Bringing the Social Sciences to Health Policy: An Appreciation of David Mechanic.

David Mechanic has been a pioneering leader in the social and behavioral sciences of health, health services, and health and mental health policy for more than fifty years. One of David's most distinctive qualities has been his vision in identifying trends and defining new research areas and perspectives in health care policy. His early work on how methods of physician payment by capitation and fee-for-service in England and the United States affected physicians' responses to patients and patient care addressed present challenges and many ongoing studies of payment mechanisms. His papers on rationing of health care established a framework for examining alternative allocation mechanisms and just decision making. Influential papers dealt with risk selection, policy challenges in managed care, reducing racial disparities, trust relationships between patients, doctors, and the public and health institutions, and the predicaments of health reform. Focusing on the implementation of the Affordable Care Act, David explored its opportunities and challenges especially in providing comprehensive and effective behavioral health services. A hallmark of his work has been his redirecting our attention to the most severely ill and those in greatest need. Less visible is the leadership and institution building endeavors and the many honors David has received.

Incomplete Markets and Imperfect Institutions: Some Challenges Posed by Trust for Contemporary Health Care and Health Policy.

As contemporary health policy promotes evidence-based practices using targeted incentives, policy makers may lose track of vital aspects of care that are difficult to measure. For more than a half century, scholars have recognized that these latter aspects play a crucial role in high-quality care and equitable health system performance but depend on the potentially frail reed of providers' trustworthiness: that is, their commitment to facets and outcomes of care not easily assessed by external parties. More recently, early experience with pay for performance in health settings suggests that enhancing financial rewards for the measurable undermines providers' commitment to the unmeasurable, degrading the trustworthiness of their practices. Reformers have looked to revised professional norms or reorganized practice arrangements to bolster the intrinsic motivations required for trustworthiness. We suggest here that these responses are likely to prove inadequate. We propose that they be complemented by a renewed policy-making commitment to nonprofit ownership among health care providers, insurers, and integrated delivery systems. We identify some of the concerns raised in the past with ownership-based policies and propose a set of responses. If these are pursued in combination, they hold the promise of a sustainable ownership-based policy reform for the United States.

Explaining racial/ethnic disparities in use of high-volume hospitals: decision-making complexity and local hospital environments.

Racial/ethnic minorities are less likely to use higher-quality hospitals than whites. We propose that a higher level of information-related complexity in their local hospital environments compounds the effects of discrimination and more limited access to services, contributing to racial/ethnic disparities in hospital use. While minorities live closer than whites to high-volume hospitals, minorities also face greater choice complexity and live in neighborhoods with lower levels of medical experience. Our empirical results reveal that it is generally the overall context associated with proximity, choice complexity, and local experience, rather than differential sensitivity to these factors, that provides a partial explanation of the disparity gap in high-volume hospital use.

American primary care physicians' decisions to leave their practice: evidence from the 2009 commonwealth fund survey of primary care doctors.

The status of the primary care workforce is a major health policy concern. It is affected not only by the specialty choices of young physicians but also by decisions of physicians to leave their practices. This study examines factors that may contribute to such decisions. We analyzed data from a 2009 Commonwealth Fund mail survey of American physicians in internal medicine, family or general practice, or pediatrics to examine characteristics associated with their plans to retire or leave their practice for other reasons in the next 5 years. Just over half (53%) of the physicians age 50 years or older and 30% of physicians between age 35 and 49 years may leave their practices for these reasons. Having such plans was associated with many factors, but the strongest predictor concerned problems regarding time spent coordinating care for their patients, possibly reflecting dissatisfaction with tasks that do not require medical expertise and are not generally paid for in fee-for-service medicine. Factors that predict plans to retire differ from those associated with plans to leave practices for other reasons. Provisions of the Patient Protection and Affordable Care Act that reduce the number of uninsured patients as well as innovations such as medical homes and accountable care organizations may reduce pressures that lead to attrition in the primary care workforce. Reasons why primary care physicians' decide to leave their practices deserve more attention from researchers and policy makers.

Health care for undocumented migrants: European approaches.

European countries have smaller shares of undocumented migrants than does the United States, but these individuals have substantial needs for medical care and present difficult policy challenges even in countries with universal health insurance systems. Recent European studies show that policies in most countries provide for no more than emergency services for undocumented migrants. Smaller numbers of countries provide more services or allow undocumented migrants who meet certain requirements access to the same range of services as nationals. These experiences show it is possible to improve access to care for undoc­umented migrants. Strategies vary along three dimensions: (1) focusing on segments of the population, like children or pregnant women; (2) focusing on types of services, like preventive services or treatment of infectious diseases; or (3) using specific funding policies, like allowing undocumented migrants to purchase insurance.

Electronic health records: an international perspective on "meaningful use".

Research has shown that the United States lags many other countries in the adoption of electronic health records (EHRs). The U.S. has now embarked on a major effort to achieve "meaningful use" of health information technology by clinicians and hospitals. This issue brief describes the extent of meaningful use in three countries with very high levels of health information technology adoption­Denmark, New Zealand, and Sweden. While all three have achieved high levels of meaningful use, none has reached 100 percent in all categories. The brief find[sic] high levels of meaningful use for EHR items and substantial information-sharing with other organizations or health authorities, although less information is shared with patients. Insights that may prove useful to the United States include providing economic incentives to encourage adoption and designating an organization to take responsibility for standardization and interoperability.

England's approach to improving end-of-life care: a strategy for honoring patients' choices.

In the U.S. health care system, and in those of many other countries, the care of dying patients is generally not performed well, with pain and other distress frequently undertreated and patients' preferences not respected. England's evidence-based End of Life Care Strategy could prove instructive. This issue brief discusses the origins, content, and implementation of the Strategy, as well as its potential impact. Both England and the United States struggle with similar challenges, including looking beyond the province of hospice and palliative-care specialists and initiating palliative services before the patient's final days. Aspects of the English approach that may be useful in the United States include strategies to help physicians recognize when patients are entering a trajectory that may end in death, the use of "death at home" as a metric for measuring progress, improving the skills of clinical and caregiving personnel through Web-based training, and developing a national improvement pathway.

Does it all add up?

Flaws in Schedule H community benefit reporting will affect systems.

Racial and ethnic differences in the use of high-volume hospitals and surgeons.

OBJECTIVE: To examine racial/ethnic differences in the use of high-volume hospitals and surgeons for 10 surgical procedures with documented associations between volume and mortality. DESIGN: Cross-sectional regression analysis. SETTING: New York City area hospital discharge data, 2001-2004. PATIENTS: Adults from 4 racial/ethnic categories (white, black, Asian, and Hispanic) who underwent surgery for cancer (breast, colorectal, gastric, lung, or pancreatic resection), cardiovascular disease (coronary artery bypass graft, coronary angioplasty, abdominal aortic aneurysm repair, or carotid endarterectomy), or orthopedic conditions (total hip replacement). MAIN OUTCOME MEASURE: Treatment by a high-volume surgeon at a high-volume hospital. RESULTS: There were 133 821 patients who underwent 1 of the 10 procedures. For 9 of the 10 procedures, black patients were significantly (P < .05) less likely (after adjustment for sociodemographic characteristics, insurance type, proximity to high-volume providers, and comorbidities) to be operated on by a high-volume surgeon at a high-volume hospital and more likely to be operated on by a low-volume surgeon at a low-volume hospital. Asian and Hispanic patients, respectively, were significantly less likely to use high-volume surgeons at high-volume hospitals for 5 and 4 of the 10 procedures and more likely to use low-volume surgeons at low-volume hospitals for 3 and 5 of the 10 procedures. CONCLUSIONS: Minority patients in New York City are doubly disadvantaged in their surgical care; they are substantially less likely to use both high-volume hospitals and surgeons for procedures with an established volume-mortality association. Better information is needed about which providers minority patients have access to and how they select them.

Racial and ethnic disparities in the use of high-volume hospitals.

Differences in the source of care could contribute to racial and ethnic disparities in health status. This study looks at a major metropolitan area and examines racial and ethnic differences in the use of high-volume hospitals for 17 services for which there is a documented positive volume-outcome relationship. Focusing on the hospitalizations of New York City area residents in the periods 1995-1996 and 2001-2002, we found, after controlling for socioeconomic characteristics, insurance coverage, proximity of residence to a high-volume hospital, and paths to hospitalization, that minority patients were significantly less likely than whites to be treated at high-volume hospitals for most volume-sensitive services. The largest disparities were between blacks and whites for cancer surgeries and cardiovascular procedures.

The accountability of nonprofit hospitals: lessons from Maryland's community benefit reporting requirements.

Under Internal Revenue Service requirements, nonprofit hospitals will begin filing new community benefit reports in 2010. Maryland has had similar requirements since 2004. This paper, based on interviews at 20 hospitals, describes how Maryland's requirements affected hospitals and their activities. Increases in reported community benefit expenditures since the program began are due to both changes in activities and better data capture. Charity care accounts for one-third of community benefit dollars. A key distinction concerns whether hospitals take an accounting or managerial approach to community benefit. The Maryland experience suggests the issues that will arise when the national requirements are implemented.

Charitable expectations of nonprofit hospitals: lessons from Maryland.

Little is known about nonprofit hospitals' community benefit spending other than for charity care. Better accountability is desirable, but critics have focused too narrowly on charity care. Using data from reporting requirements in Maryland similar to federal rules that take effect in 2010, we describe the broad range of community benefit spending in nonprofit hospitals there, which amounted to 7.4 percent of expenses in 2007. Charity care for hospital services accounted for one-third of this amount (payments to physicians for charity patients are reported separately). Hospitals' community benefit spending varies with local needs, resources, and resource allocation decisions.