Implementing value-based care at the state level: A conversation with Dr. Kara Odom Walker, Delaware Department of Health and Social Services Secretary.

Dr. Kara Odom Walker is Secretary of the Delaware Department of Health and Social Services (DHHS). Trained as a family physician, with advanced degrees in public health and health services research, Dr. Walker has worked for numerous organizations to advocate for health equity and care for underserved populations. As Delaware DHHS Secretary, she oversees a department with an annual budget of over $2 billion, responsible for health and social services administration.

What Is Human Research For? Reflections on the Omission of Scientific Integrity from the Belmont Report.

The Belmont Report has provided a useful and virtually universal framework for protecting human subjects from research abuses. However, it provides little to no guidance on the substance of human research. In an environment where major decisions concerning health-care access, funding, and regulation hinge on human research, this omission leaves downstream users of human research virtually unprotected and with few tools or frameworks to protect against a variety of practices that compromise the social value of human research. This essay advocates for the addition of a fourth principle to the Belmont three: "scientific integrity." Such a principle would seek to train human research on important social objectives while maximizing the accessibility, credibility, and generalizability of findings.

The Time Is Now to End the HIV Epidemic.

In his State of the Union Address on February 5, 2019, President Donald J. Trump announced his administration's goal to end the domestic HIV epidemic. Following the announcement of the Ending the HIV Epidemic: A Plan for America initiative, the president proposed $291 million in new funding for the fiscal year 2020 Department of Health and Human Services (HHS) budget to implement a new initiative to reduce the number of new HIV infections by 75% in the next five years (2025) and by 90% in the next 10 years (2030). This is in addition to the $20 billion the US government already spends each year, domestically, for HIV prevention and care.With this initiative, HHS recognizes that the time to end the HIV epidemic is now: we have the right data, the right biomedical and behavioral tools, and the right leadership. With the new resources, the goal is achievable.This article outlines how this initiative will be accomplished through the implementation of four fundamental strategies that will be tailored by local communities on the basis of their own needs and strengths.

Dental Public Health Practice, Infrastructure, and Workforce in the United States.

Dental public health is a unique specialty of dentistry that focuses on prevention of oral diseases among populations rather than individual patients. It encompasses several complementary disciplines and greatly varies in its functions and activities. Several federal, state, local, and nonpublic entities operationalize the mission of dental public health to improve population oral health through a diverse and vibrant workforce.

CDC's 6|18 Initiative: A Cross-Sector Approach to Translating Evidence Into Practice.

CONTEXT: As the US health care system continues to undergo dynamic change, the increased alignment between health care quality and payment has provided new opportunities for public health and health care sectors to work together. PROGRAM: The Centers for Disease Control and Prevention's 6|18 Initiative accelerates cross-sector collaboration between public health and health care purchasers, payers, and providers and highlights 6 high-burden conditions and 18 associated interventions with evidence of cost reduction/neutrality and improved health outcomes. This evidence can inform payment, utilization, and quality of prevention and control interventions. IMPLEMENTATION: The Centers for Disease Control and Prevention focused initially on public payer health insurance interventions for asthma control, unintended pregnancy prevention, and tobacco cessation. Nine state Medicaid and public health agency teams-in Colorado, Georgia, Louisiana, Massachusetts, Michigan, Minnesota, New York, Rhode Island, and South Carolina-participated in the initiative because they had previously prioritized the health condition(s) and specific intervention(s) and had secured state-level leadership support for state agency collaboration. The Centers for Disease Control and Prevention, the Centers for Medicare & Medicaid Services, the Center for Health Care Strategies, the Robert Wood Johnson Foundation, and other partners supported state implementation and dissemination of early lessons learned. EVALUATION: The Centers for Disease Control and Prevention conducted exploratory interviews to guide improvement of the 6|18 Initiative and to understand facilitators, barriers, and complementary roles played by each sector. Monthly technical assistance calls conducted with state teams documented collaborative activities between state Medicaid agencies and health departments and state processes to increase coverage and utilization. DISCUSSION: The 6|18 Initiative is strengthening partnerships between state health departments and Medicaid agencies and contributing to state progress in helping improve Medicaid coverage and utilization of effective prevention and control interventions. This initiative highlights early successes for others interested in strengthening collaboration between state agencies and between public and private sectors to improve payment, utilization, and quality of evidence-based interventions.

Leveraging the Partnership for Patients' Initiative to Improve Patient Safety and Quality Within the Military Health System.

INTRODUCTION: Partnership for Patients (PfP) was a national initiative sponsored by the Department of Health and Human Services, Centers for Medicare and Medicaid Services, to reduce preventable hospital acquired conditions (HACs) by 40% and readmissions (within 30 days) by 20%, by the end of 2013 (as compared to the baseline of CY2010). Along with partners across the nation, the Assistant Secretary of Defense for Health Affairs, Dr. Jonathan Woodson, pledged to support PfP in June 2011. Participation of the Military Health System (MHS) in PfP marked the implementation of the first enterprise-wide patient safety initiative. MATERIALS AND METHODS: Three phases of the MHS initiative were developed to meet the aims of the national PfP initiative: (1) Planning and Design, (2) Implementation, and (3) Monitoring and Sustainment. The Planning and Design phase focused on the identification of evidence-based practices (Table III); the development of implementation guides; the implementation of various communication, education, and improvement strategies; and the development of methods by which to track progress and share successes. The implementation phase focused on identifying roles and responsibilities across all levels of care; creating, disseminating, and implementing evidence-based practices at participating military treatment facilities; and establishing a structured learning action network. Finally, during the monitoring and sustainment phase, per the guidance of the Agency for Healthcare Research and Quality, an overall HAC rate was developed for quarterly analysis. The HAC rate per 1,000 dispositions (i.e., discharges) was an aggregate of all PfP HACs. Using the HAC rate, the improvement rate was calculated by comparing the current quarter's HAC rate to the baseline (CY2010). This allowed the MHS to track the overall progress across the enterprise. RESULTS: The MHS achieved a number of accomplishments, including a 15.8% cumulative reduction in HACs by the end of 2013, an 11.1% reduction in readmissions, avoided nearly 500 harm events since PfP implementation, and approximately $13.5 million in cost avoidance (on the basis of national cost estimate data available at the beginning of the PfP initiative). CONCLUSION: The two most critical lessons learned for the MHS during the PfP initiative are (1) continuous leadership engagement and inspection is vital to ensure field workers are engaged with safety and quality expectations and (2) applying a "one-size-fits-all" approach to improve a large delivery system is not effective. In addition, it is most impactful when local military treatment facility-level teams are involved in determining strategies to implement evidence-based standard processes and protocols that reduce variation when integrating practice change into daily operations. The MHS will continue to integrate PfP efforts into improvement activities by leveraging lessons learned from this initiative and determining how they can be applied to other areas of care and/or patient safety and quality initiatives. The Patient Safety Improvement Collaborative has committed to oversee and support the establishment and implementation of ongoing, focused patient safety and quality initiatives across the MHS using a collaborative vision to engage all levels of leadership and staff, and to ensure sustained improvements.

Promoting Antibacterial Drug Development: Select Policies and Challenges.

BACKGROUND: The development pipeline for antibacterial drugs has not met the demand of hospitals and healthcare providers struggling to cope with increasing problems of antibacterial resistance. Although the challenges associated with antibacterial drug development have been known for some time, previous efforts to address them have not been sufficient. There remains an urgent need for targeted incentives to foster antibacterial drug development while encouraging prudent use. OBJECTIVE: We examine the effects of two types of incentives, a 5-year delay in competition from generics and a lump-sum US$50 million prize payment upon successful US Food and Drug Administration approval, on antibacterial drug company returns. METHODS: We use the decision-tree framework developed in a study for the US Department of Health and Human Services, which models the drug company's decision process as a revenue maximizer under uncertainty. RESULTS: Our results show that, to maximize societal benefit, such incentives need to take into consideration the indication(s) the new antibacterial drug is designed to treat as well as the drug development stage. CONCLUSIONS: Optimal policies should maximize the difference between societal benefit, primarily measured as the reduction in public health burden from the development of a new antibacterial drug that treats an infectious disease while ensuring prudent use, and social cost. Here, we show that the two types of policies examined under-incentivize early-stage developers (i.e., do not achieve the desired outcome) and over-incentivize late-stage developers (i.e., achieve the desired outcome but at a cost that is higher than needed) ceteris paribus.