Who Are the Local Policy Innovators? Cluster Analysis of Municipal Tobacco Control Policies in Massachusetts.

CONTEXT: Tobacco use is a leading cause of preventable death, yet it is challenging to establish public policy to reduce tobacco use. Massachusetts has been a national leader in tobacco control, and its policy-making patterns can be informative to the country. OBJECTIVE: To identify factors associated with the adoption of tobacco policy within 351 Massachusetts municipalities. DESIGN: We obtained the 2019 Massachusetts municipality-level tobacco control policy information from Massachusetts' Tobacco Automated Fact Sheet Information system and compiled it with data from American Community Survey, Massachusetts Municipal Association, and Massachusetts state government's Web sites. We used k -means clustering method to identify statistical clustering patterns and hotspot analysis (Getis-Ord Gi*) and Local Indicators of Spatial Association to identify geographic clustering patterns. We then performed multinomial logistic regression to identify factors associated with policy clusters. SETTING: Massachusetts. PARTICIPANTS: Three hundred fifty-one municipalities in Massachusetts. MAIN OUTCOME MEASURE: Policy clusters-groups of municipalities with similar tobacco control policy behaviors. RESULTS: Based on the k -means analyses, we identified 3 clusters in Massachusetts municipal tobacco control policy behaviors: 54% (N = 191) of municipalities were "Policy Leaders" with a high adoption rate of the 6 tobacco control policies; 18% (N = 63) were "Peer-Influenced Actors" focused on tobacco purchase restrictions for individuals younger than 21 years; and 28% (N = 97) were "Policy Non-Actors," with no tobacco control policies in place. Policy Leaders were geographically clustered in larger cities and the MetroWest region. Policy Non-Actors were clustered in rural areas of Western and Central Massachusetts. Larger municipal population size, higher municipal tax income, and higher percentages of residents voting Democratic were associated with higher policy adoption activities. CONCLUSIONS: Local variation in the adoption of tobacco policies may exacerbate inequities in tobacco use and population health. Opportunities remain to implement additional tobacco control regulations at the local level to promote public health.

Knowledge Translation and WIC Food Package Regulation Change.

OBJECTIVE: Knowledge Translation (KT) is the exchange, synthesis, and ethically-sound application of knowledge. A case study methodology is used to examine KT at the organizational level of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program. METHOD: The study used purposeful sampling to select WIC informants from state WIC agencies to participate in semi-structured interviews about their individual experiences during the 2009 WIC regulation change process. Thematic coding of retrospective semi-structured interviews with key informants from WIC state agencies revealed key components of the state-level WIC regulation implementation process, and key constructs of Organizational Readiness for Knowledge Translation in the WIC program. RESULTS: WIC informants highlight that decisions made by WIC state agencies regarding how to appraise, synthesize, and adapt evidence or regulation change are constrained by the KT decisions made by federal agencies. WIC state agencies should assess their level of readiness for KT in terms of 1) innovation readiness; 2) personal readiness; and 3) institutional readiness. CONCLUSIONS: This WIC case study can help decision-makers to understand the KT process of implementing evidence-informed regulation changes, identify factors that could influence states' ability to be prepared for implementing changes, and gauge "practicality" of future WIC regulation changes.

Knowledge translation strategies designed for public health decision-making settings: a scoping review.

OBJECTIVES: To review and describe available Knowledge Translation (KT) strategies that are designed for or applied in public health decision-making settings. INTRODUCTION: KT is the exchange, synthesis, and ethically sound application of knowledge. This review proposes that KT strategies in public health settings should be understood as action plans that promote evidence use and facilitate evidence-informed decision-making. METHODS: This scoping review included studies that reported on KT strategies applied in public health settings, published between 2010 and 2017. Studies were searched using Medline, online KT database, and citation tracing. Data from 305 included studies were synthesized using a coding form and conceptually mapped to identify KT strategies used in public health settings. RESULTS: A total of 124 unique examples of KT methods or tools were identified and summarized into 38 recommended and promising KT strategies. Built on the lists of recommended strategies, this review synthesized a framework that matched all 38 KT strategies to 10 key components of the evidence-informed decision-making process. CONCLUSIONS: The public health KT strategies summarized and organized by this review promote a better understanding and more effective use of KT strategies.

Investigating consumer hospital choice: Demand and supply-side levers could address health care costs.

OBJECTIVE: Policies that aim to steer patients from higher to lower cost providers of comparable quality have potential to impact health care cost growth - but their effectiveness depends, in part, on consumer perceptions of value and willingness to make tradeoffs. We sought to understand what was required to shift substantial numbers of consumers to higher-value care settings for several "shoppable" conditions. METHODS: A discrete choice experiment (DCE) was conducted to elicit patient preferences for hospital type. We used an Internet panel of 1005 Massachusetts residents to conduct this experiment in 2016. The DCE data were analyzed using alternative-specific conditional logit regression. RESULTS: Consumers reported large influences of out of pocket costs, physician referrals and quality ratings on their choice of hospital. For example, up to a third of consumers would shift from Academic Medical Centers to community hospitals if the latter had higher quality ratings, lower copays or a physician referral. Choice of site for maternity care was most influenced by physician referral; cancer treatment and orthopedic procedures by quality ratings; and MRI by cost, suggesting that patients prioritize quality over cost as perceived risk increases. CONCLUSIONS AND IMPLICATIONS: Our findings provide guidance for identifying promising policy levers that most influence consumer choice of provider. However, the extent to which potential levers can influence choice is likely to be dependent upon the kind of care being sought.

An Early Look At SHOP Marketplaces: Low Premiums, Adequate Plan Choice In Many, But Not All, States.

The Affordable Care Act created the Small Business Health Options Program (SHOP) Marketplaces to help small businesses provide health insurance to their employees. To attract the participation of substantial numbers of small employers, SHOP Marketplaces must demonstrate value-added features unavailable in the traditional small-group market. Such features could include lower premiums than those for plans offered outside the Marketplace and more extensive choices of carriers and plans. More choices are necessary for SHOP Marketplaces to offer the "employee choice model," in which employees may choose from many carriers and plans. This study compared the numbers of carriers and plans and premium levels in 2014 for plans offered through SHOP Marketplaces with those of plans offered only outside of the Marketplaces. An average of 4.3 carriers participated in each state's Marketplace, offering a total of forty-seven plans. Premiums for plans offered through SHOP Marketplaces were, on average, 7 percent less than those in the same metal tier offered only outside of the Marketplaces. Lower premiums and the participation of multiple carriers in most states are a source of optimism for future enrollment growth in SHOP Marketplaces. Lack of broker buy-in in many states and burdensome enrollment processes are major impediments to success.

Knowledge of cost sharing and decisions to seek care.

OBJECTIVES: To assess knowledge and understanding of cost-sharing responsibilities and whether that knowledge and understanding influence actual and perceived use of healthcare services. STUDY DESIGN: A 3000-person random sample was drawn from a state employee database in Massachusetts. METHODS: Survey responses and claims analyses were used to assess knowledge of cost sharing and healthcare utilization over a 3-year study period. Trend models and logistic regression were used. RESULTS: Nearly two-thirds of respondents (62%) accurately recalled the percentage of premium that they paid; 67% recalled the correct copayment for a doctor's visit. Younger, less educated, and lower-income employees recalled their copayment more accurately than older, more educated, higher-income colleagues. Half of the respondents accurately reported the copayment amount for an emergency department visit. Greater knowledge of overall healthcare costs was positively associated with higher utilization of office visits (P <.01). Knowledge of specific office visit and emergency department copayments had no significant relationship with utilization. Self-reported delays and reductions in utilization were much more pronounced than the actual claims data indicated. CONCLUSIONS: Employees were reasonably well informed about their cost-sharing responsibilities. Knowledge of costs was associated with higher office visit utilization during the study period. Respondents who were more knowledgeable about their specific copayments for office visits and emergency department visits also were more likely to behave in what appeared to be a more cost-efficient manner, with more office visits and fewer emergency department visits.

The Massachusetts Commonwealth Health Insurance Connector: structure and functions.

The Commonwealth Health Insurance Connector Authority is the centerpiece of Massachusetts' ambitious health care reforms, which were implemented beginning in 2006. The Connector is an independent quasi-governmental agency created by the Massachusetts legislature to facilitate the purchase of affordable, high-quality health insurance by small businesses and individuals without access to employer-sponsored coverage. This issue brief describes the structure and functions of the Connector, providing a primer to policymakers interested in exploring similar reforms at the state and national level. The authors describe how the Connector works to promote administrative ease, eliminate paperwork, offer portability of coverage, and provide some standardization and choice of plans. National policymakers looking to achieve similar policy goals may find some of the structural components and functions of the Connector to be transferable to a national health reform model, say the authors.

Employee input and health care cost-containment strategies.

Health insurance premiums have risen steadily in recent years, and many employers are coping by increasing employee premium contributions. The danger with cost shifting is that a substantial number of employees will refuse offered insurance because of the escalating contribution required of them. The authors surveyed employees regarding what aspects of their insurance benefits they would be willing to give up if their policies were to be substantially trimmed. The responses were varied and influenced by income, education, current contribution to premium, and health status. Interestingly, few employees outside of unions strategize with their employers about how best to structure health insurance benefits to keep them affordable.