In This Issue
With the implementation of the Patient Protection and Affordable Care Act (ACA) taking place as this issue of The Milbank Quarterly is published, we begin with an article about Massachusetts’s experience with reforms similar to central parts of the ACA. This may foreshadow changes that may occur in other states under the ACA. The article is “Improvements in Health Status after Massachusetts Health Care Reform,” by Philip Van der Wees, Alan Zaslavsky, and John Ayanian. The authors used data from 2001 to 2011 from the annual Behavioral Risk Factor Surveillance System to compare health status measures in Massachusetts and other New England states before and after 2006 when Massachusetts enacted health reform legislation that subsequently reduced the uninsured rate in its population to less than 3 percent—the lowest in the country (Long, Stockley, and Dahlen 2012). That legislation was the model for the ACA.
The authors found that compared with other New England states, Massachusetts showed greater improvement in a series of measures of general health, physical health, and mental health, as well as prevention measures such as Pap screening, colonoscopy, and cholesterol testing. Notably, the gains in Massachusetts were most pronounced among people toward the lower end of the socioeconomic scale and were similar among white, black, and Hispanic residents. This article provides strong evidence that public policies that substantially broaden health insurance coverage can lead to measurable improvements in health status at the population level.
More than a half million Americans die of cancer each year. As the second leading cause of death, cancer presents difficult challenges regarding end-of-life care, as is shown in a compelling way in the next article in this issue, “The Lake Wobegon Effect: Are All Cancer Patients above Average?” by Jacqueline and Kevin Wolf. The sister-and-brother writing team—a medical historian and an actuary with health care expertise—describes their seventy-nine-year-old mother’s medical care between the discovery of lung cancer in a routine chest X-ray and her death fifteen months later. What makes their patient care narrative unusual is the rich body of data on which it is based. One or both of the authors were present to record most of their mother’s visits with her doctors, and they also assembled complete medical records and billing information.
After their mother’s cancer was diagnosed, her care moved from her primary care physician into the hands of specialists—surgeons, oncologists, and radiologists—all of whom offered and provided services. The options they offered—when combined with the patient’s search for hope and the belief that her chances were above average—resulted in lung surgery, chemotherapy, twenty-one radiation treatments of her head and neck, expensive prescription drugs, fifteen CT scans, three PET scans, twelve X-rays, seven MRIs, and, in the end, two months of hospice care. The total cost to Medicare, supplemental insurance, and family was $177,435 (38% of the total charges of $466,141). The authors believe that much of this care was futile and that some of it reduced the quality of their mother’s life. Much of the article is devoted to the decision-making processes that affected the care their mother received, providing a valuable window into why end-of-life care is so expensive in the United States. Well-informed narratives like this can be of significant use in developing public policies to address the difficult questions raised in end-of-life care.
The Wolfs’ article is followed by a commentary by Thomas Smith, who sequentially analyzes their mother’s case from the perspective of an oncologist, a palliative care physician, and a health services researcher and “guardian of Medicare resources.” His analysis shows that the facts of the case appear different from these various perspectives. Although many of the services Mrs. Wolf received were in line with standard clinical practice, some services (e.g., a $4,000/month drug and many of the imaging services) seem to have had little justification, and opportunities for better and earlier palliative care were missed. Smith points to the need for both better patient care guidelines in oncology and improved communications skills regarding the complex choices involved in cancer care.
The next article in this issue examines a different aspect of patient care quality. In “Hospital Board Oversight of Quality and Patient Safety: A Narrative Review and Synthesis of Recent Empirical Research,” Ross Millar, Russell Mannion, Tim Freeman, and Huw Davies report on the results of a systematic review of research on the topic. The authors are based in the United Kingdom, where scandals in recent years have highlighted problems in hospital care quality, but most of the research they review comes from the United States. Their review included two kinds of articles—those that offer expert advice about what hospital boards should be doing to monitor care quality and those that report the results of empirical research. The authors found only uneven evidence, at best, in support of the guidance provided in the advice literature about hospital governance. They suggest that both theoretical and methodological improvements are needed to develop more evidence-informed guidance regarding governance systems and practices regarding quality and patient safety.
The next article in this issue, “Medical Home Implementation: A Sensemaking Taxonomy of Hard and Soft Best Practices,” by Timothy Hoff, is about one of the care improvement provisions of the Affordable Care Act. Seeking to understand the changes needed for implementation of the ACA’s medical home provisions, Hoff interviewed physicians, nurses, and clinical support staff at six accredited medical homes located throughout the United States. His article describes the policies and practices—which he divides into “hard” and “soft” categories—that these organizations adopted. The hard practices involve activities and structural changes that accord with national standards, and the soft practices pertain more to interactions between staff and patients. The article is useful for documenting what is going on in the developing medical homes and how this relates to emerging accreditation standards. It also questions whether the relevant regulatory and incentive systems recognize the importance of the soft practices.
The final article in this issue is “Behavior Change Interventions to Improve the Health of Racial and Ethnic Minority Populations: A Tool Kit of Adaptation Approaches” by Emma Davidson and colleagues. The growing global prevalence of chronic diseases in which lifestyle factors such as smoking, physical inactivity, and unhealthy diet play a causal role has prompted interest in interventions that might help change such unhealthy behaviors. Although much evidence has accumulated about interventions for this purpose, these approaches may not be equally suitable for people from racial and ethnic minorities. The article is based on a project done for the National Institute for Health Research in the United Kingdom and focuses on the largest ethnic groups in that country—individuals of African, Chinese, and South Asian ethnic background. The research team developed a “Tool Kit of Adaptation Approaches” based on both published literature and expert interviews. The article describes the components of the tool kit, which the authors hope will be evaluated in a variety of population settings and may be helpful to policymakers and health care practitioners working to improve the health of racial and ethnic minorities.
This December 2013 issue of The Milbank Quarterly is my last one as editor, a position I have held since 2000. I am being ably succeeded by Howard Markel, MD, PhD, from the University of Michigan. This editorship has been a major part of my professional life, and I want to end by expressing my gratitude to many people, particularly to Dan Fox for appointing me to this position; to my predecessor, Paul Cleary, who has been an unfailing source of wise advice; to Tara Strome and Heidi Bresnahan, who have been the face of the journal to authors and reviewers and who have done their jobs with great competence, dedication, and creativity; and to the board and staff of the Milbank Memorial Fund for their constant support and encouragement.
I am also deeply grateful to the thousands of authors of the more than 1,900 submissions that we have considered over these years. If the Quarterly is highly cited (and it is), it is because of the quality of the submissions that we receive. But it is also due to the largely unsung work of knowledgeable and conscientious reviewers. More than 2,500 reviewers’ names have been listed at the end of the volumes published during my watch, and many of these individuals have reviewed many submissions for us. The publication of a journal is clearly a collective enterprise. Being editor of The Milbank Quarterly has provided an extraordinary window on the work of research. It has been an honor and privilege.
Bradford H. Gray
Long, S.K., K. Stockley, and H. Dahlen. 2012. Massachusetts Health Reforms: Uninsurance Remains Low, Self-Reported Health Status Improves as State Prepares to Tackle Costs. Health Affairs 31(2): 444–51.
Author(s): Bradford H. Gray
Volume 91, Issue 4 (pages 659–662)
Published in 2013