The European Green Deal and nephrology: a call for action by the European Kidney Health Alliance.

The world faces a dramatic man-made ecologic disaster and healthcare is a crucial part of this problem. Compared with other therapeutic areas, nephrology care, and especially dialysis, creates an excessive burden via water consumption, greenhouse gas emission and waste production. In this advocacy article from the European Kidney Health Alliance we describe the mutual impact of climate change on kidney health and kidney care on ecology. We propose an array of measures as potential solutions related to the prevention of kidney disease, kidney transplantation and green dialysis. For dialysis, several proactive suggestions are made, especially by lowering water consumption, implementing energy-neutral policies, waste triage and recycling of materials. These include original proposals such as dialysate regeneration, dialysate flow reduction, water distillation systems for dialysate production, heat pumps for unit climatization, heat exchangers for dialysate warming, biodegradable and bio-based polymers, alternative power sources, repurposing of plastic waste (e.g. incorporation in concrete), registration systems of ecologic burden and platforms to exchange ecologic best practices. We also discuss how the European Green Deal offers real potential for supporting and galvanizing these urgent environmental changes. Finally, we formulate recommendations to professionals, manufacturers, providers and policymakers on how this correction can be achieved.

The European Kidney Health Alliance (EKHA) and the Decade of the KidneyTM.

The European Kidney Health Alliance (EKHA) is an advocacy organization that defends the case of the kidney patients and the nephrological community at the level of the European Union (EU), and from there, top to bottom, also at the national level of the EU member states and the EU-associated countries. The Decade of the KidneyTM is a global initiative launched by the American Association of Kidney Patients (AAKP) to create greater awareness and organize patient demands for long overdue innovation in kidney care. This article describes the medical and patient burden of kidney disease, the history of EKHA, its major activities and tools for policy action, and the need for innovation of kidney care. We then describe the Decade of the KidneyTM initiative, the rationale behind why EKHA joined this activity to emanate parallel action at the European side, the novel professionalized structure of EKHA, and its immediate targets. The final aim is to align all major stakeholders for an action plan on kidney disease comparable to Europe's successful Beating Cancer Plan, with the additional intent that the EKHA model is applied also by the respective national kidney-related societies to create a broad mobilization at all levels. The ultimate aims are that the EU considers chronic kidney disease (CKD) as a major health and health-economic problem, to consequently have CKD included as a key health research target by the European Commission, and to improve quality of life and outcomes for all kidney patients.

Using a Collective Impact framework to evaluate an Australian health alliance for improving health outcomes.

Complex social issues such as population health mean that no one person, organization or sector can resolve these problems alone and instead require a collaborative approach. This study applied the Collective Impact framework to evaluate the alliance responsible for delivering a large-scale health promotion initiative. Committee meeting minutes for a 4-year period and qualitative interviews with key stakeholders (N = 14) involved in the design and implementation of the initiative explored the factors that contributed to collaborative efforts and initiative outcomes. Major strengths of the Healthier Queensland Alliance (the Alliance) stemmed from identifying a common agenda and using frequent communication to develop trust among Alliance partners. These processes were important, particularly in improving key relationships to ensure inclusivity and equity. Reinforcing activities helped to support individual organizational efforts, while shared measurement systems promoted data-driven decision-making and learning, which contributed to continuous improvement and innovation. Current findings support the use of the Collective Impact framework as a scaffold to assist collaborative alliances in working effectively and efficiently when implementing large-scale initiatives aiming to create positive social impact. This study has identified the foundations of practice to establish a successful Collective Impact alliance.

Collective action to achieve social impact requires collaboration allowing organizations to expand their resources and abilities to enhance their collective capabilities. This paper reports on the use of the Collective Impact framework to show how a collaboration of partner organizations was developed to achieve social impact in a large health promotion initiative. The study identified six foundations for practice to enable successful collective partnerships that will be useful for practitioners and policy-makers when developing health promotion initiatives targeting a range of priority groups. The Collective Impact framework offers a strategic approach for building capacity in a range of communities to navigate power dynamics and find new ways of collaboration to achieve positive social impacts for their communities.

Characteristics of Successful Health Alliance Strategies: Evidence From Rural Healthcare Experiences.

EXECUTIVE SUMMARY: The formation of regional strategic alliances continues to be a well-evidenced response to a varying array of market forces that are challenging the ability of healthcare institutions to realize their missions. Organizations that serve rural communities especially feel pressure to initiate the formation of these collaborative arrangements.In response to concerns of Pennsylvania legislators regarding the impact of these alliances on rural healthcare entities, the Center for Rural Pennsylvania funded a study of outcomes of regional strategic alliances involving rural healthcare institutions. Although the research focused on outcomes, the data also revealed organizational characteristics and patterns of decisions and actions that separated rural healthcare institutions with greater alliance outcome success from their peers serving other rural communities. Strategic leadership and interorganizational management expertise serve as the foundation for decisions and actions beginning before an active search for an alliance and culminating with the achievement of alliance goals. Commitments to collaborative leadership, purposeful partnership, coordination, and progress thematically represent the series of critical decisions and actions collectively required to achieve strategic alliance success. The case of the Laurel Health System illustrates these commitments.Although the findings are based on an intensive review of regional strategic alliances involving rural healthcare institutions, the lessons presented here are transferable to community healthcare organizations regardless of location.

Combining Quantitative Risk Assessment of Human Health, Food Waste, and Energy Consumption: The Next Step in the Development of the Food Cold Chain?

The preservation of perishable food via refrigeration in the supply chain is essential to extend shelf life and provide consumers with safe food. However, electricity consumed in refrigeration processes has an economical and an environmental impact. This study focuses on the cold chain of cooked ham, including transport, cold room in supermarket, display cabinet, transport by consumer, and domestic refrigerator, and aims to predict the risk for human health associated with Listeria monocytogenes, the amount of food wasted due to the growth of spoilage bacteria, and the electrical consumption to maintain product temperature through the cold chain. A set of eight intervention actions were tested to evaluate their impact on the three criteria. Results show that the modification of the thermostat of the domestic refrigerator has a high impact on food safety and food waste and a limited impact on the electrical consumption. Inversely, the modification of the airflow rate in the display cabinet has a high impact on electrical consumption and a limited impact on food safety and food waste. A cost-benefit analysis approach and two multicriteria decision analysis methods were used to rank the intervention actions. These three methodologies show that setting the thermostat of the domestic refrigerator to 4 °C presents the best compromise between the three criteria. The impact of decisionmaker preferences (criteria weight) and limitations of these three approaches are discussed. The approaches proposed by this study may be useful in decision making to evaluate global impact of intervention actions in issues involving conflicting outputs.

Trust, Money, and Power: Life Cycle Dynamics in Alliances Between Management Partners and Accountable Care Organizations.

Policy Points Accountable care organizations (ACOs) form alliances with management partners to access financial, technical, and managerial support. Alliances between ACOs and management partners are subject to destabilizing tension around decision-making authority, distribution of shared savings, and conflicting goals and values. Management partners may serve either as trainers, ultimately breaking off from the ACO, or as central drivers of the ACO. Management partner participation in ACOs is currently unregulated, and management partners may receive a significant portion (in some cases, majority) of shared savings. CONTEXT: Accountable care organizations (ACOs) are a prominent payment and delivery model. Though ACOs are often described as groups of health care providers, nearly 4 in 10 ACOs partner with a management company for services such as financial investment, contracting, data analytics, and care management, according to recent research. However, we know little about how and why these partnerships form. This article aims to understand the reasons providers seek partners, the nature of these relationships, and factors critical to the success or failure of these alliances. METHODS: We used qualitative data collected longitudinally from 2012 to 2017 at 2 ACOs to understand relationships between management partners and ACO providers. The data include 115 semistructured interviews and observational data from 7 site visits. Two coders applied 48 codes to the data. We reviewed coded data for emergent themes in the context of alliance life cycle theory. FINDINGS: Qualitative data revealed that management partners brought specific skills and services and also gave providers confidence in pursuing an ACO. Over time, tension between providers and management partners arose around decision-making authority, distribution of shared savings, and conflicting goals and values. We observed 2 outcomes of partnerships: cemented partnerships and dissolution. Key factors distinguishing alliance outcome in these 2 cases include degree of trust between organizations in the alliance; approach to conflict resolution; distribution of power in the alliance; skills and confidence acquired by the ACO over the life of the alliance; continuity of management partner delivery on promised resources; and proportion of savings going to the management partner. CONCLUSIONS: The diverging paths for ACOs with management partners suggest 2 different roles that management partners may play in ACO development. In some cases, management partners may serve as trainers, with the partnership dissolving once the ACO gains skills and confidence to work alone. In other cases, the management partner is a central driver of the ACO and unlikely to break off.

Patient Protection and Affordable Care Act; Adoption of the Methodology for the HHS-Operated Permanent Risk Adjustment Program for the 2018 Benefit Year Final Rule. Final rule.

This final rule adopts the HHS-operated risk adjustment methodology for the 2018 benefit year. In February 2018, a district court vacated the use of statewide average premium in the HHS-operated risk adjustment methodology for the 2014 through 2018 benefit years. Following review of all submitted comments to the proposed rule, HHS is adopting for the 2018 benefit year an HHS-operated risk adjustment methodology that utilizes the statewide average premium and is operated in a budget-neutral manner, as established in the final rules published in the March 23, 2012 and the December 22, 2016 editions of the Federal Register.

Health Care Sharing Ministries: What Are the Risks to Consumers and Insurance Markets?

Issue: Health care sharing ministries (HCSMs) are a form of health coverage in which members--who typically share a religious belief--make monthly payments to cover expenses of other members. HCSMs do not have to comply with the consumer protections of the Affordable Care Act and may provide value for some individuals, but pose risks for others. Although HCSMs are not insurance and do not guarantee payment of claims, their features closely mimic traditional insurance products, possibly confusing consumers. Because they are largely unregulated and provide limited benefits, HCSMs may be disproportionately attractive to healthy individuals, causing the broader insurance market to become smaller, sicker, and more expensive. Goal: To understand state regulator perspectives on regulation of HCSMs and the impact of these arrangements on consumers and markets. Methods: Analysis of state laws governing HCSMs in all states; interviews with officials in 13 states; and review of the membership requirements and benefits of five HCSMs. Findings and Conclusions: State regulators voiced concerns regarding the potential risks of HCSMs to consumers and their individual markets. However, in the absence of reliable data describing HCSM enrollment, regulators cannot adequately assess harm. Though limited resources and political constraints have made oversight difficult, all states, regardless of their regulatory approach to HCSMs, should obtain data to better understand the role of HCSMs in their markets.

Successes and failures of compulsory risk mitigation: re-evaluating the Turkish Catastrophe Insurance Pool.

The Turkish Catastrophe Insurance Pool (TCIP) is one of the best practices of public-private partnerships in an emerging market designed to reduce economic losses from disasters. This paper reviews the application of this compulsory mechanism along with data relating to the performance of the scheme following recent earthquakes in Turkey. We also consider the current perceptions of Turkish society towards the TCIP and how they can be enhanced. Our conclusions aim to assist stakeholders in government, homeowners, insurance companies, media, banks and civil society to appreciate the value of the system and key actions necessary to improve it.

Why a national high-risk insurance pool is not a workable alternative to the marketplace.

The Pre-Existing Condition Insurance Plan (PCIP) was a national high-risk pool established under the Affordable Care Act (ACA) to provide coverage for individuals with preexisting conditions who had been uninsured for at least six months. It was intended to be a temporary program: PCIPs opened in 2010 and closed in April 2014. At that point, those with preexisting conditions could shop for health insurance in the marketplaces, where plans are prevented from using applicants' health status to deny coverage or charge more. This issue brief draws on the PCIP experience to outline why national high-risk pools, which continue to be proposed as policy alternatives to ACA coverage expansions, are expensive to enrollees as well as their administrators and ultimately unsustainable. The key lesson--and the principle on which the ACA is built--is that insurance works best when risk is evenly spread across a broad population.

Captive insurance companies.

The landscape of the business world is changing; and now, more than ever, business owners are recognizing that life is filled with risks: known risk, calculated risk, and unexpected risk. Every day, businesses thrive or fail based on understanding the risk of owning and operating their business, and business owners are recognizing that there are alternative risk financing mechanisms other than simply taking out a basket of standard coverage as recommended by your friendly neighborhood agent. A captive insurance company is an insurance company established to provide a broad range of risk management capabilities to affiliated companies. The captive is owned by the business owner and can provide insurance to the business for potential future losses, whether or not the losses are already covered by a commercial carrier or are "self-insured." The premiums paid by your business are tax deductible. Meanwhile, the premiums that your captive collects are tax-free up to $1.2 million annually.

Pre-Existing Condition Insurance Plan program. Interim final rule with comment period.

This interim final rule with comment period sets the payment rates for covered services furnished to individuals enrolled in the Pre-Existing Condition Insurance Plan (PCIP) program administered directly by HHS beginning with covered services furnished on June 15, 2013. This interim final rule also prohibits facilities and providers who, with respect to dates of service beginning on June 15, 2013, accept payment for most covered services furnished to an enrollee in the federally-administered PCIP from charging the enrollee an amount greater than the enrollee's out-of-pocket cost for the covered service as calculated by the plan. The PCIP program was established under Section 1101 of Title I of the Patient Protection and Affordable Care Act (Affordable Care Act).