The Role of Value-Based Payment in Promoting Innovation to Address Social Risks: A Cross-Sectional Study of Social Risk Screening by US Physicians

Policy Points

• One of the most important possibilities of value‐based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. Screening patients for social risks such as housing instability and food insecurity represents an early step physician practices can take to address social needs.
• At present, adoption of social risk screening by physician practices is linked with having high innovation capacity and focusing on low‐income populations, but not exposure to value‐based payment.
• Expanding social risk screening by physician practices may require standardization and technical assistance for practices that have less innovative capacity.

ContextOne of the most important possibilities of value‐based payment is its potential to spur innovation in upstream prevention, such as attention to social needs that lead to poor health. However, there is uncertainty about the conditions under which value‐based payment will encourage health care providers to innovate to address upstream social risks.MethodsWe used the 2017‐2018 National Survey of Healthcare Organizations and Systems (NSHOS), a nationally representative survey of physician practices (n = 2,178), to ascertain (1) the number of social risks for which practices systematically screen patients; (2) the extent of practices’ participation in value‐based payment models; and (3) measures of practices’ capacity for innovation. We used multivariate regression models to examine predictors of social risk screening.FindingsOn average, physician practices systematically screened for 2.4 out of 7 (34%) social risks assessed by the survey. In the fully adjusted model, implementing social risk screening was not associated with the practices’ overall exposure to value‐based payment. Being in the top quartile on any of three innovation capacity scales, however, was associated with screening for 0.95 to 1.00 additional social risk (p < 0.001 for all three results) relative to the bottom quartile. In subanalysis examining specific payment models, participating in a Medicaid accountable care organization was associated with screening for 0.37 more social risks (p = 0.015). Expecting more exposure to accountable care in the future was associated with greater social risk screening, but the effect size was small compared with practices’ capacity for innovation.ConclusionsOur results indicate that implementation of social risk screening—an initial step in enhancing awareness of social needs in health care—is not associated with overall exposure to value‐based payment for physician practices. Expanding social risk screening by physician practices may require standardized approaches and implementation assistance to reduce the level of innovative capacity required.     

Providing skilled birth attendants and emergency obstetric care to the poor through partnership with private sector obstetricians in Gujarat, India

Problem

India has the world’s largest number of maternal deaths estimated at 117 000 per year. Past efforts to provide skilled birth attendants and emergency obstetric care in rural areas have not succeeded because obstetricians are not willing to be posted in government hospitals at subdistrict level.

Approach

We have documented an innovative public–private partnership scheme between the Government of Gujarat, in India, and private obstetricians practising in rural areas to provide delivery care to poor women.

Local setting

In April 2007, the majority of poor women delivered their babies at home without skilled care.

Relevant changes

More than 800 obstetricians joined the scheme and more than 176 000 poor women delivered in private facilities. We estimate that the coverage of deliveries among poor women under the scheme increased from 27% to 53% between April and October 2007. The programme is considered very successful and shows that these types of social health insurance programmes can be managed by the state health department without help from any insurance company or international donor.

Lessons learned

At least in some areas of India, it is possible to develop large-scale partnerships with the private sector to provide skilled birth attendants and emergency obstetric care to poor women at a relatively small cost. Poor women will take up the benefit of skilled delivery care rapidly, if they do not have to pay for it.     

消旋15(R)-15-甲基PGE2甲酯的合成

d,l-15(R)-15-Methyl-PGF_2α methyl ester 11-trimethylsilyl ether(II)wasprepared from selective monosilylation of d,l-15(R)-15-methyl-PGF_2αmethyl ester(I) withtrimethylsilyldiethylamine in acetone. Oxidation of(II ) with Collin's reagent gave d,l-15(R)-15-methyl-PGE₂ methyl ester 11-trimethylsilyl ether(III)which,without purification,was converted to d,l-15(R)-15-methyl-PGE₂ methyl ester(IV)under mild acidic conditions.     

Adrenomedullin is Inactivated in the Lungs of Neonatal Piglets

Adrenomedullin, a novel 52 amino acid peptide normally present in adult human plasma, has been shown to induce systemic hypotension in the adult rat, pig and cat, and in the new-born piglet. Little is known about the site(s) of adrenomedullin inactivation in adults or neonates. Groups of five 0–2-day old and 2-week old anaesthetized piglets were prepared to enable continuous monitoring of cardiac output, mean systemic arterial pressure, mean pulmonary artery pressure, mean systemic vascular resistance and mean pulmonary vascular resistance. In both age groups, injections of human adreno-medullin_1–52 into the left atrium produced significant (P < 0.05) reductions in mean systemic arterial pressure and mean pulmonary artery pressure. Although injections of similar doses of human adrenomedullin_1–52 into the right atrium produced significant (P < 0.05) decreases in mean pulmonary artery pressure, there were no appreciable alterations in mean systemic arterial pressure in either age group. These results suggest that the systemic vasodilator properties of human adrenomedullin_1–52 are reduced upon first pass through the pulmonary circulation in 2-week old piglets, a phenomenon that is present at birth.     

Radiographic Features of Progressive Pseudorheumatoid Arthritis

Radiographic Findings in Progressive Pseudo-rheumatoid Arthritis of Childhood were analysed on the basis of 5 of our own cases and a review of the literature. Our conclusion is that Progressive Pseudorheumatoid Arthritis of Childhood is a heterogenous disease and at least two different forms with distinctive radiographic features do exist.