Current Fiscal Environment Research Articles

An Assessment of Provider Payment Mechanisms (PPMs) in Ethiopia: Implications for Redesign of PPMs and Progress Toward Universal Health Coverage

ABSTRACT Ethiopia has made great strides in improving population health but sustaining health system and population health improvements in the current fiscal environment is challenging. Provider payment, as a function of purchasing, is a tool to use limited health resources better. This study describes the design and implementation of Ethiopia’s provider payment mechanisms (PPMs) and how they influence health system objectives and contribute to universal health coverage goals. The research team adapted the framework and analytical tools of the Joint Learning Network for Universal Health Coverage guide for assessing PPMs. Data were collected through literature review and key informant interviews with 11 purchasers and 17 health care providers. Content analysis was used to describe PPM design and implementation arrangements, and thematic analysis was used to distill effects on equity in resource distribution and access to care, efficiency, quality of care, and financial sustainability. The study revealed the PPMs had positive and negative consequences. Line-item budgets were perceived to be predictable and sustainable but had little effect on efficiency and provider performance. Fee-for-service was perceived to have negative effects on efficiency and financial sustainability but viewed positively on its ability to incentivize quality health services. Capitation and performance-based financing effects were viewed positively on equity in distribution of resources and quality respectively, but both were perceived negatively on their high administrative burden to providers. Ethiopia may consider a more nuanced approach to design blended provider payment to mitigate negative consequences while providing incentives for better quality of care and efficiency.

Lessons From Maslow: Prioritizing Funding to Improve the Quality of Community Mental Health and Substance Use Services.

Evidence-based practices (EBPs) are frequently proposed as an approach to close the quality chasm in behavioral health treatment, and many U.S. municipalities are investing in EBPs as a primary way to improve the quality of care delivered to individuals most in need. In this Open Forum, the authors argue that EBPs often cannot be successfully implemented because basic organizational needs are not met in the current fiscal environment. The authors summarize research that supports why EBPs, along with other approaches to improve quality, are likely to fail until there is adequate financing. They also propose a policy and research agenda to ameliorate and address the fiscal challenges inherent in community mental health and substance use services.

Quantifying capacity for burn care in South Africa

The Lancet Commission on Global surgery has highlighted the fact that the vast majority of surgical care is delivered and consumed in high income countries (HIC’s) yet about two thirds of the burden of surgical disease is in low and middle income countries (LMIC) where resources are grossly inadequate. In light of this we set out to audit the current resources available to treat burns in South Africa to quantify the extent of the resource deficit which needs to be addressed if we wish to close the gap in outcomes between South Africa and the developed world. Data was collected for seven out of the nine provinces. There are a total of 17 burn units with 511 beds and 8140 admissions per year across the country.Although there are some deficits in the infrastructure and staffing available to treat burn injuries in South Africa, for example access to isolation, after hours cover, dedicated temperature controlled theatres, this is difficult to alter without government buy in and the current fiscal environment. It would appear that process of care (what you do with what you have) is lacking and needs more development for example establishment of a national registry to facilitate data collection and audit, as well as the introduction of outreach programs, protocols and improving theatre efficiency.

The Case Against Participation Income—Political, Not Merely Administrative

AbstractThis article develops the position we have taken in debate with Anthony Atkinson that a participation income (PI) would be problematic from an administrative and political point of view. We argue that Atkinson remains far too optimistic about the magnitude of administrative difficulties a PI would face. Negotiating these difficulties will inevitably involve the sort of political trade‐offs PI is supposedly able to avoid when compared to its more controversial cousin, the unconditional basic income. The enduring significance of ‘The case for a participation income’, we argue, lies in the often neglected point that Atkinson intends a PI as a supplement to an eroding contribution‐based welfare state. In the current political and fiscal environment, the case for a universal support scheme set below the rate of subsistence, and supplemented by other forms of welfare support, deserves careful re‐examination.

Improving care with portfolio of physician-led cancer quality measures at an academic center.

49 Background: Development and implementation of robust reporting processes to systematically provide quality data to care teams in a timely manner is challenging. National cancer quality measures are useful, but the required manual data collection is slow and resource-intensive. We designed a largely automated measurement system with our multidisciplinary cancer care programs (CCP). Methods: CCP physician leaders (MD) identified two measures that were meaningful to their team and patients. The quality team worked with hospital and university analytics teams to develop metrics and reports. Hospital leadership provided financial incentives (FI) for each CCP if jointly set targets were met. Results: 16 metrics were identified and measured for 13 CCPs (Table). Measures spanned from new diagnosis (ND) through end of life or survivorship care, and were a mix of process and outcome measures. To build and manage metrics required 2 full-time equivalent data analysts and quality specialists over 12 months. CCP MDs received monthly reports for dissemination to their team. Almost all measures improved or maintained initial high levels (*). FI awards will be used for quality improvement, education, and team-building, as determined by CCP MDs. Conclusions: A successful quality reporting system with measured improvements takes considerable engagement and resources, including FI, data systems, and staff to build, manage, and improve measures. This may not be feasible or sustainable for centers in the current fiscal environment. [Table: see text]

Policing cost reduction strategies: an international survey

ABSTRACTIn late 2007, the world experienced the worst financial crisis in more than 70 years. This article examines the results of a survey of 162 police agencies from Australasia, Canada and the United Kingdom and the approaches they adopted to maintain service delivery levels in the current fiscal environment. Nearly two-thirds of the agencies had experienced a decrease in their operating budget since 2007 and a number of agencies had experienced a change in their source of funding and in the amount of funding received. The decreases ranged from 5% to 20%. In response to the decreases, a number of agencies did not fill sworn vacancies, cut academy recruit classes and changed work schedules. Other agencies adopted strategies that included management structure reorganisations, the contracting of services and programs which limited the types of calls from the public to which an officer was dispatched.

What's for Sale at Canadian Universities? A Mixed‐Methods Analysis of Promotional Strategies

AbstractThe current fiscal environment has driven Canadian universities to become more entrepreneurial, seeking out and competing over new sources of funding. Despite such intensifying competition, little effort has been made to document the promotional tactics that Canadian universities are using to render themselves appealing to external audiences. This study examines the contents of the home pages of English‐speaking universities in Canada. It finds that, though there are some differences in the tactics that primarily undergraduate and research‐intensive universities employ, both generally strive to emulate the same institutional ‘template’. Moreover, the usage of more unorthodox promotional tactics, drawing on labour market rhetoric or discourses of inclusivity, is limited. These findings are theorised in relation to contemporary work within organisational sociology and strategic management.

Not blogging, drinking: Peer learning, sociality and intercultural learning in study abroad

Research into study abroad students’ intercultural learning has demonstrated a need to provide pedagogical support before, during and after the study abroad experience. This article reports on the authors’ efforts to support the in-country learning of Australian study abroad students through an online guided reflection exercise (blog) with a peer-learning component. Our findings suggest that exposing students to theories of intercultural learning prior to the study abroad experience opens them to the possibility of such learning occurring. However, the unanticipated discovery that the students’ most significant intercultural learning stemmed from the processes of social drinking rather than online interaction emphasizes that participation in an unfamiliar culture is an embodied and social experience, and suggests that concentration of pedagogical efforts in familiar and disembodied online spaces may disconnect students from the very experiences on which we wish them to reflect. We therefore recommend that instructors design opportunities for peer learning through embodied social interactions between outgoing and incoming study abroad students, framed by explicit discussion of concepts in intercultural learning. Such scaffolding is likely to be more sustainable in the current Australian fiscal environment than the intensive in-country instructor intervention that is common in the North American context.

THE U.S. QUEST FOR NEW TECHOLOGICAL FOUNDATIONS OF MILITARY SUPERIORITY: DILEMMAS OF THE THIRD OFFSET STRATEGY

The last decades have witnessed a remarkable surge of interest in studying the influence of science and technology on world politics. However, not all channels of such influence have been examined with equal rigor. Whereas numerous researchers have explored meticulously the impact of technologies on warfare, the issues of using military-technological breakthroughs to achieve political goals have been addressed less frequently. This paper seeks to fill this gaping niche by decomposing the Third Offset Strategy (TOS), a recent initiative of the U.S. Department of Defense (DoD) aimed at ensuring military-technological superiority of the United States in the XXI century, predominantly, by offsetting the new capabilities of the Russian Federation and the Popular Republic of China. The first section unveils a conceptual framing of the TOS, the second section examines a variety of technological priorities, and the final section identifies key uncertainties around implementation of this initiative in the mid-term and long-term perspective. The conclusion postulates that the emergence of the TOS was determined by both an erosion of the U.S. military superiority and budget constraints, and, therefore, its content might change if budget austerity imperatives will stop dominating the DoD strategists' thinking. The launch of the third offset strategy has also important international-political aspects. First, the TOS fits in the context of the U.S. rebalance to the Asia-Pacific. Second, the American allies in Europe might face a threat of a widening technological gap with the United States and a need to boost their spending on defense research and development, which might be unfeasible in the current fiscal environment. Third, the concentration of the United States on countering high-end opponents might lead to a further marginalization of the Middle East. Fourth, the TOS is likely to contain a disinformation component and aim at dragging the peer competitors of the U.S. into an exhaustive arms race.

Financing a Cure for Diabetes in a Multipayer Environment

BackgroundFinancing medical breakthroughs or cures is becoming increasingly challenging in the current fiscal environment. ObjectivesIn this paper, we develop the precise conditions needed for a financing mechanism, HealthCoin, to work between a private payer and Medicare, to incentivize the former to invest in breakthrough therapies or cures in the US. MethodsWe illustrate the valuation of such a currency for a cure of Type 2 diabetes. ResultsWe show that without a HealthCoin, a private payer does not invest in the cure, a small fraction of the patients live up to age 65, Medicare pays for the full price of the cure at age 65 and incurs net loss in returns over the elderly ages, and the manufacturer only sells cures for those who reach age 65. In contrast, a HealthCoin is feasible in this market, incentivizing the private payer to invest in the cure during the non-elderly ages and leading to Pareto improvements for all three stakeholders. ConclusionsDiscussions around the applicability of HealthCoin for breakthrough therapies on the horizon, such as gene therapies for blindness and hemophilia B, and the feasibility of instituting such payments through new legislations or demonstration projects could be of great value.

Is the Physician Shortage Real? Implications for the Recommendations of the Institute of Medicine Committee on the Governance and Financing of Graduate Medical Education.

In July 2014, the Institute of Medicine (IOM) Committee on the Governance and Financing of Graduate Medical Education released its report calling for a major overhaul of the financing of graduate medical education (GME). Several national organizations with an interest in GME faulted the report on the basis that the IOM Committee recommendations would worsen physician shortages. However, this conclusion is based on two questionable assumptions: first, that the nation is already facing a general physician shortage; and second, that the IOM Committee recommendations would make shortages worse. The author argues that although some communities and specialties do face shortages, currently and in the future a general national physician shortage is unlikely. Reasons cited include changes in the delivery system with an increased focus on efficiency and effectiveness; the increased use of interprofessional teams facilitated by the increasing supply of nurse practitioners, physician assistants and other health professionals; and technological advances.The author concludes that the IOM Committee recommendations would support an increase in GME positions in locations and specialties where there is a documented need, in effect removing the current cap on Medicare-funded GME positions. Given the current fiscal environment, the approach recommended by the IOM Committee--steady funding levels but improved targeting to meet documented needs--may be the best strategy for maintaining GME funds and meeting the nation's physician workforce needs.

Appropriate use criteria and the impact of stress cardiovascular magnetic resonance (CMR) imaging on management of patients with known or suspected coronary artery disease

Background Stress-CMR provides important diagnostic and prognostic information in patients with known or suspected coronary artery disease. However, in the current fiscal environment, use of a newer imaging modality like stress-CMR requires evidence for direct additive impact on clinical management. Appropriate use criteria (AUC) have recently been developed to provide guidance to physicians and payers regarding the appropriateness of this test in various clinical scenarios. However, these criteria were created by expert consensus and have never been systematically validated. The aims of this study were 1) to evaluate the impact of stress-CMR on clinical management; and 2) to determine the relationship of the AUC with active clinical impact.

Rationalising Business Intelligence Systems and Explicit Knowledge Objects: Improving Evidence-Based Management in Government Programs

Public sector programs often fail to leverage their business intelligence systems and explicit knowledge objects to drive efficiency and effectiveness. Given the current federal fiscal environment and the need for effective government — a catalyst to the requirement to use "evidence and rigorous evaluation in budget, management, and policy decisions" (OMB Memorandum M-12-14) — federal programs look to business intelligence as an evidence-based decision-making practice leading to a more lean government, improving efficiency and effectiveness. However, cost overruns, technical obstacles, and next-generation information challenges stemming from pervasive computing can reduce any perceived value of utilising explicit knowledge systems to support evidence in decision making. Through the evaluation of five diverse projects tasked to address the use of evidence in decision-making practices, this research shows that achieving contextualisation of information requirements, stakeholder alignment, and the complexity/feasibility of information integration are key factors that should be analysed to improve the evidence-based decision-making practice in government programs, and may be accomplished through a systematic approach, such as the rationalisation of business intelligence systems. Thus, a rationalisation framework is provided to facilitate the management of business intelligence systems geared towards a more efficient and effective use of explicit knowledge.

Current Status of Clinical Laboratory Reimbursement

1. Rick Panning, MBA, MLS(ASCP)CM[⇑][1] 1. Chair, ASCLS Government Affairs Committee , Director of Business Development for Shared Clinical Services, Fairview Health Services, Minneapolis, MN 1. Address for Correspondence: Rick Panning, MBA, MLS(ASCP)CM , 4894 Meadow Lane, Shoreview, MN 55126, 651-280-5909, panning4{at}comcast.net. 1. Define the basic difference between retrospective reimbursement and prospective payment as it applies to laboratory services. Describe the impact this has had on the laboratory. 2. Describe how ACA has specifically impacted laboratory reimbursement in at least two ways. 3. Identify current potential threats to laboratory reimbursement. Introduction In general, reimbursement for laboratory services in this country comes from two third-party payer sources - government and private sector. This third-party payment allows patients to access laboratory services from hospitals, physician offices, long-term care and other post acute providers and private laboratories. There are many components to this complex reimbursement system, including how and when tests are covered (coverage decisions), procedure and diagnosis codes (identifying what was actually ordered and performed) and payment methodologies. While levels of reimbursement are intended to reflect the value and the cost of the service being provided, over time the level of payment has been continually reduced to meet financial goals of the government or the healthcare system. Government payers primarily reflect Medicare on the federal level and Medicaid (Medical Assistance) on the state level. The Medicare program is the most influential reimbursement system since it often impacts state programs and private payer reimbursement policies and payment levels. All public payers and approximately 67% of private payers use Medicare's payment methodologies as the basis for their own and as tools for negotiating discounts with providers.1 In our current fiscal environment, with pressures on the federal budget and concerns about the long term viability of Medicare, we have seen a change in which the Medicare program is beginning to look at private payer reimbursement levels as an opportunity to reduce its financial responsibility for laboratory reimbursement. The steady reduction in payment levels from Medicare and other payers are resulting in a negative impact on… ABBREVIATIONS: ACA – Accountable Care Act; APC – Ambulatory Patient Classification; CAH – Critical Access Hospital; CLFS – Clinical Laboratory Fee Schedule; CMS – Centers for Medicare and Medicaid Services; CPI – Consumer Price Index; DRG – Diagnosis Related Group; FEHB – Federal Employee Health Benefits; IOM – Institute of Medicine; MolDX – Molecular Diagnostics; MS-DRG – Medical Severity Diagnosis Related Group; NLA – National Limitation Amount; OIG – Office of Inspector General; OPPS – Outpatient Prospective Payment System; PPS – Prospective Payment System; SGR – Sustainable Growth Rate. 1. Define the basic difference between retrospective reimbursement and prospective payment as it applies to laboratory services. Describe the impact this has had on the laboratory. 2. Describe how ACA has specifically impacted laboratory reimbursement in at least two ways. 3. Identify current potential threats to laboratory reimbursement. [1]: #corresp-1

Multidisciplinary acute care research organization (MACRO)

Clinical research will increasingly play a core role in the evolution and growth of acute care surgery program development across the country. What constitutes an efficient and effective clinical research infrastructure in the current fiscal and academic environment remains obscure. We sought to characterize the effects of implementation of a multidisciplinary acute care research organization (MACRO) at a busy tertiary referral university setting. In 2008, to minimize redundancy and cost as well as to maximize existing resources promoting acute care research, MACRO was created, unifying clinical research infrastructure among the Departments of Critical Care Medicine, Emergency Medicine, and Surgery. During the periods 2008 to 2012, we performed a retrospective analysis and determined volume of clinical studies, patient enrollment for both observational and interventional trials, and staff growth since MACRO's origination and characterized changes over time. From 2008 to 2011, the volume of patients enrolled in clinical studies, which MACRO facilitates has significantly increased more than 300%. The percentage of interventional/observational trials has remained stable during the same period (50-60%). Staff has increased from 6 coordinators to 10, with an additional 15 research associates allowing 24/7 service. With this significant growth, MACRO has become financially self-sufficient, and additional outside departments now seek MACRO's services. Appropriate organization of acute care clinical research infrastructure minimizes redundancy and can promote sustainable, efficient growth in the current academic environment. Further studies are required to determine if similar models can be successful at other acute care surgery programs.

American Landpower and the Middle East of 2030

The Proverbial Debate As our current wars Iraq Afghanistan wind down, political deliberations in this country return to a familiar pattern. Intent on re-fighting the last a debate about future military strategy dominates the discussion. As in the past, the debate is sharpened by a budget ax suspended over the Department of Defense. The services anticipate funding cuts so deep as to allow for only one strategic approach to survival. And, as in the past, many approach the problem as bureaucrats defending turf, rather than as strategists objectively creating a military that will best serve the nation. These discussions risk overshadowing some of the most fundamental considerations necessary for developing a sound strategy--which threats will our nation most likely face and what will the military we retain be capable of doing. Even in a fiscal environment that foreshadows major reductions, elements of sound strategic planning remain invaluable. As military professionals, we need to examine threats to our national interests, current and future, and offer our best advice as to how these challenges should be addressed. If nothing else, the civilian leadership needs to be advised of those things that can and cannot be accomplished (without great cost or unacceptable risk) as a result of their decisions. This article frames a response to one future role of American land forces by examining the Middle East over the next twenty years. It begins by highlighting our enduring national interests in the region. It then considers potential threats to these interests, current and future, and attempts to assess their likelihood. Finally, those scenarios that require American ground forces are identified, along with the implications of these decisions. The intent is to provide a strategic perspective in a debate too often clouded by budgetary concerns and unnecessarily framed as an interservice, zero-sum game. The Problem with Predictions Any effort to forecast future conflicts is inherently a questionable endeavor. (1) If the past is any indication, the strategist is far more often wrong than right on the specifics. The work is doubly in jeopardy when the attempt is tied to a particular service and vulnerable to concerns of parochialism and bureaucratic interests. This article acknowledges these challenges, examining as it does the role of landpower in the Middle East for the next two decades from an Army perspective. This is not an attempt at perfect prediction nor are ground forces offered as the military panacea for all future contests in this region. There are, however, vital national interests at stake in the Middle East for the foreseeable future, and a wide range of threats to these interests. While informed observers may argue about the probability of one threat or another actually occurring, there is a general consensus regarding America's interests and the potential threats. There is little dispute that demand for petroleum will increase with the industrial expansion of China and India, or that demographic pressures and an overwhelmingly youthful population will increase political pressures on Middle Eastern regimes. The latent questions, then, are which of these threats requires a capability uniquely resident in American ground forces, and what does that mean for the Army in the current fiscal environment? While it may be impossible to predict with certainty the actions of a potential adversary, the experience of the last several conflicts has shown American ground forces, and the Army in particular, provide the nation with a set of capabilities that simply cannot be achieved solely from the other domains. Whether as a demonstration of American political intent through boots on the ground, a deterrent against the largely land-based forces of this region, a training partnership with current and future allies, or a force seasoned by a decade of war, American ground forces fill a vital and complementary role in the suite of options available to this nation in times of adversity. …

Improving Antarctic infrastructure

Noting that U.S. activities in Antarctica “are very well managed but suffer from an aging infrastructure, lack of a capital budget, and the effects of operating in an extremely unforgiving environment,” a 23 July report from the U.S. Antarctic Program Blue Ribbon Panel recommends a number of measures to improve the infrastructure, logistics, and other concerns. The panel's recommendations include continued use of the McMurdo, South Pole, and Palmer stations as the primary U.S. science and logistics hubs in Antarctica—because there are no reasonable alternatives, according to the panel—while upgrading or replacing some facilities, restoring the U.S. polar ocean feet, implementing state of‐the‐art logistics and transportation support, and establishing a long‐term facilities capital plan and budget for the U.S. Antarctic Program. “The essence of our findings is that the lack of capital budgeting has placed operations at McMurdo, and to a somewhat lesser extent at Palmer Station, in unnecessary jeopardy—at least in terms of prolonged inefficiency due to deteriorating or otherwise inadequate physical assets,” the panel wrote in the cover letter accompanying the report entitled, More and Better Science in Antarctica Through Increased Logistical Effectiveness. “The Antarctica Blue Ribbon Panel encourages us to take a hard look at how we support Antarctic science and to make the structural changes, however difficult in the current fiscal environment, that will allow us to do more science in the future,” said U.S. National Science Foundation (NSF) Director Subra Suresh.

How Smart is Smart Defense? A Review of NATO’s Smart Defense Proposal

IntroductionSince 2008, the world has experienced a severe economic crisis, one that has led to many austerity measures, including deep in defense spending in many countries. As Secretary-General Anders Fogh Rasmussen has argued, maintaining a capable and effective Alliance in this era of financial crisis presents a real and pressing challenge for NATO.1 In response to these challenges, at the Munich Security Conference in February 2011 Rasmussen launched a proposal for Defense. This proposal aims to examine how NATO can help nations to build greater security with fewer It emphasizes the need to better by prioritizing, specializing, and seeking multinational solutions.2This article will examine and analyze the proposal for Smart Defense with a view to assessing its value in helping surmount the fiscal challenges it faces. The first section will provide a brief overview of the current fiscal environment within member states, including key member states' current and planned defense spending and how these will impact burden sharing within NATO. The next section will briefly describe the Secretary-General's Smart Defense proposal, and will explore each pillar of the concept. The third section will examine the key challenges and strengths of the proposal. Finally, conclusions will be drawn about the ability of the Smart Defense proposal to help overcome the current fiscal challenges.NATO Burden Sharing and the Fiscal EnvironmentBurden sharing within occurs through a variety of direct and indirect contributions to the costs of the Alliance.3 The main way member states contribute to the Alliance is through the participation of their national armed forces in NATO, including in operations, and in efforts to ensure that national forces are interoperable with other members.4 At the Prague Summit in 2002, member states made a commitment to spend 2 percent of their GDP on defense in order to ensure that each member state was able to maintain a capable and effective defense force that was interoperable with other forces.5Constrained fiscal environments within member states have a significant impact on NATO, as this may lead member states to reduce their defense budgets and contributions to NATO. Presently, there are two key challenges for stemming from the current fiscal environment: declining defense budgets in many states, which will likely lead to capability shortfalls; and the increasing gap between European and U.S. contributions to resources. Each trend is discussed below and is followed by a review of the likely impacts on NATO.Declining Defense BudgetsWhile declining defense budgets have been a trend for some time now in Europe, the financial crisis in 2008 accelerated this trend. In 2011, for example, eighteen member states spent less on defense than in 20 10.6 Indeed, in the last two years, Europe's defense spending has gone down by roughly USD 45 billion, which is around the size of Germany's entire annual defense budget.7 The United States also faces huge spending with a USD 487 billion reduction to the US Defense budget over the next ten years.8 In addition, in 201 1 only three of NATO's twenty-eight members met the target of dedicating 2 percent of GDP to defense spending.9 As former U.S. Secretary of Defense Robert Gates recognized, the fiscal, political, and demographic realities make [achieving the 2 percent of GDP target] unlikely to happen anytime soon. 10 Added to this are the concerns that these cuts have been carried out with little or no coordination with other member states of the Alliance.11An Increasing Gap between U.S. and European ContributionsSince the beginning of NATO, there have been concerns about the equality of the Alliance's burden-sharing arrangements, particularly between contributions made by the United States and those from its European allies. …

Delivering on US Climate Finance Commitments

At the United Nations climate change conference in Copenhagen in 2009 and Cancun in 2010, the United States joined other developed countries in pledging to mobilize $100 billion in public and private sector funding to help developing countries reduce greenhouse gas emissions and adapt to a warmer world. With a challenging US fiscal outlook and the failure of cap-and-trade legislation in the US Congress, America's ability to meet this pledge is increasingly in doubt. This paper identifies, quantifies, and assesses the politics of a range of potential US sources of climate finance. It finds that raising new public funds for climate finance will be extremely challenging in the current fiscal environment and that many of the politically attractive alternatives are not realistically available absent a domestic cap-and-trade program or other regime for pricing carbon. Washington's best hope is to use limited public funds to leverage private sector investment through bilateral credit agencies and multilateral development banks.

Promising New Procedure Offers Hope for Patients With Intracerebral Hemorrhage

vent onward transmission of HIV, I believe that considerable changes are possible in resources and policy that would lend themselves to further prevention of HIV infection. When benefits outweigh costs by orders of magnitude, we will see changes in the United States. Policy changes will result from logical thinking.” While Cohen noted that he will participate in discussions of policies about who to treat and when, his role as principal investigator of HPTN 052 is “to report the results and let them speak for themselves.” Meanwhile, advocates for HIVinfected patients continue to stress the importance of making drugs available to patients who need them, and the shortsightedness of not doing so. An individual unable to access an ADAP and whose HIV infection progresses to full-blown AIDS may be categorized as disabled and become eligible for Medicaid, Macsata pointed out. Those Medicaid costs, he said, are 2.5 times greater than accessing drugs through ADAPs. “From a public health standpoint, it just doesn’t make sense.” What needs to be done to put ADAPs on a more solid footing throughout the country? “An additional $360 million is necessary for FY 2012 to meet projected needs,” said Penner, “although given the current federal fiscal environment, the request is for an additional $106 million.”