Creating Incentives to Move Upstream: Developing a Diversified Portfolio of Population Health Measures Within Payment and Health Care Reform

I examined the feasibility of developing a balanced portfolio of population health measures that would be useful within the current deliberations about health care and payment reform.My commentary acknowledges that an obstacle to the selection of population health metrics is the differing definitions of population health. Rather than choosing between these definitions, I identified five categories of indicators, ranging from traditional clinical care prevention interventions to those that measure investment in community-level nonclinical services, that in various combinations might yield the most promising results.I offer concrete examples of markers in each of the categories and show that there is a growing number of individuals eager to receive concrete recommendations and implement population health pilot programs.Wellness and prevention are receiving more and more attention during the implementation phases of the Affordable Care Act (ACA).1 Supported by the federal government, with additional efforts such as the State Innovation Models Initiative grants and by nonprofit groups such as the Robert Wood Johnson Foundation, movements are afoot to alter the current incentives that focus the health care system on illness rather than wellness—incentives that encourage health care clinicians to test, prescribe, and treat even when there is little apparent health value in doing so but reimbursement is guaranteed.2,3Often, discussions about how to focus on prevention within clinical settings have been limited to the consideration of medically oriented interventions, such as immunization. However, in a surprising number of settings this limited framework is being expanded to think outside the box and even outside the clinical setting itself. Sometimes referred to as “primary prevention” or “upstream prevention interventions,” such approaches attempt to alter the conditions in people’s lives so that the easier behaviors are the healthier ones.4,5The atmosphere is ripe for considering the ways to link prevention to clinical care because of the momentum to move away from fee-for-service to value-based global payment for health care.6,7 In these new models, global payment is tied to the fulfillment of a set of prioritized health indicators, including those that emphasize wellness and the avoidance of the utilization of expensive and sometimes unnecessary hospitalizations, emergency department visits, and medical interventions. If the measures are not met, an accountable care organization or other provider group may lose a financial bonus and even risk future contracts with payers. Other innovative payment approaches also create opportunities for the promotion of wellness. For instance, many states are implementing delivery system reform incentive payment programs, partnerships between the federal government and state Medicaid programs, to support safety net providers who care for patients with complex socioeconomic barriers to improved health.Coinciding with these changes is the expanded prevalence of practice models that may lend themselves to support for a population health focus. The integrative care approach of patient-centered medical homes, including the chronic disease–focused Medicaid health homes, is more likely than is a conventional model to recognize the importance of addressing the conditions of patients’ lives.These changing circumstances have created a new openness to nontraditional approaches to keeping people and communities healthy. But although the moment exists for meaningful change, it may not last long. The ACA’s implementation and the Centers for Medicare and Medicaid Services’ distribution of hundreds of millions of dollars in funding for state innovation model (SIM) grants have created an environment in which unprecedented discussions are taking place on a relatively tight timeline. In state after state efforts are under way to engage public and commercial payers in an overhaul of the payment system. In the case of the SIM grants, the states are given just four years to shift to value-based contracting as the predominant reimbursement mechanism with aligned and consistent quality measures across insurers. As these discussions occur, public health leaders have to be prepared to participate. More importantly, they need to offer concrete and specific suggestions that fit into an insurance-oriented framework and have a demonstrable benefit in cost and quality.Various approaches to identify meaningful population-based health measures are being examined. These include state-specific exercises such as the Massachusetts Statewide Quality Advisory Committee, a legislatively mandated body charged with compiling the proven and most promising health indicators to assist in the state’s innovative cost control and quality promotion initiatives. Although initially prioritizing the selection of at least a few population health indicators, Massachusetts postponed this task in part because of the lack of concrete, evidence-based measures of prevention and wellness and the enormity of the effort to sift through the more conventional treatment-oriented indicators.8There have been national high-profile efforts as well. Starting in 2012 the Institute of Medicine Roundtable on Population Health Improvement convened several stakeholders’ dialogues to examine what was needed to improve population health. It produced a useful summary report regarding population health improvement that highlighted the importance of collaborations involving multiple stakeholders and the use of financial incentives to align the interests of physicians and hospitals.9 The participants in these meetings offered thoughtful insights into the groundwork needed to establish the incentives for population health and highlighted numerous positive examples of such activities around the country.Beginning in 2011 the National Quality Forum began a two-phase process that led to their endorsement of 24 clinically focused population health measures. These measures provide a valuable building block for the development of a coordinated approach to population health and its relationship to clinical care. The National Quality Forum recently formed a Health and Well-Being Standing Committee to review specific health measures that thus far have had a traditional clinical focus. In addition, it formed a Health and Human Services Department–funded Population Health Framework Committee and a Population Health Task Force to further its consideration of this work.10The Centers for Medicare and Medicaid Services’ Innovation Center funding of SIM has led states to transform health care systems by creating and testing new models of care delivery and payment. The recent second round of the SIM grant awards required states to include a population health component that was integrated with value-based contracting and patient-centered medical homes. Many of the funded states have expressed an interest in guidance on the development and use of population health measures.7,11In each of these settings, there has been general agreement that the study of population health measures is a relatively nascent field and lacks an optimal reservoir of information and experience. Nonetheless, in these various endeavors there has been an oft-repeated recognition that the current period offers a window of opportunity that should not be missed.The specific proposals for population health metrics that have been offered for consideration in these various settings have differed—often dramatically—on the basis of the definition of population health (e.g., is it limited to a clinical practice or focused on the larger geographic community?), the size of practice (e.g., does it apply only to accountable care organizations [ACOs] and the largest practices or does it also apply to smaller medical groups?), and the intervention setting (e.g., do the action steps occur only in clinical settings or do they also occur in the patients’ homes, neighborhoods, or cities?). This definitional variation has led to some confusion as the discussions have proceeded and likely impeded progress in the effort to identify meaningful metrics.Rather than choosing between approaches, it may be useful to conceptualize a portfolio of proposals that in various combinations—depending on the circumstances—might yield the most promising results. Based on the types of proposals that have been offered in recent years, such a portfolio might include the following five categories:

1. traditional clinical prevention interventions;
2. health indicators of the universe of patients treated in a particular practice or health system;
3. health indicators of the residents within a community, a catchment area, or the total population;
4. indicators of support for ancillary services that are patient centered and evidence based but often delivered outside a clinical setting or community-level care; and
5. indicators of support for improving the living conditions in the neighborhoods, workplaces, and schools of the patient population or, as Centers for Disease Control and Prevention director Tom Frieden, MD, MPH, refers to them, context-changing interventions that encourage healthy behaviors.4

Traditional clinical prevention interventions and practice-based population measures involve data that can be captured in the routine manner of a one-to-one encounter of a patient with a clinician and then aggregated across a practice or system. Total population measures involve data predominantly collected by local, state, or federal health officials. Community-level care and context-changing interventions often involve what may be referred to as process measures as well as outcome measures. These process measures are systemwide resource and policy action steps that extend beyond the one-on-one provision of patient care. They aim to positively influence the conditions in specific communities or in certain settings, such as prisons, resulting in the widespread prevention of illness and injury. Such measures are most feasible for sizable organizational entities, such as ACOs, vertically integrated health care systems, and large hospitals. Requirements for process measures could be written into licensing or certification rules or regulations.The indicators selected may vary from state to state, taking into account the diseases and risk factors that are most prevalent and costly and those for which there are clearly identifiable effective actions steps. Whenever possible, the time frames for results for the indicators in each of these five categories should be both short and long term. Some short-term cost savings (or at least cost neutrality) and short-term positive health outcomes are necessary to guarantee continued support from elected officials and from health plans under pressure to perform. However, at the same time, many population health measures will take years to demonstrate measurable positive health outcomes—and some may turn out to be costly but deemed necessary because of the impact they have on the health and well-being of the population. A case can be made that all five areas are needed to optimize health and wellness.     

Pay for performance in hospitals: implications for nurses and nursing care

As pay-for-performance programs gain momentum, hospital administrators and clinical leaders will need to consider the organization's infrastructure and measures that promote quality management initiatives. Many hospital performance measures by the Centers for Medicare & Medicaid Services involve chronic diseases that may be best managed by an interdisciplinary team-based approach, of which nurses are significant members. While the primary focus of pay-for-performance has been concentrated on physicians, comparatively less attention has been given to the potential impact on nurses and nursing care. Moreover, the impact of the pay-for-performance measures on nursing labor and processes has not been well studied. Within acute care settings, increasing attention has focused on the structure of nursing, such as number and skill mix of nursing personnel, processes of care, and influence on patient outcomes. As pay-for-performance standards evolve and encompass patient outcomes, attention to nursing's contribution will follow. Nursing leadership will need to address a number of strategies to (a) address the impact of pay-for-performance on nursing performance measures as well as (b) on staff nurses' ability to contribute to the organization's efforts in achieving pay-for-performance standards, including education, documentation, team collaboration, and patterns of care.     

Health benefits of primary care social work for adults with complex health and social needs: a systematic review

The prevalence of complex health and social needs in primary care patients is growing. Furthermore, recent research suggests that the impact of psychosocial distress on the significantly poorer health outcomes in this population may have been underestimated. The potential of social work in primary care settings has been extensively discussed in both health and social work literature and there is evidence that social work interventions in other settings are particularly effective in addressing psychosocial needs. However, the evidence base for specific improved health outcomes related to primary care social work is minimal. This review aimed to identify and synthesise the available evidence on the health benefits of social work interventions in primary care settings. Nine electronic databases were searched from 1990 to 2015 and seven primary research studies were retrieved. Due to the heterogeneity of studies, a narrative synthesis was conducted. Although there is no definitive evidence for effectiveness, results suggest a promising role for primary care social work interventions in improving health outcomes. These include subjective health measures and self‐management of long‐term conditions, reducing psychosocial morbidity and barriers to treatment and health maintenance. Although few rigorous study designs were found, the contextual detail and clinical settings of studies provide evidence of the practice applicability of social work intervention. Emerging policy on the integration of health and social care may provide an opportunity to develop this model of care.     

Violence Against Women and Reproductive Health: Toward Defining a Role for Reproductive Health Care Services

Since a large proportion of U.S. women receive reproductive health care services each year, reproductive health care settings offer an important opportunity to reach women who may be at risk of or experiencing intimate partner violence (IPV). Although screening women for IPV in clinical health care settings has been endorsed by national professional associations and organizations, scientific evidence suggests that opportunities for screening in reproductive health care settings are often missed. This commentary outlines what is known about screening and intervention for IPV in clinical health care settings, and points out areas that need greater attention. The ultimate goal of these recommendations is to increase the involvement of reproductive health care services in sensitive, appropriate, and effective care for women who may be at risk of or affected by IPV.     

Mobile Health in China: A Review of Research and Programs in Medical Care,Health Education,and Public Health

There are nearly 1 billion mobile phone subscribers in China. Health care providers, telecommunications companies, technology firms, and Chinese governmental organizations use existing mobile technology and social networks to improve patient–provider communication, promote health education and awareness, add efficiency to administrative practices, and enhance public health campaigns. This review of mobile health in China summarizes existing clinical research and public health text messaging campaigns while highlighting potential future areas of research and program implementation. Databases and search engines served as the primary means of gathering relevant resources. Included material largely consists of scientific articles and official reports that met predefined inclusion criteria. This review includes 10 reports of controlled studies that assessed the use of mobile technology in health care settings and 17 official reports of public health awareness campaigns that used text messaging. All source material was published between 2006 and 2011. The controlled studies suggested that mobile technology interventions significantly improved an array of health care outcomes. However, additional efforts are needed to refine mobile health research and better understand the applicability of mobile technology in China's health care settings. A vast potential exists for the expansion of mobile health in China, especially as costs decrease and increasingly sophisticated technology becomes more widespread.     

Defining Remoteness from Health Care: Integrated Research on Accessing Emergency Maternal Care in Indonesia

The causes of maternal death are well known, and are largely preventable if skilled health care is received promptly. Complex interactions between geographic and socio-cultural factors affect access to, and remoteness from, health care but research on this topic rarely integrates spatial and social sciences. In this study, modeling of travel time was integrated with social science research to refine our understanding of remoteness from health care. Travel time to health facilities offering emergency obstetric care (EmOC) and population distribution were modelled for a district in eastern Indonesia. As an index of remoteness, the proportion of the population more than two hours estimated travel time from EmOC was calculated. For the best case scenario (transport by ambulance in the dry season), modelling estimated more than 10,000 fertile aged women were more than two hours from EmOC. Maternal mortality ratios were positively correlated with the remoteness index, however there was considerable variation around this relationship. In a companion study, ethnographic research in a subdistrict with relatively good access to health care and high maternal mortality identified factors influencing access to EmOC, including some that had not been incorporated into the travel time model. Ethnographic research provided information about actual travel involved in requesting and reaching EmOC. Modeled travel time could be improved by incorporating time to deliver request for care. Further integration of social and spatial methods and the development of more dynamic travel time models are needed to develop programs and policies to address these multiple factors to improve maternal health outcomes.     

Impact of New Information Technologies on Training and Continuing Education for Rural Health Professionals

Recently developed and emerging information and communications technologies offer the potential to move the clinical training of physicians and other health professionals away from the resource intensive urban academic health center, with its emphasis on tertiary care, and into rural settings that may be better able to place emphasis on the production of badly needed primary care providers. These same technologies also offer myriad opportunities to enhance the continuing education of health professionals in rural settings. This article explores the effect of new technologies for rural tele-education by briefly reviewing the effect of technology on health professionals' education, describing ongoing applications of tele-education, and discussing the likely effect of new technological developments on the future of tele-education. Tele-education has tremendous potential for improving the health care of rural Americans, and policy-makers must direct resources to its priority development in rural communities.     

Preparing the workforce for integrated healthcare: A systematic review

Integrated healthcare is recommended to deliver care to individuals with co-occurring medical and mental health conditions. This literature review was conducted to identify the knowledge and skills required for behavioral health consultants in integrated settings. A review from 1999 to 2015 identified 68 articles. Eligible studies examined care to the U.S. adult population at the highest level of integration. The results provide evidence of specific knowledge of medical and mental health diagnoses, screening instruments, and intervention skills in integrated primary care, specialty medical, and specialty mental health. Further research is required to identify methods to develop knowledge/skills in the workforce.     

The 1990s and Beyond: Determining the Need for Community Health and Primary Care Nurses for Rural Populations*

ABSTRACT: Increased numbers of primary care and advanced practice nurses with unique generalist skills will be required to meet the accelerating physiologic and sociocultural health care needs of rural populations. Several factors have been identified that will influence the demands and position of community-based nurses in rural practice settings during the next decade. A back-to-basics type of health care offered out of a growing elderly population; technological breakthroughs that make it possible for more chronically ill patients to live at home; serious substance abuse and other adolescent problems; AIDS; and high infant morbidity and mortality statistics are only some of the concerns that will demand nursing intervention. These changes speak to the need for improved nursing coordination, stronger collegial relationships, and better communication between physicians and nurses. Health care is moving in new directions to offer more efficient and technologically sophisticated care. These changes enhance the need for clinically expert educators who teach and jointly practice in programs with a rural focus. Telecommunications, and heightened computer literacy, will play a major role both in nursing education and clinical practice. The goals of kindergarten through 12th grade health promotion and disease prevention strategies in school health will be the norm and will require better prepared, and positions for, school nurses. More midwives and public health nurses will be needed to care for the growing population of sexually active adolescents who are in need of family planning and prenatal care. Underinsured and indigent populations will continue to fall within the purview of midlevel practitioners, as will providing anesthesia services in small rural hospitals. The transition of some rural hospitals into expanded primary care units (e.g., EACHs and RPCHs), and new models of case management will greatly influence nursing demands. This paper will further identify critical areas of advanced practice nursing within community settings, including new relationships with other health care providers, and will introduce strategies upon which rural health policy recommendations for the 1990s can be addressed.     

Pay for performance and medical education: strategies for preparing physicians of the future

Performance-based reimbursement has become an increasingly important topic in the field of medicine and one that has met with significant legislative support. Small- and large-scale pilot programs in the United States and more comprehensive programs implemented abroad have yielded preliminary findings that raise several interesting questions regarding the form that pay-for-performance programs will take and concerns about the unintended and unforeseen consequences of this new reimbursement approach. One important area that has not been explored, however, is the potential implications of pay for performance to "clinician educators"-individuals from diverse health-related disciplines who both provide health care and are responsible for training the next generation of health care professionals. Because the effect of pay for performance is likely to vary by health care discipline, we focus here on potential implications for physician educators. Our objective is to analyze the experience to date with pay for performance, make predictions from these experiences about the potential impact of pay for performance on the education of resident physicians, and propose educational strategies that might be useful in positioning physician trainees for success as they enter the workforce.     

The 1990s and Beyond: Determining the Need for Community Health and Primary Care Nurses for Rural Populations*

Increased numbers of primary care and advanced practice nurses with unique generalist skills will be required to meet the accelerating physiologic and sociocultural health care needs of rural populations. Several factors have been identified that will influence the demands and position of community-based nurses in rural practice settings during the next decade. A back-to-basics type of health care offered out of a growing elderly population; technological breakthroughs that make it possible for more chronically ill patients to live at home; serious substance abuse and other adolescent problems; AIDS; and high infant morbidity and mortality statistics are only some of the concerns that will demand nursing intervention. These changes speak to the need for improved nursing coordination, stronger collegial relationships, and better communication between physicians and nurses. Health care is moving in new directions to offer more efficient and technologically sophisticated care. These changes enhance the need for clinically expert educators who teach and jointly practice in programs with a rural focus. Telecommunications, and heightened computer literacy, will play a major role both in nursing education and clinical practice. The goals of kindergarten through 12th grade health promotion and disease prevention strategies in school health will be the norm and will require better prepared, and positions for, school nurses. More midwives and public health nurses will be needed to care for the growing population of sexually active adolescents who are in need of family planning and prenatal care. Underinsured and indigent populations will continue to fall within the purview of midlevel practitioners, as will providing anesthesia services in small rural hospitals. The transition of some rural hospitals into expanded primary care units (e.g., EACHs and RPCHs), and new models of case management will greatly influence nursing demands. This paper will further identify critical areas of advanced practice nursing within community settings, including new relationships with other health care providers, and will introduce strategies upon which rural health policy recommendations for the 1990s can be addressed.     

Outcomes of enhanced prenatal services for Medicaid-eligible women in public and private settings.

OBJECTIVE: With changes in Medicaid, more low-income women are receiving prenatal care in private practice settings. The authors sought to determine whether private settings can provide the enhanced prenatal support services for low-income women that have been offered for decades in public settings. METHODS: The authors analyzed birth outcomes of Medicaid-eligible women receiving care from public and private providers certified to deliver enhanced prenatal care services, which included assessments of nutritional, psychosocial, and health educational risks and individualized counseling along with clinical care. Birth outcomes were compared by type of provider setting using multivariate logistic regression models to adjust for differences in risks and use of care. RESULTS: Among settings certified to deliver enhanced perinatal support services, private physicians'' offices had the best risk-adjusted birth outcomes and public health department clinics the worst, while public hospital clinics had outcomes no different from private physicians'' offices. Adjusted for prenatal care use, outcomes were still better for women seen in private physicians'' offices than for women seen in public health department clinics, community clinics, or private hospital clinics. CONCLUSIONS: The findings suggest that given a certification process, private providers can provide enhanced support services as effectively as providers in public practice settings.     

Return on investment in pay for performance: a diabetes case study

With purchasers' increasing frustration with healthcare costs, more innovative approaches to performance-based reimbursement are in demand. Establishing pay-for-performance programs has become a popular strategy for reorienting payments from rewarding volume to rewarding adherence to performance measures. However, while performance on quality measures has improved, no reports exist about the return on investment (ROI) of pay-for-performance programs. This article compares the overall costs of implementing and maintaining a pay-for-performance program with the resulting cost trend savings for diabetes care for a health maintenance organization's (HMO's) population. The program was a five-year partnership (2000-2004) between a health plan and an independent practice association (IPA) for the HMO product. It reported performance scores on quality, patient satisfaction, and practitioner efficiency at the individual physician level. Physician performance reporting began in 1999, and payment for that performance began in 2002. The cost of the program was 1,150,000 dollars yearly. Savings for diabetes alone in 2003, the first post-intervention year, were 1,894,471dollars. Second-year (2004) savings against the two-year rolling trend were 2,923,761 dollars. For 2003, the resulting ROI was 1.6:1, and for 2004, it was 2.5:1. To our knowledge, this article is the first report of a positive ROI for an HMO-based pay-for-performance program, and it begins to answer the question of whether the investment in such programs is worth the effort.     

Improving Health and Building Human Capital Through an Effective Primary Care System

To improve population health, one must put emphasis on reducing health inequities and enhancing health protection and disease prevention, and early diagnosis and treatment of diseases by tackling the determinants of health at the downstream, midstream, and upstream levels. There is strong theoretical and empirical evidence for the association between strong national primary care systems and improved health indicators. The setting approach to promote health such as healthy schools, healthy cities also aims to address the determinants of health and build the capacity of individuals, families, and communities to create strong human and social capitals. The notion of human and social capitals begins to offer explanations why certain communities are unable to achieve better health than other communities with similar demography. In this paper, a review of studies conducted in different countries illustrate how a well-developed primary health care system would reduce all causes of mortalities, improve health status, reduce hospitalization, and be cost saving despite a disparity in socioeconomic conditions. The intervention strategy recommended in this paper is developing a model of comprehensive primary health care system by joining up different settings integrating the efforts of different parties within and outside the health sector. Different components of primary health care team would then work more closely with individuals and families and different healthy settings. This synergistic effect would help to strengthen human and social capital development. The model can then combine the efforts of upstream, midstream, and downstream approaches to improve population health and reduce health inequity. Otherwise, health would easily be jeopardized as a result of rapid urbanization.     

The experience of pay for performance in English family practice: a qualitative study

PURPOSE We conducted an in-depth exploration of family physicians’ and nurses’ beliefs and concerns about changes to the family health care service as a result of the new pay-for-performance scheme in the United Kingdom (Quality and Outcomes Framework [QOF]).METHODS Using a semistructured interview format, we interviewed 21 family doctors and 20 nurses in 22 nationally representative practices across England between February and August 2007.RESULTS Participants believed the financial incentives had been sufficient to change behavior and to achieve targets. The findings suggest that it is not necessary to align targets to professional priorities and values to obtain behavior change, although doing so enhances enthusiasm and understanding. Participants agreed that the aims of the pay-for-performance scheme had been met in terms of improvements in disease-specific processes of patient care and physician income, as well as improved data capture. It also led to unintended effects, such as the emergence of a dual QOF-patient agenda within consultations, potential deskilling of doctors as a result of the enhanced role for nurses in managing long-term conditions, a decline in personal/relational continuity of care between doctors and patients, resentment by team members not benefiting financially from payments, and concerns about an ongoing culture of performance monitoring in the United Kingdom.CONCLUSIONS The QOF scheme may have achieved its declared objectives of improving disease-specific processes of patient care through the achievement of clinical and organizational targets and increased physician income, but our findings suggest that it has changed the dynamic between doctors and nurses and the nature of the practitioner-patient consultation.     

Clinical Preventive Services for Older Adults: The Interface Between Personal Health Care and Public Health Services

Healthy aging must become a priority objective for both population and personal health services, and will require innovative prevention programming to span those systems. Uptake of essential clinical preventive services is currently suboptimal among adults, owing to a number of system- and office-based care barriers.To achieve maximum health results, prevention must be integrated across community and clinical settings. Many preventive services are portable, deliverable in either clinical or community settings. Capitalizing on that flexibility can improve uptake and health outcomes.Significant reductions in health disparities, mortality, and morbidity, along with decreases in health spending, are achievable through improved collaboration and synergy between population health and personal health systems.BETWEEN 2010 AND 2050, the population of Americans aged 65 years and older is expected to more than double, swelling to nearly 89 million. This “silver tsunami,” composed mostly of Baby Boomers (the first of whom crossed the 65-year line in 2011), will pose serious challenges for our nation’s public health and health care systems, along with state and federal budgets, family finances, and private sector profitability. Healthy aging, too often viewed as a peculiar product of luck or luxury, must become a priority objective for both population and personal health services—and will require innovative prevention programming to span those systems.Chronic illness currently represents an estimated 83% of total US health expenditures and 99% of Medicare spending.1 Increasing rates of costly chronic conditions, many of which are not well managed,2–5 are associated with significant Medicare spending increases.6,7 Each year, more than half of Medicare beneficiaries are treated for 5 or more chronic conditions.6 The average Medicare enrollee sees 2 primary care physicians and 5 specialists working in 4 different practices annually8; those with 5 or more chronic conditions see an average of 14 different physicians a year.9 Care fragmentation results in suboptimal uptake of clinical preventive services (CPS) among US adults3,10: only 33% of women and 40% of men aged 65 years and older are fully up to date with all preventive services recommended for all adults in this age range,11 and less than a quarter of adults aged 50 to 64 years have received all these services.12 Even if adults receive recommended disease screening, a positive finding may not lead to effective treatment: although blood pressure screening in older adults is relatively high, hypertension is controlled in only half of patients.13Preventing chronic diseases and keeping chronically ill older adults healthier are imperatives to drive improvements in health, quality of life, and value in US health spending.14 Population-based primary prevention works to avert disease. It must be reinforced with patient-focused primary prevention and coupled with effective secondary prevention to detect illness as well as tertiary prevention aimed at better managing existing illness and preventing additional disease and disability. To achieve maximum health results, prevention must be integrated across community and clinical settings. Many preventive services are portable—deliverable in either clinical or community settings. Capitalizing on that flexibility can improve uptake and health outcomes.Optimal use of CPS—particularly for cardiovascular conditions—could avert an estimated 50 000 to 100 000 deaths per year among adults younger than 80 years and 25 000 to 40 000 deaths per year among those younger than 65 years.15 Increasing uptake of selected high-value CPS to 90% could produce an additional 1.89 million quality-adjusted life years.16 Outside clinical settings, the Trust for America’s Health has estimated that an investment of $10 per person per year in community-based programs tackling physical inactivity, poor nutrition, and smoking could yield more than $16 billion in medical cost savings annually within 5 years—a return on investment of $5.60 for every $1 spent, without considering the additional gains in worker productivity, reduced absenteeism at work and school, and enhanced quality of life.17 Significant reductions in health disparities, mortality, and morbidity—and attendant decreases in health spending—are achievable through improved collaboration and synergy between population health and personal health systems.18 We discuss essential CPS for older adults, emerging delivery models that encompass health care and community settings to boost uptake, and public health priorities in a changing US health system.     

Provider Perceptions of Reproductive Health Service Quality in Jordanian Public Community Health Centers

Enhancing the quality of reproductive health care delivery in developing countries is a key prerequisite to increased utilization and sustainability of these services in the target population. Our objective was to assess the perception of quality of reproductive health (RH) care services provided by Jordanian Ministry of Health community-based centers from the perspective of service providers in these settings. A purposeful nationwide sample of 50 primary health care providers took part in five focus group discussions with the purpose of exploring their perceptions of the quality of care provided by their centers and perceived barriers to the provision of quality RH care. Health care providers felt that the quality of RH care provided by their centers was suboptimal. Focus group participants reported numerous barriers to the provision of high quality-care in the clinical setting. These included issues related to patient overload, patient and physician characteristics, as well as problems inherent to supervisory and administrative functions. Exploring and aligning goals and expectations of RH care providers and administrators may result in improvements in the quality of RH care service delivery and morale in public health settings in Jordan, which is a requirement for public sector reform.