Commentary: Community Health Workers and Peace Building Through Health in the Israeli-Palestinian Conflict After October 7th.

Health professionals, despite increasing challenges, with notable exceptions, always pursue peace through health because it is who we are-we are here to heal both at the individual and the community level. This applies to the long-standing Israeli-Palestinian conflict. Unfortunately, till now, nongovernmental organizations have had minimal impact on the conflict. This commentary makes 2 recommendations for donor countries after the fighting subsides: Do not insist on Israeli-Palestinian joint ventures at least for the short term and focus as much as possible your funding on interventions that improve community health.

Community-Based Health Interventions Are Critical for Peace Building in the Worsening Israeli-Palestinian Conflict.

Israeli settlements in the occupied Palestinian Territories (oPT) continue to expand and there is little communication between the 2 sides. Countries not directly engaged in the conflict are uninterested in a dignified solution to the Israeli-Palestinian conflict. This article argues that international organizations, donors, and third states should encourage the following peace-building approaches when considering health care initiatives in this conflict. The first is community oriented lay-led initiatives which should improve health outcomes, enhance the ability of Palestinians to develop resilience and promote peace-building between Israelis and Palestinians. Secondly, this strengthening can, in the absence of the impact of international advocacy for a dignified solution to this long-standing conflict, lead to locally driven peace-building while measurably improving health.

Fitting Community-Centered Population Health (CCPH) Into the Existing Health Care Delivery Patchwork: The Politics of CCPH.

The COVID-19 crisis has nakedly exposed the problems and huge holes in the health care system of the United States. For today, we need to address the current pandemic from the point of view of both control and suppression. But such efforts could also provide insights into a post-pandemic restructuring of health care. If one or several states succeed in addressing the COVID pandemic together with an associated modest economic resurgence, citizens could develop the trust in state leadership necessary to finally make fundamental changes in our health care system. Such change is a once in a century opportunity.

COVID-19 Crisis Creates Opportunities for Community-Centered Population Health: Community Health Workers at the Center.

Dealing with the COVID-19 coronavirus requires a coordinated transnational effort. We propose a 2-stage state-led effort that utilizes community health workers (CHWs). We spell out what is beginning to occur in states to control and suppress COVID-19. In the second stage, we suggest working with these CHWs as a key element in the next evolution of our health care system: community-centered population health.

Permanent Interests Versus Paying for Better Outcomes: Two of the 10 Lessons I Learned Over the Past 30 Years Researching the Connections Between Payment and Health Care Quality.

In the wake of the election of Donald Trump, I resigned from my research work. I decided to become politically involved and since I am a health care professional, in June 2018, I started a bipartisan political consulting firm, Ask Nurses and Doctors (AND; www.asknursesdoctors.com). This start-up is focused on electing candidates or incumbents committed to health care reform. There are 2 approaches to universal coverage-either the Affordable Care Act or Medicare for All. To implement either approach, there are 10 lessons from my 30 years of research that may be useful to enact universal coverage.

Access to Affordable, High-Quality Health Insurance for Rural Residents and Its Impact on Their Health and on Rural Hospitals.

Access to rural health care is an ongoing challenge for those living in America's countryside. Hospital closures, a fragmented and dislocated care delivery system, disproportionate levels of chronic illness, and poverty combine to present significant obstacles to health reform. This article highlights the major challenges in rural health care and specifies financial and delivery policy options that can strengthen rural health care. In particular, this article suggests a return to a prepaid approach within the umbrella organizational framework of what we term "rural convening entities." These entities would serve as the control of telehealth hubs for the communities they serve.

Nursing Home Compare Star Rankings and the Variation in Potentially Preventable Emergency Department Visits and Hospital Admissions.

Measurement of the quality of US health care increasingly emphasizes clinical outcomes over clinical processes. Nursing Home Compare Star Ratings are provided by Medicare to help select better nursing home care. The authors determined the rates and types of 2 important clinical outcomes-potentially preventable hospital admissions and potentially preventable emergency department (ED) visits-for a subset of 439,011 long-term nursing homes residents residing in 12,883 nursing homes throughout the United States over a 2-year period (2010-2011) and compared them with the Star Rating system. This study found that (1) the likelihood of potentially preventable events increases with increasing burden of chronic illness, (2) the principle reasons for hospital admissions and ED visits (eg, septicemia, pneumonia, confusion, gastroenteritis) are not part of existing nursing home quality measures, (3) the rate of potentially preventable admissions and ED visits for nursing homes residents varies greatly both across and within states, with 5 states having in excess of 20% more than the national average for both, and (4) the Nursing Home Compare Stars measure has limited correlation with rates of these potentially preventable events. Nursing Home Compare Star rankings could benefit by incorporating outcomes measures such as preventable hospitalizations and ED visits, and by comparing nursing home performance on results drawn from across states rather than within them. Such reform could better help users find nursing homes of higher quality and stimulate homes to improve quality in ways that benefit residents.

Will Hospital Peer Grouping by Patient Socioeconomic Status Fix the Medicare Hospital Readmission Reduction Program or Create New Problems?

BACKGROUND: In 2016 the U.S. Congress directed the Centers for Medicare & Medicaid Services (CMS) to implement the 21st Century Cures Act to fix a flaw in the Hospital Readmissions Reduction Program (HRRP). One section of the Act is intended to remove bias in calculating penalties for hospitals treating large percentages of low socioeconomic status (SES) patients. A study was conducted to analyze the effect of the introduction of SES hospital peer groups on the number and distribution of the hospitals being penalized. METHODS: The CMS analysis files for the fiscal year 2017 HRRP final rule and Disproportionate Share Hospital adjustments were used to assign hospital peer groups. The median excess readmission ratios for hospital peer groups were calculated, and the resulting pattern of hospital penalties within peer groups was analyzed. RESULTS: The findings suggest that because CMS assigns individual HRRP penalties on six clinical conditions but proposes to assign hospitals to a single SES peer group based on all admissions, it will ignore substantial differences in the distribution of peer group medians across these conditions. For surgical cases, as expected, hospitals with fewer patients had higher readmission rates, while for medical cases, hospitals with fewer patients had fewer readmissions. These findings may result in distortion of the peer group adjustment intended to correct for SES. CONCLUSION: Hospital peer groups may create unintended redistributions of penalties through distortion of peer group medians. An observed relationship between lower-volume hospitals and fewer readmissions for medical conditions requires additional research to establish its basis.

Moving Toward Paying for Outcomes in Medicaid.

Medicaid can improve beneficiary health and help sustain its own future by embracing payment for outcomes. Good precedents exist from states such as Florida, Maryland, Minnesota, New York, Ohio, Pennsylvania, and Texas. Medicaid outcome measures include preventable admissions, readmissions, emergency department visits, and inpatient complications; early elective deliveries; infant and child mortality; patient-reported outcomes, satisfaction, and confidence; and reduction in low-value care. Criteria to prioritize initiatives include potential savings, availability of established models, impact on health status, and Medicaid's ability to effect change. We offer 5 principles for success, emphasizing clinically credible initiatives that generate actionable information for clinicians.

Achieving Improved Outcomes Through Value-Based Purchasing in One State.

Beginning as early as 2009, Texas began to put the antecedents in place for an effective Medicaid value-based purchasing model. Since those early activities were undertaken, Texas Medicaid is emerging as a national leader in value-based purchasing and has produced exceptional results that clearly demonstrate the value proposition associated with alignment of financial incentives. This article presents several years of data and preliminary results of this effort. This study found significant improvements in a number of outcomes. Further improvement will depend on implementation of financial incentives and ongoing commitment to paying for better outcomes. This ongoing commitment includes many additional programs that hospitals, in particular, have put in place such as improved handwashing techniques.

Dramatic Changes in Health Care Professions in the Past 40 Years.

During the forty-year life of the Journal of Ambulatory Care Management, revolutionary transformations have occurred in the roles of existing health professions, as has the emergence of new categories of health professionals. This paper specifies the reasons for these dramatic changes, the new types of health care professions that have emerged, changes in existing professions, and suggestions of future directions. Many of these changes will be impacted by what occurs in Washington, DC in the debate over the Accountable Care Act.

Is the CMS Hospital-Acquired Condition Reduction Program a Valid Measure of Hospital Performance?

In October 2014, the Centers for Medicare & Medicaid Services began reducing Medicare payments by 1% for the bottom performing quartile of hospitals under the Hospital-Acquired Condition Reduction Program (HACRP). A tight clustering of HACRP scores around the penalty threshold was observed resulting in 13.2% of hospitals being susceptible to a shift in penalty status related to single decile changes in the ranking of any one of the complication or infection measures used to compute the HACRP score. The HACRP score also was found to be significantly correlated with several hospital characteristics including hospital case mix index. This correlation was not confirmed when an alternative method of measuring hospital complication performance was used. The sensitivity of the HACRP penalties to small changes in performance and correlation of the HACRP score with hospital characteristics call into question the validity of the HACRP measure and method of risk adjustment.

Quality Improvement Initiatives Need Rigorous Evaluation: The Case of Pressure Ulcers.

The Partnership for Patients (PfP) and the Agency for Healthcare Research and Quality (AHRQ) have reported a 23.5% decline in hospital-acquired pressure ulcers (HAPU) over 4 years resulting in a cumulative cost savings of more than $10 billion and 49 000 averted deaths, claiming that this significant decline may have been spurred in part by Medicare payment incentives associated with severe (stage 3 or 4) HAPUs. Hospitals with a high rate of severe HAPUs have a payment penalty imposed, creating a financial disincentive to report severe HAPUs, possibly contributing to the magnitude of the reported decline. Despite the financial disincentive to report, the number of severe HAPUs found in claims data over the corresponding 4-year period did not decline but instead remained unchanged. The results from claims data, combined with some flaws in estimating HAPUs, call into question the validity of the decline in HAPUs reported by PfP and AHRQ.

How Encouraging Provider Collaboration and Financial Incentives Can Improve Outcomes for Persons With Severe Psychiatric Disorders.

This Open Forum addresses the challenging situation involving decisions about when to hospitalize patients for psychiatric care. Because the evidence base for when to hospitalize patients is incomplete, current practice is to hospitalize only patients who are in crisis. This Open Forum provides a suggested set of payment options that can provide financial incentives to change practice patterns and lead to better clinical outcomes.

Paying for On-Patent Pharmaceuticals: Limit Prices and the Emerging Role of a Pay for Outcomes Approach.

In this article we propose a new approach to pricing for patent-protected (on-patent) pharmaceuticals. We describe and define limit pricing as a method for drug companies to maximize revenue for their investment by offering budget-neutral pricing to encourage early adoption by payers. Under this approach, payers are incentivized to adopt innovative but expensive drugs more quickly if drug companies provide detailed analyses of the net impact of the new pharmaceutical upon total health budgets. For payers to adopt use of a new pharmaceutical, they would require objective third-party evaluation and pharmaceutical manufacturer accountability for projected outcomes efficacy of their treatments on population health. The pay for outcomes underpinning of this approach falls within the wider aspirations of health reform.