX fertilizer plant explosion that destroyed half of the town, and the super typhoon that struck the Philippines, leaving a swath of death and destruction in its path.

The risks are ever present. And when something big and bad occurs, we are sure to hear about it. But there is a headline that you haven’t seen plastered atop the front pages of newspapers, or on the scroll that occupies the bottom of your television screens. Decreasing emergency preparedness funding is every bit a looming disaster as those noted above and very well may impact the manner and degree to which we are able to respond to such events.

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A Policy Dialogue On Connected Health

December 19th, 2013
by Janet Marchibroda

Editor’s note: In addition to Janet Marchibroda (photo and linked bio above), this post was coauthored by Chris Fleming, Health Affairs Blog Editor.

What is telehealth or “connected health”? What is driving the use of connected health and what are its benefits? To achieve its full potential, what key challenges must be overcome? What are the central policy issues that must be addressed?

These are some of the questions explored by a group of leaders representing providers, payers, research and philanthropic organizations, and technology companies (listed at the end of this post), convened by Health Affairs and the Bipartisan Policy Center (BPC) last month. The session was organized partly to prepare for an upcoming Health Affairs thematic issue on connected health, to which former Senate Majority Leader and BPC Health Project Co-Chair Bill Frist—who chaired the discussion—will contribute.

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The Untold Story Of 2013: Governors Lead In Health Care Transformation

December 17th, 2013
by Dan Crippen and Frederick Isasi

As 2013 winds to a close, it is a good time for the health policy community to reflect on a historic year for our nation. The most talked about health care issues have centered on the rollout of new health insurance and Medicaid coverage as part of the Affordable Care Act. However, another watershed reform of our health care system has been taking root across the country, relatively unnoticed and with many governors at the helm.

These efforts are focused on broad, statewide reforms designed to dramatically alter the way we think about, deliver and pay for health care. The reforms move away from a siloed and fractured delivery system and are focused on two key objectives: improving the health of the nation, and reducing the financial burden of health care on the government, employers and individuals.

The drive for these reforms results from several key pressures. Perhaps most urgent is the fiscal pressure bearing down on states. Governors have acutely experienced the effect of decades of rapidly escalating health care costs, and almost all states are under a requirement to balance their budgets. Governors must, therefore, account for growth in spending in Medicaid and CHIP, state employee and retiree health insurance, and indigent health care. Often these increases must be funded by increased tax revenue or reductions in other areas of state spending, for example education or transportation.

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HA Briefings: Register For Emergency Medicine Event And Watch Workforce Briefing Online

November 27th, 2013
by Chris Fleming

Please join Health Affairs Founding Editor John Iglehart on Wednesday, December 4, 2013, at the National Press Club in Washington, DC, for a Health Affairs briefing at which we will unveil the December issue of the journal, a thematic volume titled “The Future of Emergency Medicine: Challenges And Opportunities.” And if you missed the briefing on our November workforce issue, video and speaker materials are available on our website.

The December emergency medicine event will feature remarks by Dr. Nicole Lurie, Assistant Secretary for Preparedness and Response at the US Department of Health and Human Services.

Wednesday, December 4, 2013
8:30 a.m. – Noon

National Press Club
529 14th Street NW (Metro Center)
Washington, DC


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

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Narrative Matters: Providing Dental Care In Remote Corners Of Alaska

November 21st, 2013
by Chris Fleming

In the November Health Affairs Narrative Matters essay, one of the nation’s few dental therapists explains why his profession could help address dental workforce shortages in the United States. Conan Murat’s article is freely available to all readers, or you can subscribe to iTunes and listen to him read it.

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