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From the Editor Health Equity
Alan B. Cohen
Back to The Milbank Quarterly
For 100 years, the Milbank Quarterly has been a respected presence among the leading scholarly journals in the fields of public health and health policy. As journal editor since 2018, I have been privileged to maintain the traditions established by my predecessors while also embracing new editorial directions that emphasize population health and health equity.
As the Quarterly approaches its centennial anniversary, I am pleased to announce the publication in April 2023 of a special issue containing 36 timely and forward-looking articles by leading thinkers and scholars that examine the most important challenges facing population health over the next 10 years, along with policy prescriptions and strategies for meeting those challenges. The special issue is organized into six broad thematic areas central to the future of population health:
Stay tuned — more details will follow in the March 2023 issue!
This issue of the Quarterly opens with three thoughtful Perspectives. In the current workplace environment, paid paternity leave has been a contentious policy issue for some time. In “Paid Leave for Fathers: Policy, Practice, and Reform,” Y. Tony Yang and colleagues review the arguments for and against government policies that secure paid leave for all parents, regardless of gender. They argue that such policies can reduce structural inequalities and promote fathers’ engagement in parenting, and are likely to be most effective when they secure full or near-full wage replacement that provides incentives for fathers to take leave. They caution, however, that workplaces and organizations must participate in the culture shift, encouraging paternity leave rather than reinforcing the status quo perceptions of males as “breadwinners.”
In 2021, a proposed settlement agreement between four major pharmaceutical manufacturers and distributors and 46 state Attorneys General raised important questions about abatement conceptualization and measurement for allocating settlement funds among substate entities. In “Conceptualizing and Measuring Abatement from the Opioid Epidemic: A Case Study from Pennsylvania,” Danielle Rhubart and colleagues outline the political economy tensions undergirding the settlement and allocation, present a conceptual framework for abatement, and describe how an abatement formula was developed for Pennsylvania to allocate settlement funds. The authors summarize key considerations for future settlement allocation efforts.
Low-value care is common in clinical practice and can lead to patient harm and wasteful spending. Much of this low-value care stems from the use of medical device-based procedures. In “A Policy Approach to Reducing Low Value Device-Based Procedure Use,” Sanket Dhruva and colleagues describe a novel academic-policymaker collaboration that employs evidence-based clinical coverage for device-based procedures through prior authorization-based policies for Louisiana’s Medicaid beneficiary population. The eight-step process includes evidence synthesis as well as stakeholder engagement and input, and holds potential to reduce low-value device-based care.
In addition to these Perspectives, the December issue contains seven original research articles covering a range of topics. In “Assessment of Population-Level Disadvantage Indices to Inform Equitable Health Policy,” Rushina Cholera and colleagues examine several indices of disadvantage implemented during the COVID-19 pandemic to identify place-based patterns of social risk and to guide equitable health policy. Focusing on 14 disadvantage indices that were used three or more times from 2018 to 2021 with national-level data and available at the census-tract or block-group level, the authors compare social determinants of health domains across indices and use geospatial analyses to compare disadvantage profiles across geographic areas. They find that indices differ in geographic granularity and use varied metrics to represent place-based social risk. Within the same geographic area, different indices can provide differences in social risk values and interpretations, potentially leading to varied public health or policy responses.
Numerous states have adopted policies intended to address prenatal drug use, many of which utilize existing child welfare mechanisms despite evidence that these policies might disincentivize treatment-seeking behavior. In “Development and Implementation of State and Federal Child Welfare Laws Related to Drug Use in Pregnancy,” Alexander McCourt and colleagues use legal mapping and qualitative interviews to examine child welfare laws in all 50 states and the District of Columbia related to substance use in pregnancy from 1974 to 2019, with a particular focus on laws adopted in 19 states between 2009 and 2019. Their findings reveal variation in implementation within and across states, with significant challenges posed by existing policies and a lack of guidance for practitioners. They contend that many such policies may disincentivize treatment-seeking among pregnant people who use drugs and may lead to family separation. They believe that state policymakers and practitioners could benefit from a treatment-oriented approach to prenatal substance use and from additional state and federal guidance.
Policy shifts toward greater health information transparency, including patient access to electronic visit notes, provide new opportunity for patients and families to help identify clinically relevant errors, “blind spots,” and safety hazards that are difficult for clinicians or health care organizations to see. In “Patient Identification of Diagnostic Safety Blind Spots and Participation in ‘Good Catches’ through Shared Visit Notes,” Sigall Bell and colleagues investigate whether sharing clinical notes with patients can support identification of diagnostic safety blind spots and avoid breakdowns in the diagnostic process. Using a mixed-methods approach, the authors analyze patient-reported ambulatory documentation errors among 22,889 patients at three US health care centers. Reported blind spots include inaccurate symptoms or histories, failures or delays in diagnosis, errors of omission, and problems with tests, referrals or appointment access. Many patients act on the blind spots they identify, resulting in “good catches” that may prevent potential negative consequences. The authors conclude that patients who read notes have unique insight about potential errors in their medical records that could influence diagnostic reasoning, and that organizations should encourage patient review of visit notes, build systems to track patient-reported blind spots, and promote equity in note access.
Many adults with serious mental illness, especially those living in low-income and minority communities, have limited access to specialty community mental health services. Medicaid expansion might encourage facilities to offer these services, but this decision will depend on the type of facility ownership, the service cost structure, and the available payment mechanisms. In “What Explains Changes in Availability of Specialty Mental Health Services?” Helen Newton and colleagues analyze data from the National Mental Health Services Survey to examine trends in the use of 7 specialty mental health services from 2010 to 2019, finding that declines in psychiatric emergency walk-in services and psychotropic medication services were smaller among facilities in Medicaid expansion states than in non-expansion states. Public facilities were the only facility type to report increases in service availability over the study period, while for-profit facilities experienced the largest declines. Overall, specialty mental health services are still not widely offered in community settings even with significant investments in Medicaid and even though Medicaid expansion has been associated with slower declines in service availability.
Minority and low socioeconomic patient populations historically have faced poorer health and disproportionate burden of disease in the United States. With diagnostic molecular genetic testing becoming more commonplace in the health care system, the way in which genetic testing is used can either exacerbate or reduce health disparities. In “Toward a More Just System of Care in Molecular Pathology,” Cullen Lilley and colleagues provide case scenarios – loosely based on real-life patients – to illustrate the impacts of complex policy decisions and unintentional biases in technology. The authors find that access to diagnostic molecular genetic testing is neither equitable nor sufficient, owing to at least 5 major factors: (1) cost to the patient; (2) location; (3) lack of provider buy-in; (4) dataset bias; and (5) lack of public trust. They believe that molecular genetic pathology can be made more equitable through the concerted efforts of multiple stakeholders to confront and alleviate the five major factors identified in the study.
In 2012, the Centers for Medicare and Medicaid Services implemented the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. In Phase 1 (2012 to 2016), clinical or education-based interventions aimed to reduce hospitalizations among long-stay nursing home residents (Clinical-Only). In Phase 2 (2016 to 2020), the Initiative added a Medicare payment incentive for treating residents with certain conditions within the nursing home. In “CMS Initiative to Reduce Potentially Avoidable Hospitalizations among Long-Stay Nursing Facility Residents: Lessons Learned,” Denise Tyler and colleagues report on a mixed methods study to determine the effectiveness of the Initiative and to explore facilitators of and barriers to implementation that participating nursing homes experienced. They find that the Clinical-Only intervention in Phase 1 was successful in reducing hospitalizations, but that the Phase 2 interventions were not. The authors conclude that reducing hospitalizations among nursing home residents hinges upon the availability and support of clinical staff who can provide ongoing education to direct-care staff in the nursing home, as well as hands-on care. Use of Medicare payment incentives alone to encourage on-site treatment of residents was insufficient to reduce hospitalizations. Unless nursing homes are adequately staffed to treat residents with acute care needs, further reductions in hospitalizations will be difficult to achieve.
In closing, we invite readers to explore the Quarterly’s website for timely opinion pieces on important policy issues. Recent contributions include:
Alan B. Cohen became editor of The Milbank Quarterly in August 2018. He currently is a research professor in the Markets, Public Policy, and Law Department at the Boston University Questrom School of Business, and professor of health law, policy and management at the Boston University School of Public Health. He previously directed the Scholars in Health Policy Research Program and the Investigator Awards in Health Policy Research for the Robert Wood Johnson Foundation. Earlier in his career, he held faculty positions at Johns Hopkins University and Brandeis University, and spent 8 years at the Robert Wood Johnson Foundation. He is a member of the National Academy of Social Insurance. He received his BA in psychology from the University of Rochester, and his MS and ScD in health policy and management from the Harvard School of Public Health.
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