Advisory Commission Research Articles

Comparative Effectiveness Research: What It Means for Radiology

The coming years will be an ideal time for investigators in radiology to develop a comparative effectiveness research (CER) initiative and to establish a lasting precedent for CER in our field.

Teaching & Learning Guide for: The Nature of Contemporary Prejudice: Insights from Aversive Racism

Intergroup bias is one of the most actively researched topics in the field of social psychology. Hundreds of books and thousands of research articles have addressed this issue over more than half a century. Although the psychological roots of blatant prejudices are well documented, the development of more subtle and often unintentional forms in societies in which its expression is discouraged poses new and unique challenges to the pursuit of justice and equality in contemporary society. Our interests in the psychological underpinnings of prejudice as researchers and educators are both practical and conceptual. On the practical side, understanding the nature of contemporary forms of prejudice has clear implications for developing effective techniques for combating bias and discrimination. In 1967, nearly 3 years after the landmark Civil Rights Act of 1964, race riots in the United States prompted the Kerner Commission to investigate the sources of racial tension. Upon the conclusion of its investigation, the commission cited White America’s failure to assist Blacks in need, rather than actively trying to harm Blacks, as a primary cause of racial disparities and, ultimately, civil unrest (Report of the National Advisory Commission on Civil Disorders, 1968). Indeed, it was research on the differential helping behavior of politically liberal Whites toward Black and White motorists who were stranded on a highway that represented the first empirical work on aversive racism (Gaertner, 1973). Considerable subsequent research on aversive racism has revealed that the consequences of subtle bias can be as severe and pernicious as those of blatant prejudice. Conceptually, the complexities of contemporary forms of prejudice and recent advances in techniques and tools for studying non-conscious biases make this research area an exciting and challenging one. We hope that this guide can help orient educators to the many excellent resources that exist and convey our enthusiasm for exploring what psychological methods and theories can contribute to understanding one of the most challenging social issues faced in contemporary society.

Health Reform Advances With MH Amendments on Board

Health Reform Advances With MH Amendments on Board

Spotlight Is on Heart Failure Readmissions

Mitchel L. Zoler is with the Philadelphia bureau of Elsevier Global Medical News. ORLANDO — “Hospital readmissions” have become the latest bad-practice buzzwords out of Washington, and the American College of Cardiology is scrambling to put a lid on unnecessary readmissions. The ACC is alarmed because the worst readmissions offender in medicine is heart failure, linked to about one-third of all 30-day U.S. hospital readmissions, according to data collected by the Centers for Medicare & Medicaid Services. A 2008 report by the Medicare Payment Advisory Commission estimated that eliminating unnecessary hospital readmissions for heart failure could save Medicare $900 million annually. The stick that the CMS seems poised to wield against readmissions is bundling of reimbursement for Medicare beneficiaries. This would mean a hospital receives a fixed amount for all care for a hospitalized heart failure patient during the next 30 days, including subsequent readmissions. This prospect prodded the ACC to respond with a new program aimed at paring back readmissions through better attention to the handoff of the discharged. During a press briefing at the annual meeting of the ACC, Jack Lewin, MD, the college's CEO, announced the H2H program (www.acc.org/h2h/Enrollment/Default.aspx), an educational initiative in collaboration with the Institute for Healthcare Improvement. The program seeks to encourage better communication between the physicians who oversee heart failure patients while they're hospitalized and the community cardiologists, primary care physicians, and nurses who see patients once they're discharged. An immediate goal of the H2H program is to cut unnecessary readmissions for heart failure patients by 20% over the next 3 years, Dr. Lewin said. The ACC said it will seek involvement of other professional societies. The campaign against readmissions that the Obama administration, Congress, and the CMS are expected to launch “is a big deal. This is here to stay. This is where people will look, thinking that [readmissions] are low-hanging fruit,” Harlan M. Krumholz, MD, said at the meeting. “We need to think about patients, and be sure there are not unintended consequences that cause patients to suffer,” said Dr. Krumholz, professor of medicine, epidemiology, and public health at Yale University in New Haven, Conn. Dr. Krumholz conceded that until now “hospitals did not have any incentive to improve the transition of care, and so no one worked on it.” He recommended that the CMS give hospitals and other health care providers incentives to do a better job in getting discharged patients hooked into outpatient, disease-management programs. Working to reduce readmissions for heart failure is a practical and viable area, said Eric G. Tangalos, MD, CMD. “Intensive monitoring of the posthospital patient pays off more for heart failure than just about anything else. Nursing homes, especially if they are allowed to embrace the medical home model, will have the resources to do this. Nursing home care teams can keep people with [heart failure] out of the hospital. It just takes more monitoring, more resources, and more talent than what reimbursement now allows.” Dr. Tangalos, a primary care internal medicine consultant at the Mayo Clinic, Rochester, Minn., said that hospitals, nursing homes, and payers are “all on the same page regarding the issue of reducing readmissions. CMS and Congress are looking at eliminating some of the disincentives and implementing more constructive reasons to keep readmissions low.”

The Advisory Commission on Human Rights in the Netherlands

The Advisory Commission on Human Rights in the Netherlands

Reform, Regulation, and Research — An Interview with Gail Wilensky

Gail Wilensky, Ph.D., is an economist who served in the administration of President George H.W. Bush, first as the administrator of the Health Care Financing Administration (forerunner to the Centers for Medicare and Medicaid Services) and later as White House health policy advisor. In 1997, she became the first chair of the Medicare Payment Advisory Commission, and during the 2008 presidential campaign, she was an advisor to Senator John McCain (R-AZ). She is a senior fellow at Project HOPE. John Iglehart, a national correspondent for the Journal, interviewed Dr. Wilensky on August 7, 2009. John Iglehart: Many Republicans oppose reform . . .

Rehospitalizations among Patients in the Medicare Fee-for-Service Program

Conclusion: Rehospitalization among Medicare beneficiaries occurs frequently. Summary: Under current law, payment is available from Medicare for most rehospitalizations. An exception is for patients rehospitalized for the same condition ≤24 hours after discharge from which they had initially been hospitalized. Policy changes are being considered that would create payment incentives to reduce rates of rehospitalization. Reducing rehospitalization is an important component of President Obama's health care reform proposals (Washington Post, Feb 26, 2009). The Medicare Payment Advisory Commission (MEDPAC) has suggested that hospitals receive from Centers for Medicare and Medicaid Services a confidential report of risk-adjusted rehospitalization rates and that these rates be published after 2 years. It has also been suggested that hospitals with high-risk adjusted rates of rehospitalization should receive lower average per case payments. Although reducing rehospitalizations is clearly a potential means of reducing costs, there is actually little information on the frequency and patterns of rehospitalization. The authors therefore analyzed Medicare claims from 2003 and 2004 in an attempt to describe patterns of rehospitalization and relationships of rehospitalization to demographic characteristics of the patients and the characteristics of the hospitals. During the period analyzed, 1,855,702 Medicare beneficiaries were hospitalized, of which 19.6% were rehospitalized ≤30 days; at 90 days, 34% had been rehospitalized. Within the first year after discharge, 68.9% of patients who had been discharged with a medical condition and 53% who had been discharged after surgical procedures were rehospitalized or had died. Of patients discharged with a medical condition and who were rehospitalized ≤30 days after discharge, 52.2% had no bill for a visit to a physician's office between the time of discharge and rehospitalization. After surgical discharge, 70.5% of rehospitalizations ≤30 days were for a medical condition. The average stay of rehospitalized patients was 0.6 days longer than that of patients in the same diagnostic-related group whose most recent hospitalization had been ≥6 months previously. The estimated cost to Medicare of unplanned rehospitalizations in 2004 was $17.4 billion. Vascular surgical patients had a 23.9% rate of rehospitalization ≤30 days. This comprised 1.4% of all rehospitalizations of Medicare patients. Rehospitalization was for additional vascular surgery in 14.8% and amputation in 5.8%. In comparison, rehospitalizations ≤30 days occurred in 13.5% of patients undergoing cardiac stent procedures, 15.6% of patients undergoing major bowel surgery, and 17.9% of those undergoing hip or femur surgeries. Overall rates of rehospitalization were region-dependent. The lowest rates were in the Pacific Northwest and the Intermountain West. Comment: Rehospitalization is a huge problem. The data indicated that the risk of rehospitalization persists over time. Additional studies will be required to understand the relative contributions of inadequate discharge planning, insufficient outpatient and community care, and progression of illness to rates of rehospitalization. Vascular surgeons should note that among the surgical groups analyzed, vascular surgery had the highest rates of rehospitalization. This has significant implications for the relationship between vascular surgeons and their hospital administrators should there eventually be instituted a financial penalty for rehospitalization of surgical patients.

Two Visions of Responsibility: How National Commissions Contributed to Jornalism Ethics, 1963–1975

The early 1970s witnessed significant developments in journalism ethics as news organizations revised or adopted codes of conduct, appointed ombudsmen, formed news councils, and took the first steps toward integrating newsrooms. Although some scholars have argued that this emphasis on ethics was a result of the Hutchins Commission or Watergate, this monograph suggests an additional factor: three national commissions that criticized the news media between 1964 and 1970. The President's Commission on the Assassination of President Kennedy, the National Advisory Commission on Civil Disorders, and the National Commission on the Causes and Prevention of Violence accused journalists of prejudice, sensationalism, and even inciting violence. The commissions have been mostly ignored in regard to journalism ethics, and few scholars if any have attempted to tie together the impact of all three. This monograph presents a history of ideas — notions about journalists' responsibilities — to shed new light on how journalism ethics developed in the twentieth century. Watergate highlighted issues like the use of anonymous sources, but it did not specifically suggest what journalists should do. The three commissions did. They challenged journalists to fundamentally rethink their work and the purpose of it. From a process of challenge and response, an expanded sense of media responsibility arose. This monograph offers an analytical framework of freedom and responsibility to help explain the impact these commissions had on the practice and standards of journalism in the 1960s, 1970s, and beyond.

A Mom With a Mission: Grace’s Law in New Jersey Requires Insurance Coverage of Hearing Aids

A Mom With a Mission: Grace’s Law in New Jersey Requires Insurance Coverage of Hearing Aids

What Do Debt Loads Say about California's Fiscal Condition?

THE CALIFORNIA Journal of Politics & Policy Volume 1, Issue 1 What Do Debt Loads Say about California’s Fiscal Condition? John Decker California Debt and Investment Advisory Commission Abstract For the past seven years, the state spent more from the General Fund than its tax structure generated. To help cover the difference, the state borrowed from institu- tional investors. Should Californians be concerned? More broadly, how does debt fit into the annual budget debate? Evaluation of debt loads help Californians assess the fiscal prudence and sustainability of the state’s fiscal structures. KEYWORDS: debt, budget deficits, California fiscal condition Acknowledgements: I am thankful to Jerry Lubenow for his continuing interest in this topic and his careful editing. Thanks, too, to my colleagues at the State Treasur- er’s Office for their review, Steve Coony, Paul Rosenstiel, and Tom Dresslar. www.bepress.com/cjpp

MedPAC Urges 1.1% Fee Increase in 2010

WASHINGTON — Medicare advisers unanimously voted to recommend increasing physician fees by 1.1% next year, while expressing dismay that their June 2008 recommendation to boost primary care pay has not yet been acted upon. The Medicare Payment Advisory Commission—better known as MedPAC—is charged with advising Congress on setting payment rates for physicians, hospitals, and other health care providers. Its recommendations are included in twice-yearly reports issued in March and June. Under current law, Medicare physician fees are due to be reduced by 21% in 2010. MedPAC initially considered recommending that physician fees be updated by the projected change in input prices, minus an overall productivity goal that was established by the U.S. Bureau of Labor Statistics. The formula translated into a 1.1% increase, but many MedPAC commissioners were uncomfortable with the language and the possibility that it could be used to reduce fees. Some even suggested that the panel should be considering a larger increase than 1.1%, but Chairman Glenn Hackbarth said he would not vote to approve a higher number, partly because Medicare has a statutory obligation to keep beneficiaries' Part B premiums for physician services in check. As fees rise, so do Part B premiums. There seems to be no indication that Medicare reimbursement policy is leading to access problems for beneficiaries, according to reports from MedPAC staff members. Commissioner Nancy Kane, an associate dean of education at the Harvard School of Public Health in Boston, said that the 1.1% increase in fees would not be enough for primary care. “Primary care is in a huge state of crisis,” said Ms. Kane, who expressed concern that it could be 7-10 years before Medicare rewards physicians for participation in medical homes. “That may not be fast enough,” she said, adding that the demonstration is a “drop in the pond. We need to move a whole ocean.” Mr. Hackbarth pointed out that MedPAC had recommended a pilot project to help move the process along, but acknowledged that “we're talking about a significant amount of time, still.” He said he expected that interim data might support quicker action. The panel also voted unanimously to again include its June 2008 recommendation that Congress establish a budget-neutral payment adjustment for primary care services. Primary care could get another boost if Congress follows MedPAC's recommendation to change the equipment use rate for imaging machines that cost more than $1 million. Currently, CMS pays physicians based on an estimate that magnetic resonance imaging, computed tomography, and positron-emission tomography are used an average 25 hours per week, but data suggest that 45 hours per week is a more accurate and better target, said MedPAC staff member Ariel Winter. The goal is to push physicians to be more efficient with use of the devices. Adopting the new rate would reduce the practice expense relative value unit by almost 8%. That change would provide a savings of about $900 million annually, said Mr. Winter. The money could be reallocated to primary care pay and other physician services, if the recommendation is adopted. MedPAC commissioners also voted to increase hospital payments by the projected increase in the market basket, and to reward high-quality, high-performing facilities with a larger, unspecified increase. However, they agreed to reduce the indirect medical education (IME) payment by 1%. MedPAC staff said that the IME payment is set at more than twice the impact of teaching on hospital costs. The American Hospital Association said it was happy with the vote to increase payments overall. But the IME reduction would “negatively affect” teaching hospitals. Alicia Ault is an associate editor with Elsevier Global Medical News.

Analysis of Growth of Interventional Techniques in Managing Chronic Pain in the Medicare Population: A 10-Year Evaluation from 1997 to 2006

Recent reports of the United States Government Accountability Office (GAO), the Medicare Payment Advisory Commission (MedPAC), and the Office of Inspector General (OIG) expressed significant concern with overall fiscal sustainability of Medicare and exponential increase in costs for interventional pain management techniques. Interventional pain management (IPM) is an evolving specialty amenable to multiple influences. Evaluation and isolation of appropriate factors for increasing growth patterns have not been performed. Analysis of the growth of interventional techniques in managing chronic pain in Medicare beneficiaries from 1997 to 2006. To evaluate the use of all interventional techniques. The standard 5% national sample of the CMS carrier claim record data for 1997, 2002, and 2006 was utilized. This data set provides information on Medicare enrollees in the fee-for-service Medicare program. Current procedural technology (CPT) codes for 1997, 2002, and 2006 were used to identify the number of procedures performed each year, and trends in expenditures. Interventional techniques increased significantly in Medicare beneficiaries from 1997 to 2006. Overall, there was an increase of 137% in patients utilizing IPM services with an increase of 197% in IPM services, per 100,000 Medicare beneficiaries. The majority of the increases were attributed to exponential growth in the performance of facet joint interventions. There was a 13.9-fold difference in the increase between the state with the lowest rate and the state with the highest rate in utilization patterns of interventional techniques (California 37% vs. Connecticut 514%), with an 11.6-fold difference between Florida and California (431% vs. 37% increase). In 2006, Florida showed a 12.7-fold difference compared to Hawaii with the lowest utilization rate. Hospital outpatient department (HOPD) expenses constituted the highest increase with fewer patients treated either in an ambulatory surgery center (ASC) or in-office setting. Overall HOPD payments constituted 5% of total 2006 Medicare payments, in contrast to 57% of total IPM payments, an 11.4-fold difference. The limitations of this study include a lack of inclusion of Medicare participants in Medicare Advantage plans and potential documentation, coding, and billing errors. This study shows an overall increase of IPM services of 197% compared to an increase of 137% in patients utilizing IPM services from 1997 to 2006.

Family Law for the Underclass: Underscoring Law's Ideological Function

Law School; Ph.D. in American Studies, University of Michigan. The author thanks Richard Delgado, Edward Fallone, Lisa Ikemoto, Elise Papke, and Jessica Slavin for critical readings of earlier versions of this Article and Martin Price, Marquette University Law School Class of ’08, for valuable research assistance. 1. Lawrence M. Friedman, Law, Lawyers, and Popular Culture, 98 YALE L.J. 1579, 1585 (1989). 2. In launching a new law and humanities journal, a miffed Owen Fiss noted that law and economics had become “the interdisciplinary method for studying law.” Owen M. Fiss, The Challenge Ahead, 1 YALE J.L. & HUMAN., at viii, ix (1988-89). 3. The Eisenhower Foundation estimated in 2008 that 37 million Americans lived in poverty and the proportion of the poor below half the poverty line had grown from 30% in 1975 to 43% in 2006. The child poverty rate increased from 15% in 1968 to 17% in 2006. EISENHOWER FOUND., WHAT TOGETHER WE CAN DO: A FORTY YEAR UPDATE OF THE NATIONAL ADVISORY COMMISSION ON CIVIL DISORDERS 3 (2008), available at http://www.eisenhowerfoundation.org/kerner.php. 4. See CHRISTOPHER JENCKS, RETHINKING SOCIAL POLICY: RACE, POVERTY, AND THE FAMILY LAW FOR THE UNDERCLASS: UNDERSCORING LAW’S IDEOLOGICAL FUNCTION

Trends—Public Support for Presidential Nomination Reform

Trends—Public Support for Presidential Nomination Reform

Epidemiological Research on Children's Environmental Health-Clarification of Environmental Risks that Affect Children's Development-

In accordance with the Declaration of the Environment Leaders of the Eight on Children's Environmental Health (Miami Declaration) in 1997, the Japanese government (the Ministry of Environment, Japan) organized a commission tasked to discuss issues related to the present situation of the environmental health of children (Advisory Commission for Children's Environmental Health). Epidemiological research on children's environmental health has been recommended as one of the priority projects by the commission because the effects of environmental factors on children's health are clarified by only studies using children as subjects, particularly, a birth cohort study, and not by animal experiments. The Advisory Committee of Epidemiological Research on Children's Environmental Health was established in 2007 and decided to start a nationwide birth cohort study following up children from pregnancy to 12 years old. Under the Advisory Committee, a working group composed of scientific experts, including epidemiologists, toxicologists, obstetricians, orthopedists, and statisticians, was organized in 2008. Pilot studies are going to be conducted in several areas in Japan with the support of the working group. Study hypotheses will also be decided by the working group soon. The full-scale survey will start in 2010.

Virtual Nikuradse

In this paper we derive an accurate composite friction factor versus Reynolds number correlation formula for laminar, transition and turbulent flow in smooth and rough pipes. The correlation is given as a rational fraction of rational fractions of power laws which is systematically generated by smoothly connecting linear splines in log-log coordinates with a logistic dose function algorithm. We convert Nikuradse's (1933) (J. Nikuradse, 1933 Stromungsgesetz in rauhren rohren, vDI Forschungshefte 361. (English translation: Laws of flow in rough pipes). Technical report, NACA Technical Memorandum 1292. National Advisory Commission for Aeronautics (1950), Washington, DC.) data for six values of roughness into a single correlation formula relating the friction factor to the Reynolds number for all values of roughness. Correlation formulas differ from curve fitting in that they predict as well as describe. Our correlation formula describes the experimental data of Nikuradse's (1932, 1933) (J. Nikuradse, Laws of turbulent flow in smooth pipes (English translation), NASA (1932) TT F-10: 359 (1966).) and McKeon et al. (2004) (B.J. McKeon, C.J. Swanson, M.V. Zaragola, R.J. Donnelly, and J.A. Smits, Friction factors for smooth pipe flow, J. Fluid Mech. 511 (2004), 41–44.) but it also predicts the values of friction factor versus Reynolds number for the continuum of sand-grain roughness between and beyond those given in experiments. Of particular interest is the connection of Nikuradse's (1933) data for flow in artificial rough pipes to the data for flow in smooth pipes presented by Nikuradse (1932) and McKeon et al. (2004) and for flow in effectively smooth pipes. This kind of correlation seeks the most accurate representation of the data independent of any input from theories arising from the researchers ideas about the underlying fluid mechanics. As such, these correlations provide an objective metric against which observations and other theoretical correlations may be applied. Our main hypothesis is that the data for flow in rough pipes terminates on the data for smooth and effectively smooth pipes at a definite Reynolds number R σ(σ); if λ = f(Re, σ) is the friction factor in a pipe of roughness parameter σ then λ = f(R σ(σ), σ) is the friction factor at the connection point. An analytic formula giving R σ(σ) is obtained here for the first time.

Dr. Ehrlich and Dr. Atomic: Beauty vs. Horror in Science

Dr. Ehrlich and Dr. Atomic: Beauty <i>vs.</i> Horror in Science

Innovative operational seasonal water supply forecasting technologies

Today's Western United States is home to nearly one-third of the American population. The region has experienced rapid population growth in recent years. Continued urban growth, combined with economic changes and federal environmental mandates, are exerting increased pressure on the Western United States' irrigated agriculture. Serving these competing uses, in the face of uncertain and extreme weather, can be difficult. Managers of a fixed water supply must operate their projects within an ever-shrinking margin of error (Western Water Policy Review Advisory Commission 1998). Improved water supply technologies and products will help resource managers to improve water use efficiencies wherever possible. This article describes some of the recent advances by the USDA Natural Resources Conservation Service in its mission to support Western US water managers.

MedPAC Eyes Hospital-SNF Readmissions

MedPAC Eyes Hospital-SNF Readmissions

Self-contained Bioethics and the Politics of Legal Prohibition

Law and bioethics have traditionally expressed an elective affinity. Bioethics has often spoken “in the language of the law,” or at least in a pidgin that the law can easily understand, and bioethicists have conceptualized their principles and arguments in ways that make them amenable to legal translation. However, there has always been a tradition of bioethical reflection, what I describe as “self-contained bioethics,” that is deeply suspicious of its own readability to legal forms of interpretation; a tradition for which proximity to the law and a consideration of the actual circumstances of legal action compromises the purity of ethical inquiry. The article examines the work of President Bush's Council on Bioethics on human cloning as an example of this type of bioethical inquiry. In its 2002 report “ Human Cloning and Human Dignity: An Ethical Inquiry” the Council professed to keep specific legal and policy options at arm's length to better explore the ethical significance of the issues at stake without being “skewed” by considerations of practical expediency. The article compares the form of bioethical advice produced by the Council with the opinion on human cloning that its predecessor, the National Bioethics Advisory Commission (NBAC), issued in 1997. In NBAC's report the discussion of the paths of legal action was thoroughly and explicitly integrated into the moral analysis. Ultimately, the President's Council resorted to the law, understood as an instrument of absolute prohibition, to translate its purified moral argument into social reality in the form of a ban or a moratorium. Yet, by not using legal considerations to focus and refine its bioethical inquiry, and instead resorting to the law merely as a tool of proscription, the Council guarantees that its advice remains as controversial in the short term as ineffective in the long run.