Hydrodiplomacy and adaptive governance at the U.S.-Mexico border: 75 years of tradition and innovation in transboundary water management.

The United States and Mexico have engaged in hydrodiplomacy-a practice of transboundary water management that blends water diplomacy and science diplomacy--for more than 75 years, since the adoption of the Treaty of 1944 and the creation of the International Boundary and Water Commission. We examine six major turning points in U.S.-Mexico hydrodiplomacy to ascertain the key factors in the region's history of resolving transboundary water issues. We find that recognized adaptive governance indicators-such as social learning, sustained relationships, flexible governance mechanisms, and state and non-state networks are essential elements of hydrodiplomacy. Our research suggests that robust and foundational institutions comprise another key indicator of adaptive governance specifically in transboundary contexts. A commitment to both science and diplomacy have been important components underlying the effectiveness of hydrodiplomacy in the border region. Binational networks involving diverse state and non-state actors at multiple scales have increasingly played a pivotal role in shaping desirable hydrodiplomatic outcomes in the region.

Dialogic science-policy networks for water security governance in the arid Americas.

Addressing wicked problems challenging water security requires participation from multiple stakeholders, often with conflicting visions, complicating the attainment of water-security goals and heightening the need for integrative and effective science-policy interfaces. Sustained multi-stakeholder dialogues within science-policy networks can improve adaptive governance and water system resilience. This paper describes what we define as "dialogic science-policy networks," or interactions -- both in structural and procedural terms -- between scientists and policy-makers that are: 1) interdisciplinary, 2) international (here, inter-American), 3) cross-sectoral, 4) open, 5) continual and iterative in the long-term, and 6) flexible. By fostering these types of interactions, dialogic networks achieve what we call the 4-I criteria for effective science-policy dialogues: inclusivity, involvement, interaction, and influence. Here we present several water-security research and action projects where some of these attributes may be present. Among these, a more comprehensive form of a dialogic network was intentionally created via AQUASEC, a virtual center and network initially fostered by a series of grants from the Inter-American Institute for Global Change Research. Subsequently, AQUASEC has significantly expanded to other regions through direct linkages and additional program support for the International Water Security Network, supported by Lloyd's Register Foundation and other sources. This paper highlights major scientific and policy achievements of a notable suite of science-policy networks, shared practices, methods, and knowledge integrating science and policy, as well as the main barriers overcome in network development. An important gap that remains for future research is the assessment and evaluation of dialogic science-policy networks' long-term outcomes.

The impact of PPS on hospital-sponsored post-acute services: a case study of Delaware Medicare providers.

Hospitals were the first providers to experience the change in Medicare reimbursement from a cost basis to the prospective payment system (PPS). In the 1980s, this switch was accomplished through the development of diagnosis-related groups, a unique formula for Medicare reimbursement of inpatient hospital services. During that time, the concern was that, with the anticipated reduced payments to hospitals, adverse impacts on Medicare beneficiaries were likely, including premature release of patients from hospital care resulting in medical complications, increased readmissions, prolonged episodes of recuperation, and preventable mortality. The Balanced Budget Act of 1997 (BBA) mandated the implementation of the PPS for Medicare providers of skilled nursing home care and home health care. This change from cost-based reimbursement to PPS raised concerns that these providers would react as hospitals had done-that is, skilled nursing homes might limit their admission of Medicare patients and home health agencies might cut back on visits. As a result of that, hospitals might be faced with providing care for these post-acute patients without receiving additional reimbursement, and these changes in utilization patterns would be of critical importance to both providers and Medicare beneficiaries. This article examines the decisions that providers made in response to the perceived impact of the BBA. Qualitative data were derived from provider interviews. The article concludes with a discussion of how changes in Medicare reimbursement policy have influenced providers of post-acute care services to alter their level of participation in Medicare and the impact this may have on the general public as well as on Medicare beneficiaries.

Prospective payment and the provision of post-acute care: how the provisions of the Balanced Budget Act of 1997 altered utilization patterns for Medicare providers.

The Balanced Budget Act of 1997 mandated implementation of the prospective payment system for determining Medicare payments to skilled nursing facilities (SNFs) and home health agencies (HHAs). This study assessed the preliminary impact of the changes in reimbursement policy on hospitals, nursing homes, and home health agencies in the United States and the mid-Atlantic region, and conducted micro-level analyses of providers in one state, Delaware. An interrupted time series analysis used aggregate and provider-specific data from the Center for Medicare & Medicaid Services. Nationally, providers experienced significant changes in the number of patients, frequency of service, and payment amounts during the years immediately following implementation of PPS. HHAs reduced the number of visits per patient. In Delaware, hospital-owned nursing homes reduced their Medicare utilization, and proprietary facilities increased their utilization. One-third of the HHAs in Delaware withdrew from Medicare participation. Additional micro-level analyses are needed to substantiate the findings of the Delaware case study and to determine why providers adjusted their utilization of services to Medicare beneficiaries.