Ten Years Later: Reflections on Critics' Worst-Case Scenarios for the Affordable Care Act.

The primary goals of the Affordable Care Act (ACA) were to increase the availability and affordability of health insurance coverage and thereby improve access to needed health care services. Numerous studies have overwhelmingly confirmed that the law has reduced uninsurance and improved affordability of coverage and care for millions of Americans. Not everyone believed that the ACA would lead to positive outcomes, however. Critics raised numerous concerns in the years leading up to the law's passage and full implementation, including about its consequences for national health spending, labor supply, employer health insurance markets, provider capacity, and overall population health. This article considers five frequently heard worst-case scenarios related to the ACA and provides research evidence that these fears did not come to pass.

Improving access to health services in Canada.

The Commonwealth Fund 2017 report ranked Canada's healthcare system low in access to care and last among all 11 counties studied in terms of timeliness of care. While long wait times for certain elective surgical procedures appear to be emblematic of Canadian Medicare, they are not inevitable. Wait times could be improved by focusing on public awareness and measurement of wait times and improving the appropriateness, efficiency (eg, with implementation of single-entry models for surgical referrals and greater use of ambulatory surgery), and productivity of surgical care (eg, by activity-based funding for surgical procedures and by reducing the cost of perioperative care). Ideas on how physician leaders can build on recent accomplishments are provided.

Distribution of health care resources in Mongolia using the Gini coefficient.

BACKGROUND: Attaining the perfect balance of health care resources is probably impracticable; however, it is possible to achieve improvements in the distribution of these resources. In terms of the distribution of health resources, equal access to these resources would make health services available to all people. The aim of this study was to compare the distributions of health care resources in urban, suburban, and rural areas of Mongolia. METHODS: We compared urban and rural areas using the Mann-Whitney U test and further investigated the distribution equality of physicians, nurses, and hospital beds throughout Mongolia using the Gini coefficient-a common measure of distribution derived from the Lorenz curve. Two indicators were calculated: the distribution per 10 000 population and the distribution per 1000 km2 area. RESULTS: Urban and rural areas were significantly different only in the distribution of physicians per population. However, in terms of the distribution per area, there were statistical differences in physicians, nurses, and hospital beds. We also found that distributions per population unit were equal, with Gini coefficients for physicians, nurses, and hospital beds of 0.18, 0.07, and 0.06, respectively. Distributions per area unit were highly unequal, with Gini coefficients for physicians, nurses, and hospital beds of 0.74, 0.67, and 0.69, respectively. CONCLUSIONS: Although the distributions of health care resources per population were adequate for the population size, a striking difference was found in terms of the distributions per geographical area. Because of the nomadic lifestyle of rural and remote populations in Mongolia, geographical imbalances need to be taken into consideration when formulating policy, rather than simply increasing the number of health care resources.

Best practices in PA development: Lessons from three countries.

As the PA profession moves into its 50th year and develops globally, its flexibility and underlying principles make it adaptable to a wide range of healthcare needs and governmental priorities. A key feature of effective PA development is adapting the profession to the needs of each country rather than adopting it exactly as it has developed in the United States. The successful adaptation of new PA models must assure that the new profession meets a societal need, such as increasing healthcare access for specific populations or geographic areas.

How the government intervention affects the distribution of physicians in Turkey between 1965 and 2000.

INTRODUCTION: One of the main weaknesses of the health system in Turkey is the uneven distribution of physicians. The diversity among geographical districts was huge in the beginning of the 1960s. After the 1980s, the implementation of a two-year compulsory service for newly graduated physicians is an interesting and specific experience for all countries. The aim of this study is to analyse the distribution of physicians, GPs and specialists between the years 1965-2000 and the efficiency of the strict 15 year government intervention (1981-1995). METHODS: The data used in this study includes the published data by the Ministry of Health and The State Institute of Statistics between the years 1965-2000. Covering 35 years for total physicians, GPs and specialists, Gini coefficients are calculated so as to observe the change in the distribution. In order to measure the efficiency of government intervention, Gini index belonging to the previous 15 years (first period-1965 to 1980) and the last 15 years (second period) of 1981 when the compulsory service was enacted is also analysed including the statistical tests. RESULTS: In 1965, the Gini for total physician is quite high (0.47), and in 2000 it decreases considerably (0.20). In 1965, the Gini for GPs and the Gini for specialists is 0.44 and 0.52, respectively and in 2000 these values decrease to 0.13 and 0.28, respectively. It is observed that, with this government intervention, the level of diversity has decreased dramatically up to 2000. Regarding to regression, the rate of decrease in Gini index in the second period is higher for the GPs than that of the specialists. CONCLUSION: The inequalities in the distribution between GPs and specialists are significantly different; inequality of specialist distribution is higher than the GP. The improvement of the inequality in the physician distribution produced by the market mechanism shows a long period when it is left to its own devices. It is seen that the compulsory service policy is efficient since the physician distribution has improved significantly. The government intervention provides a faster improvement in the GP distribution.

Task sharing within a managed clinical network to improve child health in Malawi.

BACKGROUND: Eighty per cent of Malawi's 8 million children live in rural areas, and there is an extensive tiered health system infrastructure from village health clinics to district hospitals which refers patients to one of the four central hospitals. The clinics and district hospitals are staffed by nurses, non-physician clinicians and recently qualified doctors. There are 16 paediatric specialists working in two of the four central hospitals which serve the urban population as well as accepting referrals from district hospitals. In order to provide expert paediatric care as close to home as possible, we describe our plan to task share within a managed clinical network and our hypothesis that this will improve paediatric care and child health. PRESENTATION OF THE HYPOTHESIS: Managed clinical networks have been found to improve equity of care in rural districts and to ensure that the correct care is provided as close to home as possible. A network for paediatric care in Malawi with mentoring of non-physician clinicians based in a district hospital by paediatricians based at the central hospitals will establish and sustain clinical referral pathways in both directions. Ultimately, the plan envisages four managed paediatric clinical networks, each radiating from one of Malawi's four central hospitals and covering the entire country. This model of task sharing within four hub-and-spoke networks may facilitate wider dissemination of scarce expertise and improve child healthcare in Malawi close to the child's home. TESTING THE HYPOTHESIS: Funding has been secured to train sufficient personnel to staff all central and district hospitals in Malawi with teams of paediatric specialists in the central hospitals and specialist non-physician clinicians in each government district hospital. The hypothesis will be tested using a natural experiment model. Data routinely collected by the Ministry of Health will be corroborated at the district. This will include case fatality rates for common childhood illness, perinatal mortality and process indicators. Data from different districts will be compared at baseline and annually until 2020 as the specialists of both cadres take up posts. IMPLICATIONS OF THE HYPOTHESIS: If a managed clinical network improves child healthcare in Malawi, it may be a potential model for the other countries in sub-Saharan Africa with similar cadres in their healthcare system and face similar challenges in terms of scarcity of specialists.

Integrating community health workers within Patient Protection and Affordable Care Act implementation.

CONTEXT: The Patient Protection and Affordable Care Act's (PPACA) emphasis on community-based initiatives affords a unique opportunity to disseminate and scale up evidence-based community health worker (CHW) models that integrate CHWs within health care delivery teams and programs. Community health workers have unique access and local knowledge that can inform program development and evaluation, improve service delivery and care coordination, and expand health care access. As a member of the PPACA-defined health care workforce, CHWs have the potential to positively impact numerous programs and reduce costs. OBJECTIVE: This article discusses different strategies for integrating CHW models within PPACA implementation through facilitated enrollment strategies, patient-centered medical homes, coordination and expansion of health information technology (HIT) efforts, and also discusses payment options for such integration. RESULTS: Title V of the PPACA outlines a plan to improve access to and delivery of health care services for all individuals, particularly low-income, underserved, uninsured, minority, health disparity, and rural populations. Community health workers' role as trusted community leaders can facilitate accurate data collection, program enrollment, and provision of culturally and linguistically appropriate, patient- and family-centered care. Because CHWs already support disease management and care coordination services, they will be critical to delivering and expanding patient-centered medical homes and Health Home services, especially for communities that suffer disproportionately from multiple chronic diseases. Community health workers' unique expertise in conducting outreach make them well positioned to help enroll people in Medicaid or insurance offered by Health Benefit Exchanges. New payment models provide opportunities to fund and sustain CHWs. CONCLUSION: Community health workers can support the effective implementation of PPACA if the capacity and potential of CHWs to serve as cultural brokers and bridges among medically underserved communities and health care delivery systems is fully tapped. Patient Protection and Affordable Care Act and current payment structures provide an unprecedented and important vehicle for integrating and sustaining CHWs as part of these new delivery and enrollment models.

[Vulnerable children detected by the school health service: the forgotten?]. / Enfants en situation de vulnérabilité médico-psycho-sociale repérés par la médecine scolaire: les oubliés du réseau de soins?

The current health needs of children largely exceeds the biomedical model. The school doctor occupies a special position where he can take into account the social determinants of health and identify vulneirable children. After the detection by the school health service, the harmonious development of, the child requires that health professionals cooperate in a "preventive network".

Tackling health workforce challenges to universal health coverage: setting targets and measuring progress.

Human resources for health (HRH) will have to be strengthened if universal health coverage (UHC) is to be achieved. Existing health workforce benchmarks focus exclusively on the density of physicians, nurses and midwives and were developed with the objective of attaining relatively high coverage of skilled birth attendance and other essential health services of relevance to the health Millennium Development Goals (MDGs). However, the attainment of UHC will depend not only on the availability of adequate numbers of health workers, but also on the distribution, quality and performance of the available health workforce. In addition, as noncommunicable diseases grow in relative importance, the inputs required from health workers are changing. New, broader health-workforce benchmarks - and a corresponding monitoring framework - therefore need to be developed and included in the agenda for UHC to catalyse attention and investment in this critical area of health systems. The new benchmarks need to reflect the more diverse composition of the health workforce and the participation of community health workers and mid-level health workers, and they must capture the multifaceted nature and complexities of HRH development, including equity in accessibility, sex composition and quality.

Les ressources humaines de la santé devront être renforcées pour pouvoir réaliser la couverture sanitaire universelle. Les points de référence existants des effectifs de santé se concentrent exclusivement sur la densité des médecins, infirmiers et sages-femmes, et ils ont été développés avec l'objectif d'atteindre une couverture relativement élevée des accouchements médicalisés et des autres services de santé essentiels qui sont importants pour la réalisation des objectifs du Millénaire pour le développement (OMD) de la santé. Cependant, la réalisation de la couverture sanitaire universelle ne dépendra pas seulement de la disponibilité d'un nombre approprié de professionnels de la santé, mais également de la distribution, de la qualité et de la performance des effectifs de santé disponibles. En outre, comme le nombre des maladies non transmissibles ne cesse de croître, les contributions requises de la part des professionnels de la santé sont en train de changer. Des points de référence nouveaux et plus larges des effectifs de santé ­ et un cadre de suivi correspondant ­ doivent donc être développés et inclus dans l'agenda pour la couverture sanitaire universelle afin de catalyser l'attention et les investissements dans ce domaine critique des systèmes de santé. Les nouveaux points de référence doivent refléter la composition plus diverse des effectifs de santé et la participation des agents sanitaires des collectivités et des agents sanitaires de niveau intermédiaire, et ils doivent saisir la nature polymorphe et la complexité du développement des ressources humaines de la santé, y compris en ce qui concerne l'équité dans l'accessibilité, la composition sexospécifique et la qualité.

Es fundamental fortalecer la acción de los recursos humanos en sanidad (RHS) para alcanzar la cobertura universal de la salud (CUS). Los parámetros de referencia actuales sobre el personal sanitario se centran exclusivamente en la densidad de médicos, enfermeros y comadronas, y se desarrollaron con el fin de alcanzar una cobertura relativamente alta de asistencia especializada durante el parto y otros servicios de salud esenciales, que fueran para lograr los Objetivos de Desarrollo del Milenio (ODM). Sin embargo, la consecución de la cobertura universal de la salud no solo depende de la disponibilidad de un número adecuado de personal sanitario, sino también de la distribución, la calidad y el desempeño del personal sanitario disponible. Además, la contribución necesaria por parte del personal sanitario cambia a medida que la importancia de las enfermedades no transmisibles crece relativamente. Por lo tanto, es necesario desarrollar e incluir en el programa otros parámetros de referencia más amplios y actuales, así como su marco de seguimiento correspondiente, de modo que los trabajadores comunitarios de salud puedan catalizar la atención y la inversión en esta área clave del sistema sanitario. Los nuevos puntos de referencia deben reflejar la composición más plural del personal sanitario y la participación de los trabajadores comunitarios de salud, así como de los trabajadores sanitarios de nivel medio. De esta manera, deben captar las múltiples facetas y complejidades del desarrollo de los recursos humanos para sanidad, incluyendo la equidad en la accesibilidad, la composición por sexo y la calidad.

State Standards for Insurance Access to Oncologists.

As the market for health insurance plans expands, each state is responsible for setting standards to ensure that plans contain adequate coverage for cancer care. Little is currently known about what criteria states use for network adequacy of insurance plans. We contacted representatives of the Department of Insurance (or equivalent) for 50 states and the District of Columbia, as well as searched official state websites to compile data on network adequacy standards for cancer care nationwide. The standards of 16 (31.4%) states contained only qualitative elements for access to an oncologist (eg, "reasonable access"), 7 (13.7%) states included only quantitative elements (eg, travel distance and time restrictions), and 24 (47.1%) states included standards with both qualitative and quantitative elements. Standards from 4 states were not available. States should make certain that robust, transparent protections exist to ensure that patients are able to access high-quality cancer care without experiencing the financial toxicity associated with out-of-network billing.

Addressing the maldistribution of health resources in Sichuan Province, China: A county-level analysis.

INTRODUCTION: The equity of health resource allocation geographically is a contested topic. Sichuan Province, located in Southwest China, has varied topography, providing us with natural materials to explore the determinants of health resource distribution. MATERIALS AND METHODS: Spatial panel econometric models were constructed to explore the relationship between health resources and factors such as health care service demand and socioeconomic and demographic perspectives using data from Sichuan Province for eight consecutive years (2010-2017). RESULTS: Health care service demands were found to be a major driving force behind the distribution of health resources, showing that an increase in health care service demands draws health resources to specific counties and surrounding areas. From a socioeconomic perspective, gross domestic product per capita and the average wage show a positive association with health resources. In addition, the total population and proportion of the urban population have diverse effects in regard to health-related human resources but have the same effects on material and financial health resources. CONCLUSIONS: Our results provide the Chinese government with evidence needed to formulate and promulgate effective policies, especially those aiming to tackle inequity among different regions.

Personalized Graduate Medical Education and the Global Surgeon: Training for Resource-Limited Settings.

PROBLEM: The World Health Organization and the World Bank have identified improvement in access to surgical care as an urgent global health challenge and a cost-effective investment in public health. However, trainees in standard U.S. general surgery programs do not have adequate exposure to the procedures, technical skills, and foundational knowledge essential for providing surgical care in resource-limited settings. APPROACH: The Michael E. DeBakey Department of Surgery at Baylor College of Medicine (BCM) created a 7-year global surgery track within its general surgery residency in 2014. Individualized rotations equip residents with the necessary skills, knowledge, and experience to operate in regions with low surgeon density and develop sustainable surgical infrastructures. BCM provides a formal, integrated global surgery curriculum-including 2 years dedicated to global surgery-with surgical specialty rotations in domestic and international settings. Residents tailor their individual experience to the needs of their future clinical practice, region of interest, and surgical specialty. OUTCOMES: There have been 4 major outcomes of the BCM global surgery track: (1) increased exposure for trainees to a broad range of surgeries critical in resource-limited settings, (2) meaningful international partnerships, (3) contributions to global surgery scholarship, and (4) establishment of sustainable global surgery activities. NEXT STEPS: To better facilitate access to safe, timely, and affordable surgical care worldwide, global surgeons should pursue expertise in topics not currently included in U.S. general surgical curricula, such as setting-specific technical skills, capacity building, and organizational collaboration. Future evaluations of the BCM global surgery track will assess the effect of individualized education on trainees' professional identities, clinical practices, academic pursuits, global surgery leadership preparedness, and comfort with technical skills not encompassed in general surgery programs. Increasing availability of quality global surgery training programs would provide a critical next step toward contributing to the delivery of safe surgical care worldwide.

Exploring the potential for foreign-trained dentists to address workforce shortages and improve access to dental care for vulnerable populations in the United States: a case study from Washington State.

BACKGROUND: To address dental workforce shortages in underserved areas in the United States, some States have enacted legislation to make it easier for foreign dental school graduates to become licensed dentists. However, the extent to which foreign dental school graduates will solve the problem of dental workforce shortages is poorly understood. Furthermore, the potential impact that foreign-trained dentists have on improving access to dental care for vulnerable patients living in dental Health Professional Shortage Areas (HPSAs) and those enrolled in public insurance programs, such as Medicaid, is unknown. The objective of this paper is to provide a preliminary understanding of the practice behaviors of foreign-trained dentists. The authors used Washington State as a case study to identify the potential impact foreign dental school graduates have on improving access to dental care for vulnerable populations. The following hypotheses were tested: a) among all newly licensed dentists, foreign-trained dentists are more likely to participate in the Medicaid program than U.S.-trained dentists; and b) among newly licensed dentists who participated in the Medicaid program, foreign-trained dentists are more likely to practice in dental HPSAs than U.S.-trained dentists. METHODS: The authors used dental license and Medicaid license data to compare the proportions of newly licensed, foreign- and U.S.-trained dentists who participated in the Medicaid program and the proportions that practiced in a dental HPSA. RESULTS: Using bivariate analyses, the authors found that a significantly lower proportion of foreign-trained dentists participated in the Medicaid program than U.S.-trained dentists (12.9% and 22.8%, respectively; P = 0.011). Among newly licensed dentists who participated in the Medicaid program, there was no significant difference in the proportions of foreign- and U.S.-trained dentists who practiced in a dental HPSA (P = 0.683). CONCLUSIONS: Legislation that makes it easier for foreign-trained dentists to obtain licensure is unlikely to address dental workforce shortages or improve access to dental care for vulnerable populations in the United States. Licensing foreign dental school graduates in the United States also has ethical implications for the dental workforces in other countries.

Combining Drive Time and Urologist Density to Understand Access to Urologic Care.

OBJECTIVE: To improve our understanding of timely access to urologic care, we leveraged driving time combined with a measure of urologist density. MATERIALS AND METHODS: We identified all urologists who billed Medicare using National Provider Identifier in 2015 and geocoded their practice location. We developed drive-time based service areas for each provider using Esri's street network dataset stratified into 30, 60, 90, and 120-minute areas. Population characteristics were aggregated and block groups were assigned to a Hospital Referral Region. RESULTS: We identified 10,170 urologists that billed Medicare in 2015 in the United States. Compared to the northeast, vast expanses of land across the western United States have drive times to urology care >60 minutes. However, less than 13% of the US population is unable to obtain urologic care within 30 minutes. Likely reflecting rural populations, White and American Indian populations are represented in greater proportion among those requiring a longer drive time to urologic care. Disparities were noted between areas with timely access to a high versus low density of urologists; low density areas have a greater proportion of Black and Asian populations and greater income inequality. CONCLUSIONS: Drive time to urologists combined with urologist density is a novel approach to investigating urologic care access and a tool for health disparities research. While almost all of the US population lives within 1-hour drive time to a urologist there remains important differences in the population severed by high compared to low provider density.

Increased access to nurse practitioner care in rural Nebraska after removal of required integrated practice agreement.

Nebraska is a largely rural state with many communities defined as medically underserved by primary care providers. In 2014, the state legislature voted to eliminate the requirement for an integrated practice agreement (IPA) between nurse practitioners (NPs) and physicians. This report describes changes in access to primary health care in rural and underserved areas of Nebraska after removal of the IPA barrier to practice. The report compares the number of primary care NPs working in medically underserved areas before and after the legislation that ended the required IPA. In addition, anecdotes will be provided of NP and patient experiences in rural, NP-owned practices in Nebraska after IPA requirements were eliminated.

Minimally disruptive medicine for patients with complex multimorbidity

BACKGROUND: Patients with complex multimorbidity often experience a substantial burden because of the treatments they receive as well as the burden of their chronic health problems. There has been increasing recognition of this issue, particularly in the UK and US. OBJECTIVE: This article summarises the evolution of the concept ‘minimally disruptive medicine’ for patients with complex multimorbidity. It outlines some of the factors that should be considered in assessing both the burden of treatment and a patient’s capacity to cope with this workload. The potential role of shared decision-making and discussion aids such as the Instrument for Patient Capacity Assessment (ICAN) tool are highlighted. DISCUSSION: Australian general practice is at the forefront of care for patients with complex multimorbidity. The explicit inclusion of assessment of treatment burden and capacity would encourage healthcare that is kind, empathic andfeasible.

The surgical workforce: averting a patient access crisis.

This article examines the state of the medical and surgical workforce, and how business-based and economic principles such as supply and demand have continued to shape it. Specifically, this article focuses on the following topics: past and present efforts to determine physician supply; where workforce shortages are most apparent at this time; and the factors that are contributing to the current shortfalls and their broader implications. In addition, the author looks ahead to determine what changes we need to support, promote, and make to meet our patients' evolving needs and expectations.