www.mobilehealthmap.org 617‐442‐3200 New research shows that mobile health clinics improve health outcomes for hard to reach populations in cost‐effective and culturally competent ways . A Harvard Medical School study determined that for every dollar invested in a mobile health clinic, the US healthcare system saves $30 on average. Mobile health clinics, which offer a range of services from preventive screenings to asthma treatment, leverage their mobility to treat people in the convenience of their own communities. For example, a mobile health clinic in Baltimore, MD, has documented savings of $3,500 per child seen due to reduced asthma‐related hospitalizations. The estimated 2,000 mobile health clinics across the country are providing similarly cost‐effective access to healthcare for a wide range of populations. Many successful mobile health clinics cite their ability to foster trusting relationships. Qualitative research in such mobile health clinics has found that patients value the informal, familiar environment in a convenient location, with staff who “are easy to talk to,” and that the staff’s “marriage of professional and personal discourses” provides patients the space to disclose information themselves. A communications academic argued that mobile health clinics’ unique use of space is important in facilitating these relationships. Mobile health clinics park in the heart of the community in familiar spaces, like shopping centers or bus stations, which lend themselves to the local community atmosphere.

Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care

The need is urgent to bring US health care costs into a sustainable range for both public and private payers. Commonly, programs to contain costs use cuts, such as reductions in payment levels, benefit structures, and eligibility. A less harmful strategy would reduce waste, not value-added care. The opportunity is immense. In just 6 categories of waste—overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse—the sum of the lowest available estimates exceeds 20% of total health care expenditures. The actual total may be far greater. The savings potentially achievable from systematic, comprehensive, and cooperative pursuit of even a fractional reduction in waste are far higher than from more direct and blunter cuts in care and coverage. The potential economic dislocations, however, are severe and require mitigation through careful transition strategies.

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Eliminating Waste in US Health Care

BIOMEDICAL RESEARCH POLICY COMMITTEE REPORT WAS PUBLISHED AS A SUPPLEMENT TO THE AUGUSTJOURNAL OF MEDICAL EDUCATION. A REPRINT IS ENCLOSED. REQUESTS FOR ADDITIONAL COPIES SHOULD BE ADDRESSED TO THISOFFICE. -COPIES ARE BEING SENT TO MEMBERS OF CONGRESS AND THE KEY MEMBERS OF THE ADMINISTRATION. CALLING UPON-YOUR SENATORSAND CONGRESSMEN TO TELL THE STORY OF THE ROLE. OF MEDICAL SCHOOLS IN BIOMEDICAL RESEARCH AND HEALTH CARE IS IMPORTANT.I STRONGLY URGE THAT YOU MAKE AN 411 APPOINTMENT TO SEE YOUR CONGRESSIONAL REPRESENTATIVES WHILE YOU ARE IN WASHINGTON FOR THE COUNCIL MEETINGON OCTOBER 29. UPON REQUEST WE CAN SUPPLY THE NAMES OF APPOINTMENT SECRETARIES AND PHONE NUMBERS OF YOUR SENATORS AND CONGRESSMEN. APPROPRIATIONS COMMITTEE ACTED WITH EXTRAORDINARY ALACRITY THIS YEAR. THE-NIH APPROPRIATION WAS INCREASED BY 242 MILLION DOLLARSOVER 1971, REPRESENTING A 142 MILLION DOLLAR INCREASE OVER. THE ADMINISTRATION BUDGET, THE BLUE SHEET ASCRIBES APPROPRIATIONS OUTCOME TO THE EFFECTIVENESS OF THE COALITION FOR HEALTH FUNDING UNDER THE LEADERSHIP OF JOHN A. D. COOPER.

The Association of American Medical Colleges

Influencing behaviour: The mindspace way

Evidence is accumulating that nurses completing pre-licensure programs are not equipped with the essential knowledge and skills for today’s nursing practice, nor prepared to continue learning for tomorrow’s nursing. Citing the need to improve quality and increase capacity, this paper offers three recommendations for transforming nursing education: (1) Create new nursing education systems which use existing resources in community colleges and universities and which provide for common prerequisites and a shared competency-based nursing curriculum and instructional materials. (2) Convene one or more expert panels to develop model pre-licensure curricula which: (a) can be used as a framework by faculty in community college-university partnerships for development of their local curriculum; (b) are based on emerging health care needs and widely accepted nursing competencies as interpreted for new care delivery models; (c) incorporate best practices in teaching and learning. (3) Invest in a national initiative to develop and evaluate new approaches to pre-licensure clinical education, including a required post-graduate residency under a restricted license. The author notes that these changes will require significant investment in the reforms, as well as in nursing education research and faculty development. The return on investment would be improved educational capacity and a better prepared nursing workforce, responsive to emerging health care needs and rapidly changing health care delivery systems. TRANSFORMING PRE-LICENSURE NURSING EDUCATION: PREPARING THE NEW NURSE TO MEET EMERGING HEALTH CARE NEEDS The Carnegie Foundation for the Advancement of Teaching joins a chorus of calls for transformation of pre-licensure nursing education (Benner et al., 2009b). Citing the shift of significant responsibility to nurses for managing complex medical regimens, as well as increasing complexity of community based practices, Benner and colleagues concluded that nurses entering the field are not equipped with the essential knowledge and skills for today’s practice nor prepared to continue learning for tomorrow’s nursing (p. 31). They found (1) weak curricula in natural sciences, technology, social sciences and humanities, and in developing cultural competency; (2) weak classroom instruction and limited integration between classroom and clinical experiences; (3) limited strategies in helping The Future of Nursing: Leading Change, Advancing Health Copyright National Academy of Sciences. All rights reserved.

The Future of Nursing: Leading Change, Advancing Health Key Messages and Report Recommendations

This paper draws on international evidence on medical spending to examine what the United States can learn about making its healthcare system more efficient. We focus primarily on understanding contemporaneous differences in the level of spending, generally from the 2000s. Medical spending differs across countries either because the price of services differs (for example, a coronary bypass surgery operation may cost more in the United States than in other countries) or because people receive more services in some countries than in others (for example, more bypass surgery operations). Within the price category, there are two further issues: whether factors earn different returns across countries and whether more clinical or administrative personnel are required to deliver the same care in different countries. We first present the results of a decomposition of healthcare spending along these lines in the United States and in Canada. We then delve into each component in more detail—administrative costs, factor prices, and the provision of care received—bringing in a broader range of international evidence when possible. Finally, we touch upon the organization of primary and chronic disease care and discuss possible gains in that area.

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The (paper) work of medicine: understanding international medical costs.

Objectives  To estimate differences in annual income of physicians in the United States by race and sex adjusted for characteristics of physicians and practices. Design  Cross sectional survey study. Setting  Nationally representative samples of US physicians. Participants  The 2000-13 American Community Survey (ACS) included 43 213 white male, 1698 black male, 15 164 white female, and 1252 black female physicians. The 2000-08 Center for Studying Health System Change (HSC) physician surveys included 12 843 white male, 518 black male, 3880 white female, and 342 black female physicians. Main outcome measures  Annual income adjusted for age, hours worked, time period, and state of residence (from ACS data). Income was adjusted for age, specialty, hours worked, time period, years in practice, practice type, and percentage of revenue from Medicare/Medicaid (from HSC physician surveys). Results  White male physicians had a higher median annual income than black male physicians, whereas race was not consistently associated with median income among female physicians. For example, in 2010-13 in the ACS, white male physicians had an adjusted median annual income of $253 042 (95% confidence interval $248 670 to $257 413) compared with $188 230 ($170 844 to $205 616) for black male physicians (difference $64 812; P Conclusions  White male physicians earn substantially more than black male physicians, after adjustment for characteristics of physicians and practices, while white and black female physicians earn similar incomes to each other, but significantly less than their male counterparts. Whether these differences reflect disparities in job opportunities is important to determine.

https://www.bmj.com/content/bmj/353/bmj.i2923.full.pdf

Differences in incomes of physicians in the United States by race and sex: observational study

Limited data exist on differences in time spent on household activities and child care between male and female physicians, which may influence sex differences in hours worked professionally. We studied sex differences among married physicians in time spent on household activities (eg, cleaning and cooking) and child care (eg, bathing and homework) from 2003 through 2016 using the American Time Use Survey, a detailed time use survey administered by the US Census. Overall, we found that female physicians with children spent 100.2 minutes (95% CI, 67.0-133.3 minutes) more per day on household activities and child care than did male physicians, a finding that was qualitatively similar after adjustment for work hours outside the home of both spouses. These patterns may reflect societal norms that ultimately influence physician sex differences in hours worked professionally.

Sex Differences in Time Spent on Household Activities and Care of Children Among US Physicians, 2003-2016.

Background:There is increasing policy interest in public reporting and tying financial incentives to metrics of patient safety. How black-serving hospitals fare on these measures will have important implications for disparities in care.Objectives:To determine how black-serving hospitals perform on p

How do black-serving hospitals perform on patient safety indicators? Implications for national public reporting and pay-for-performance.

Objectives To estimate the prevalence and incidence of divorce among US physicians compared with other healthcare professionals, lawyers, and non-healthcare professionals, and to analyze factors associated with divorce among physicians. Design Retrospective analysis of nationally representative surveys conducted by the US census, 2008-13. Setting United States. Participants 48 881 physicians, 10 086 dentists, 13 883 pharmacists, 159 044 nurses, 18 920 healthcare executives, 59 284 lawyers, and 6 339 310 other non-healthcare professionals. Main outcome measures Logistic models of divorce adjusted for age, sex, race, annual income, weekly hours worked, number of years since marriage, calendar year, and state of residence. Divorce outcomes included whether an individual had ever been divorced (divorce prevalence) or became divorced in the past year (divorce incidence). Results After adjustment for covariates, the probability of being ever divorced (or divorce prevalence) among physicians evaluated at the mean value of other covariates was 24.3% (95% confidence interval 23.8% to 24.8%); dentists, 25.2% (24.1% to 26.3%); pharmacists, 22.9% (22.0% to 23.8%); nurses, 33.0% (32.6% to 33.3%); healthcare executives, 30.9% (30.1% to 31.8%); lawyers, 26.9% (26.4% to 27.4%); and other non-healthcare professionals, 35.0% (34.9% to 35.1%). Similarly, physicians were less likely than those in most other occupations to divorce in the past year. In multivariable analysis among physicians, divorce prevalence was greater among women (odds ratio 1.51, 95% confidence interval 1.40 to 1.63). In analyses stratified by physician sex, greater weekly work hours were associated with increased divorce prevalence only for female physicians. Conclusions Divorce among physicians is less common than among non-healthcare workers and several health professions. Female physicians have a substantially higher prevalence of divorce than male physicians, which may be partly attributable to a differential effect of hours worked on divorce.

https://www.bmj.com/content/bmj/350/bmj.h706.full.pdf

Dan P. Ly

Papers

The (paper) work of medicine: understanding international medical costs.

Differences in incomes of physicians in the United States by race and sex: observational study

Sex Differences in Time Spent on Household Activities and Care of Children Among US Physicians, 2003-2016.

How do black-serving hospitals perform on patient safety indicators? Implications for national public reporting and pay-for-performance.

Divorce among physicians and other healthcare professionals in the United States: analysis of census survey data