Strengthening the Center for Medicare and Medicaid Innovation's Approach to Constructing Alternative Payment Models.

The Center for Medicare and Medicaid Innovation (CMMI) seeks to develop evidence-based alternative payment models (APM) to improve health care quality and reduce costs, but its performance in achieving these goals has been mixed. In October 2021, CMMI released its Innovation Strategy Refresh to highlight challenges faced by payment models and suggest new strategic approaches for the upcoming decade. While a welcome recast of organizational goals, the Refresh leaves space for how CMMI will address persistent issues. These include how CMMI can best engage physicians and patients in APMs, minimize conflicting incentives among APMs, reduce selection bias in model participation, and, ultimately, transition away from the fee-for-service framework that underlies much of Medicare reimbursement. This article provides guidance to CMMI's vision by examining challenges within CMMI's strategy for model building and offering solutions to mitigate these issues. These strategies include engaging beneficiaries in APM incentives, expanding operational flexibility to improve clinical behaviors (e.g., waivers), rectifying issues with conflicting model incentives, building voluntary short-term and mandatory long-term incentives to mitigate selection bias, and transitioning to an overriding population-based model to constrain net costs. Policy Points The Center for Medicare and Medicaid Innovation (CMMI) seeks to develop evidence-based alternative payment models (APM) to improve care quality and reduce health care cost, but its performance in achieving these goals has been mixed. In October 2021, CMMI released a "strategic refresh" of its goals but left space for how persistent issues to model development would be addressed. We propose strategies to engage physicians and patients in APMs, minimize conflicting incentives among APMs, reduce selection bias in model participation, and, ultimately, transition away from the fee-for-service framework that underlies much of Medicare reimbursement.

Prospective Pilot Study Evaluating SARS-CoV-2 Transmission-Limiting Measures in an On-Site School.

OBJECTIVES: The purpose of our study is to evaluate the feasibility and reliability of a comprehensive set of preventive measures in limiting secondary transmission of COVID-19 in schools. METHODS: A prospective cohort study was conducted to evaluate SARS-CoV-2 transmission in an independent K-8 school in San Mateo County, California. The research was conducted between September 14, 2020 through March 22, 2021 and consisted of: 1) demographic and epidemiological questionnaires; 2) daily symptom reporting; 3) weekly RT-PCR testing; and 4) periodic on-site qualitative observations. RESULTS: One hundred eighty (79%) students and 63 (74%) on-site staff/contractors were enrolled. Participants reported symptoms in 144 (<1%) daily surveys of the 19,409 collected. Among those who reported symptoms and exposures, none tested positive during the 22-week study period. Of all participants, a total of 6 tested positive for SARS-CoV-2 at least once by RT-PCR; all were asymptomatic at time of testing. No in-school transmission occurred. Mask adherence was high among all grades, and incidents of improper mask use mostly occurred during noninstruction time. Physical distancing was well-enforced during class time and snack breaks, although adherence during noninstruction time waned as the school year progressed. CONCLUSIONS: Our comprehensive, prospective study following COVID-19 transmission over 22 weeks in a K-8 school demonstrates that: 1) surveillance testing is important for detecting asymptomatic infections in schools; 2) monitoring symptoms may not be necessary and/or sufficient for COVID-19; and 3) younger children can adhere to key mitigation measures (eg, masking) which have the potential to limit transmission.

Factors influencing care-seeking behaviour for mental illness in India: a situational analysis in Tamil Nadu.

BACKGROUND: The contribution of mental illness to the total burden of disease in India nearly doubled from 1990 to 2017, increasing from 2.5% of the total disability-adjusted life years in 1990 to 4.7% in 2017. Despite efforts by the Indian government, a treatment gap of 75-85%, with heterogeneity across multiple dimensions, exists across India. We conducted a qualitative study in Tamil Nadu, India, to better understand the contextual factors affecting the care-seeking behaviour for mental illness. METHODS: Qualitative methods, including semi-structured interviews and focus groups (FGs), were conducted with stakeholders involved in the mental health care pathway in Tamil Nadu. Ten semi-structured interviews and five FGs were conducted and analysed using an inductive approach to identify codes, using Dedoose v7, related to the emerging themes and categories. RESULTS: Our analyses identified three key areas that influence care-seeking: views on what causes and/or constitutes mental illness, stigma and discrimination associated with mental illness and broader factors influencing decision-making. CONCLUSIONS: The specific contextual factors identified by our study can be used to design and implement approaches that can help to address some of the issues that influence the care-seeking behaviour and manifest in the treatment gaps seen in Tamil Nadu and in India, more generally.

COVID-19 vaccine challenges: What have we learned so far and what remains to be done?

Developing and distributing a safe and effective SARS-CoV-2 (COVID-19) vaccine has garnered immense global interest. Less than a year after COVID-19 was declared a pandemic, several vaccine candidates had received emergency use authorization across a range of countries. Despite this scientific breakthrough, the journey from vaccine discovery to global herd immunity against COVID-19 continues to present significant policy challenges that require a collaborative, global response. We offer a framework for understanding remaining and new policy challenges for successful global vaccine campaigns against COVID-19 as well as potential solutions to address them. Decision-makers must be aware of these challenges and strategize solutions that can be implemented at scale. These include challenges around maintaining R&D incentives, running clinical trials, authorizations, post-market surveillance, manufacturing and supply, global dissemination, allocation, uptake, and clinical system adaption. Alongside these challenges, financial and ethical concerns must also be addressed.

COVID-19 antibody seroprevalence in Santa Clara County, California.

BACKGROUND: Measuring the seroprevalence of antibodies to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is central to understanding infection risk and fatality rates. We studied Coronavirus Disease 2019 (COVID-19)-antibody seroprevalence in a community sample drawn from Santa Clara County. METHODS: On 3 and 4 April 2020, we tested 3328 county residents for immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies to SARS-CoV-2 using a rapid lateral-flow assay (Premier Biotech). Participants were recruited using advertisements that were targeted to reach county residents that matched the county population by gender, race/ethnicity and zip code of residence. We estimate weights to match our sample to the county by zip, age, sex and race/ethnicity. We report the weighted and unweighted prevalence of antibodies to SARS-CoV-2. We adjust for test-performance characteristics by combining data from 18 independent test-kit assessments: 14 for specificity and 4 for sensitivity. RESULTS: The raw prevalence of antibodies in our sample was 1.5% [exact binomial 95% confidence interval (CI) 1.1-2.0%]. Test-performance specificity in our data was 99.5% (95% CI 99.2-99.7%) and sensitivity was 82.8% (95% CI 76.0-88.4%). The unweighted prevalence adjusted for test-performance characteristics was 1.2% (95% CI 0.7-1.8%). After weighting for population demographics, the prevalence was 2.8% (95% CI 1.3-4.2%), using bootstrap to estimate confidence bounds. These prevalence point estimates imply that 53 000 [95% CI 26 000 to 82 000 using weighted prevalence; 23 000 (95% CI 14 000-35 000) using unweighted prevalence] people were infected in Santa Clara County by late March-many more than the ∼1200 confirmed cases at the time. CONCLUSION: The estimated prevalence of SARS-CoV-2 antibodies in Santa Clara County implies that COVID-19 was likely more widespread than indicated by the number of cases in late March, 2020. At the time, low-burden contexts such as Santa Clara County were far from herd-immunity thresholds.

The Economic Footprint of Interventional Radiology in the United States: Implications for Systems Development.

PURPOSE: Despite the growing presence of interventional radiology (IR) in inpatient care, its global impact on the health care system remains uncharacterized. The aim of this study was to quantitate the use of IR services rendered to hospitalized patients in the United States and the impact on cost. METHODS: The National Inpatient Sample 2016 was queried. Using the International Classification of Diseases, 10th revision, Clinical Modification/Procedure Classification System, adult inpatients who underwent routine IR procedures were identified. Unadjusted and adjusted analyses were performed. Weighted patient data are presented to provide national estimates. RESULTS: Of the 29.7 million inpatient admissions in 2016, 2.3 million (7.8%) had at least one IR procedure. Patients who needed IR were older (62.8 versus 57.1 years, P < .001), were sicker on the basis of the All Patient Refined Diagnosis Related Groups (27% major or extreme versus 14% for non-IR, P < .001), and had higher inpatient mortality (8.2% versus 1.7%, P < .001). While representing 7.8% of all admissions, this cohort accounted for 18.4% ($68.4 billion) of adult inpatient health care costs and about 3 times higher mean hospitalization cost compared with other inpatients ($29,402 versus $11,062, P < .001), which remained significant even after controlling for age and All Patient Refined Diagnosis Related Group. CONCLUSIONS: Approximately 1 in 10 US inpatients are treated by IR during their hospitalizations. These patients are sicker, with about 4 times higher mortality and 2.5 times greater length of stay, accounting for almost one-fifth of all health care costs. These findings suggest that IR should have a voice in discussions of means to save costs and improve patient outcomes in the United States.

A molecular dynamics study of the binary complexes of APP, JIP1, and the cargo binding domain of KLC.

Mutations in the amyloid precursor protein (APP) are responsible for the formation of amyloid-ß peptides. These peptides play a role in Alzheimer's and other dementia-related diseases. The cargo binding domain of the kinesin-1 light chain motor protein (KLC1) may be responsible for transporting APP either directly or via interaction with C-jun N-terminal kinase-interacting protein 1 (JIP1). However, to date there has been no direct experimental or computational assessment of such binding at the atomistic level. We used molecular dynamics and free energy estimations to gauge the affinity for the binary complexes of KLC1, APP, and JIP1. We find that all binary complexes (KLC1:APP, KLC1:JIP1, and APP:JIP1) contain conformations with favorable binding free energies. For KLC1:APP the inclusion of approximate entropies reduces the favorability. This is likely due to the flexibility of the 42-residue APP protein. In all cases we analyze atomistic/residue driving forces for favorable interactions. Proteins 2017; 85:221-234. © 2016 Wiley Periodicals, Inc.