RÉSUMÉ
Policy Points Electronic health records (EHRs) are subject to the implicit bias of their designers, which risks perpetuating and amplifying that bias over time and across users. If left unchecked, the bias in the design of EHRs and the subsequent bias in EHR information will lead to disparities in clinical, organizational, and policy outcomes. Electronic health records can instead be designed to challenge the implicit bias of their users, but that is unlikely to happen unless incentivized through innovative policy. CONTEXT: Health care delivery is now inextricably linked to the use of electronic health records (EHRs), which exert considerable influence over providers, patients, and organizations. METHODS: This article offers a conceptual model showing how the design and subsequent use of EHRs can be subject to bias and can either encode and perpetuate systemic racism or be used to challenge it. Using structuration theory, the model demonstrates how a social structure, like an EHR, creates a cyclical relationship between the environment and people, either advancing or undermining important social values. FINDINGS: The model illustrates how the implicit bias of individuals, both developers and end-user clinical providers, influence the platform and its associated information. Biased information can then lead to inequitable outcomes in clinical care, organizational decisions, and public policy. The biased information also influences subsequent users, amplifying their own implicit biases and potentially compounding the level of bias in the information itself. The conceptual model is used to explain how this concern is fundamentally a matter of quality. Relying on the Donabedian model, it explains how elements of the EHR design (structure), use (process), and the ends for which it is used (outcome) can first be used to evaluate where bias may become embedded in the system itself, but then also identify opportunities to resist and actively challenge bias. CONCLUSIONS: Our conceptual model may be able to redefine and improve the value of technology to health by modifying EHRs to support more equitable data that can be used for better patient care and public policy. For EHRs to do this, further work is needed to develop measures that assess bias in structure, process, and outcome, as well as policies to persuade vendors and health systems to prioritize systemic equity as a core goal of EHRs.
Sujet(s)
Dossiers médicaux électroniques , Modèles théoriques , Biais (épidémiologie) , Prestations des soins de santé , HumainsRÉSUMÉ
This article describes the tension that the coronavirus disease 2019 (COVID-19) pandemic brought up between administrators and physicians and offers a potential set of solutions to deal with it.
Sujet(s)
Personnel administratif/organisation et administration , COVID-19/épidémiologie , Leadership , Médecins/organisation et administration , Personnel administratif/économie , Épuisement professionnel/épidémiologie , Épuisement professionnel/prévention et contrôle , Relations communauté-institution , Humains , Satisfaction professionnelle , Pandémies , Médecins/économie , SARS-CoV-2RÉSUMÉ
To mark the 25th anniversary of the journal, each issue in 2020 will include an interview with a health care thought leader. The October issue features a conversation with Kavita K. Patel, MD, MS, nonresident fellow at The Brookings Institution and editorial board member of AJMC®.
Sujet(s)
Betacoronavirus , Infections à coronavirus/thérapie , Politique de santé , Prévention des infections/organisation et administration , Pneumopathie virale/thérapie , COVID-19 , Programmes gouvernementaux/organisation et administration , Humains , Prévention des infections/législation et jurisprudence , Pandémies/législation et jurisprudence , Qualité des soins de santé/organisation et administration , SARS-CoV-2RÉSUMÉ
OBJECTIVES: In the move toward value-based payment, new payment models have largely been designed by payers and focused on the role of primary care providers. We examine a new phase of payment reform wherein providers, mostly specialists, are designing alternative payment models (APMs) for their own practices through a task force, called the Physician-Focused Payment Model Technical Advisory Committee, created by the Medicare Access and CHIP Reauthorization Act of 2015. Although it is a potentially notable shift in payment reform, little is known about the content of these proposals to date. STUDY DESIGN: Qualitative systematic review of physician-focused payment model proposals submitted to CMS. METHODS: We analyzed the first wave of new payment models proposed. For each of the 24 proposals submitted by physicians and physician groups, we assessed the models on their 10 key dimensions and evaluated underlying themes across all or many of the models to gain insights into what providers are looking for in APMs within the constraints of the rules established by the HHS secretary. RESULTS: Key features of the models and our analysis include bearing financial risk, a reliance on case management, embrace of new technologies, and consideration of legal barriers. CONCLUSIONS: We discuss how specialists may help lead in the evolving payment landscape and recommend how these models might be improved. Payers and policy makers could benefit from our findings, which reflect how providers view financial risk in APMs and provide guidance on the types of payment reforms that they may embrace in the journey toward value.
Sujet(s)
Défense du consommateur/économie , Médecins/psychologie , Rôle professionnel , Système de paiements préétablis/économie , Système de paiements préétablis/normes , Mécanismes de remboursement/économie , Mécanismes de remboursement/normes , Adulte , Attitude du personnel soignant , 14886/économie , 14886/normes , Femelle , Dépenses de santé/normes , Dépenses de santé/statistiques et données numériques , Humains , Mâle , Adulte d'âge moyen , États-UnisSujet(s)
Accountable care organizations (USA)/économie , Médecins/économie , Mécanismes de remboursement/législation et jurisprudence , Barème d'honoraires , Régimes de rémunération à l'acte/économie , Réforme des soins de santé/législation et jurisprudence , Medicare (USA)/législation et jurisprudence , Patient Protection and Affordable Care Act (USA) , Soins centrés sur le patient/économie , États-UnisSujet(s)
Accountable care organizations (USA) , Maladies cardiovasculaires/économie , Coûts des soins de santé/statistiques et données numériques , Cardiologie , Maladies cardiovasculaires/thérapie , Maîtrise des coûts , Humains , Évaluation de programme , Amélioration de la qualité , Qualité des soins de santé , Mécanismes de remboursement , États-UnisSujet(s)
Coûts des soins de santé/normes , Medicare (USA)/normes , Commission de révision de la rémunération des médecins/normes , Médecins/normes , Qualité des soins de santé/normes , Dépenses de santé/normes , Humains , Medicare (USA)/économie , Commission de révision de la rémunération des médecins/économie , Médecins/économie , Qualité des soins de santé/économie , États-UnisRÉSUMÉ
The Patient Protection and Affordable Care Act (ACA) contains within it three significant legislative constructs: to enhance access to health care, improve quality, and decrease cost. Also known as the Triple Aim, these three simple, yet monumental, goals have been the object of actions to date as well as future implementation efforts. This article will identify sections of the legislation that would directly provide areas of opportunity to improve health and achieve the triple aim for the oncology profession.
Sujet(s)
Couverture d'assurance , Oncologie médicale , Tumeurs/économie , Patient Protection and Affordable Care Act (USA) , Accountable care organizations (USA)/législation et jurisprudence , Faillite , Essais cliniques comme sujet/économie , Participation aux coûts/législation et jurisprudence , Régimes de rémunération à l'acte/législation et jurisprudence , Rétroaction , Prévision , Dépenses de santé/législation et jurisprudence , Humains , Remboursement par l'assurance maladie/législation et jurisprudence , Medicaid (USA)/économie , Oncologie médicale/économie , Oncologie médicale/législation et jurisprudence , Medicare (USA)/économie , Tumeurs/thérapie , Frais d'ordonnance , Amélioration de la qualité , Qualité des soins de santé , États-UnisRÉSUMÉ
Community health centers (CHCs) play a critical role in the primary care safety net. Partnerships between CHCs and faith-based organizations are promoted as a way to increase outreach to underserved populations and support health-promoting behaviors and effective disease management. Through six focus groups (totaling 58 participants), we explored low-income residents' perspectives (African American, Latino, and White) of their communities, the meaning of health, the role of spirituality, and their experiences with and preferences for congregation-based health programming to inform future outreach efforts of a CHC. We found that community perspectives varied based on race/ethnicity and neighborhood, but health concerns tended to cluster by race/ethnicity alone. We also found that spirituality was deemed important for health by all racial-ethnic groups, but attendance at religious services, religious affiliation, and preferences for congregation-based health programming varied across and within groups. Community health center-faith based partnerships could facilitate health care access in underserved communities but may have limited reach among certain subgroups and individuals.
Sujet(s)
Centres de santé communautaires/organisation et administration , Religion et médecine , Adolescent , Adulte , 1766/psychologie , 1766/statistiques et données numériques , Sujet âgé , Attitude envers la santé , Femelle , Groupes de discussion , État de santé , Hispanique ou Latino/psychologie , Hispanique ou Latino/statistiques et données numériques , Humains , Relations interinstitutionnelles , Los Angeles , Mâle , Adulte d'âge moyen , Enquêtes et questionnaires , 38413/psychologie , 38413/statistiques et données numériques , Jeune adulteRÉSUMÉ
The authors describe various new models of physician payment that can serve as a foundation for a shift away from the current reimbursement system for cancer care to support better outcomes and avoid preventable costs, as well as how these reforms can be supported in a blended payment model that transitions away from but still contains elements of fee-for-service payments.
Sujet(s)
Prestations des soins de santé/organisation et administration , Soins centrés sur le patient/organisation et administration , Prestations des soins de santé/économie , Humains , Participation des patients/économie , Soins centrés sur le patient/économie , Remboursement incitatif , États-UnisRÉSUMÉ
OBJECTIVE: In Taiwan, the carrier rate of hepatitis B surface antigen is 15% to 20%, one of the highest in the world. Among chronic hepatitis B (CHB) patients, hepatitis B e antigen (HBeAg)-negative accounts for approximately 40% to 50% of these patients. A recent study found that peginterferon alfa-2a (40 KD) is more effective than lamivudine in treating HBeAg-negative CHB, but its cost-effectiveness has not been evaluated. Our objective is to evaluate the incremental cost-effectiveness of 48 weeks of peginterferon alfa-2a compared to 48 weeks of lamivudine, from the perspective of the Taiwan Bureau of National Health Insurance. METHODS: A Markov model was used to simulate the natural history of HBeAg-negative CHB in a cohort of 40-year-old patients. Efficacy, disease progression, economic, and quality-of-life data were derived from published literature and a survey of clinical experts in Taiwan. Life expectancy, quality-adjusted life expectancy, lifetime costs in New Taiwan Dollars (NTD) (1 USD = 31.96 NTD), and incremental cost-effectiveness ratios (ICERs) were calculated. RESULTS: The gain in quality-adjusted life-years (QALYs) for 48 weeks of peginterferon alfa-2a compared to 48 weeks of lamivudine was 0.45 at an additional cost of 157,000 NTD (4900 USD), resulting in an ICER of 347,000 NTD (10,900 USD) per QALY gained. The 95% central range for the ICER from a probabilistic sensitivity analysis was 228,000-566,000 NTD (7100-17,700 USD). CONCLUSIONS: In HBeAg-negative CHB, 48 weeks of treatment with peginterferon alfa-2a compared to 48 weeks of lamivudine appears to offer life expectancy and quality-of-life improvements at an acceptable cost-effectiveness ratio.
Sujet(s)
Antiviraux/économie , Hépatite B chronique/traitement médicamenteux , Hépatite B chronique/économie , Interféron alpha/économie , Lamivudine/économie , Polyéthylène glycols/économie , Antiviraux/usage thérapeutique , Analyse coût-bénéfice , Coûts des soins de santé/statistiques et données numériques , Antigènes e du virus de l'hépatite virale B/sang , Humains , Interféron alpha-2 , Interféron alpha/usage thérapeutique , Lamivudine/usage thérapeutique , Chaines de Markov , Programmes nationaux de santé/économie , Polyéthylène glycols/usage thérapeutique , Années de vie ajustées sur la qualité , Protéines recombinantes , TaïwanRÉSUMÉ
BACKGROUND: Peginterferon alpha-2a (40 kDa), a new treatment for chronic hepatitis B, produces seroconversion within 48 weeks in approximately 32% of HBeAg-positive patients. Over a defined treatment duration it offers improved efficacy over lamivudine, but at higher cost. We assessed the clinical outcomes and costs, from the perspective of the UK National Health Service, of 48 weeks of peginterferon alpha-2a (40 kDa) vs. 4 years of lamivudine. METHODS: Cost-effectiveness was analysed using a state-transition Markov model simulating HBeAg-positive chronic hepatitis B natural history. Efficacy data were obtained from a large randomized trial comparing peginterferon alpha-2a (40 kDa) with lamivudine over 48 weeks. Use of adefovir salvage treatment for lamivudine-resistant patients was also evaluated. Long-term lamivudine efficacy, treatment durability, disease progression, cost, and quality-of-life estimates were derived from the literature. One-way and probabilistic sensitivity analyses evaluated uncertainty. RESULTS: Treatment with peginterferon alpha-2a (40 kDa) for 48 weeks resulted in higher discounted total healthcare costs ( pound 3100), but an increase of 0.3 discounted quality-adjusted life years compared with long-term lamivudine, giving an incremental cost-effectiveness ratio of pound 10,400 per quality-adjusted life year gained ( pound 8300- pound 15,400 in one-way sensitivity analyses). The cost-effectiveness acceptability curve showed intervention was below the pound 30,000/QALY threshold in over 95% of the simulations. When adefovir was included for patients with lamivudine resistance, peginterferon alpha-2a (40 kDa) had an incremental cost of pound 6100/QALY gained. CONCLUSIONS: Treatment with peginterferon alpha-2a (40 kDa) for a defined duration of 48 weeks, although more expensive than lamivudine therapy, provides improvement in health outcomes, with a cost-effectiveness ratio well below the current UK cost-effectiveness threshold.
Sujet(s)
Antiviraux/économie , Antigènes e du virus de l'hépatite virale B/sang , Hépatite B chronique/traitement médicamenteux , Interféron alpha/économie , Lamivudine/économie , Polyéthylène glycols/économie , Adulte , Antiviraux/administration et posologie , Antiviraux/usage thérapeutique , Analyse coût-bénéfice , Calendrier d'administration des médicaments , Coûts des médicaments/statistiques et données numériques , Coûts des soins de santé/statistiques et données numériques , Hépatite B chronique/économie , Humains , Interféron alpha-2 , Interféron alpha/administration et posologie , Interféron alpha/usage thérapeutique , Lamivudine/administration et posologie , Lamivudine/usage thérapeutique , Chaines de Markov , Modèles économétriques , Polyéthylène glycols/administration et posologie , Polyéthylène glycols/usage thérapeutique , Qualité de vie , Protéines recombinantes , Sensibilité et spécificité , Royaume-UniRÉSUMÉ
Improving the quality of care is a national priority in the United States; however, it is not clear how to accelerate progress for mental health care. We recommend advances in three capacities: (1) developing quality improvement resources applicable to a diverse set of mental health disorders, clients, and service settings; (2) improving the infrastructure for providing evidence-based psychotherapy and psychosocial interventions; and (3) promoting innovation in financial incentives for quality improvement in mental health care. We also discuss the need to develop leadership among health care stakeholders and community engagement to promote public commitment to high-quality care in mental health.