Journal articles on the topic 'Managed care plans United States'

Managed care was designed to bring stability and balance to healthcare delivery in the United States, but its experience in the legal system has involved only moderate stability and very little balance. There has been a trend toward broad deference to the industry, so that managed care organizations (MCOs) are largely immune from liability. At the same time, some courts have suggested that the entire managed care model rests on sketchy legal ground. Meanwhile, commentators have disagreed on such fundamental questions as whether legal disputes arising under managed care should be resolved according to contract law or tort law. Moreover, the extent to which the Employee Retirement Income Security Act of 1974 (ERISA) governs, or moots, patients’ claims against MCOs has never been entirely clear—and because ERISA controls a vast number of health insurance plans, this legal issue is extremely significant.

AbstractManaged health care has recently generated a great deal of distrust, even anger, in the public mind. To be sure, much of this public reaction is based on anecdotal evidence and one-dimensional thinking. But many unbiased experts observing managed care today are themselves unhappy with the health care industry's performance. While these observers find little justification for the current political backlash against managed care, they are also disappointed that today's health plans have not made a more positive difference. Indeed, informed observers commonly regret that the new arrangements for the financing and delivery of care have done so little to get physicians to adopt truly efficient practices, achieving not only cost reductions but also substantial improvements in health status and patient outcomes— that is, in the quality of care. Although managed care has not demonstrably harmed the overall quality of health care in the United States, it has done little to improve it.

AbstractA major reorganization of healthcare services is occurring in the United States. It has evolved from the solo- and group-practice models of the 1940s with fee-for-service and insurer-indemnification financing that used paper-based information systems to support preventive medical services. In the 1990s there emerged nation-wide, managed-care plans employing enhanced computer-based information systems with online preventive medical practice guidelines and Internet-supported home-care telemedicine. It is helpful to review how this major reengineering of medicine has come about.

I n the current cost- and resource-constrained healthcare environment in the United States, characterized by declining government reimbursement and increased utilization scrutiny by managed care plans, providers are challenged to continue delivering quality care to more patients while also more effectively managing practice economics. Employing technology to improve practice efficiency is one of the most promising solutions to this dilemma. We have demonstrated that the integration of ultra-widefield (UWF) retinal imaging in our practice is cost-effective. It has allowed us to increase the number of patient encounters while simultaneously raising the quality of care, and increasing patient satisfaction.

On the eve of the presidential inauguration, the U.S. health system faces rising costs of care, growing numbers of uninsured, wide variations in quality of care, and mounting public dissatisfaction. Despite spending more on health care than any other country, a recent Commonwealth Fund Commission on a High Performance Health Care System National Scorecard reports that the United States is lagging far behind other major industrialized countries — all of which provide universal health insurance — in five key domains: healthy lives, access, quality, equity, and efficiency. U.S. national performance is well below benchmarks of top performance set by other countries or high performing states, hospitals, or health plans within the United States, with broad disparities in experience depending on geographic location, income, race/ethnicity, and insurance coverage. National leadership is required to manage the growing health care crisis in the United States and improve care for all Americans.

When individuals, families, and employers select health plans in the United States, they are typically only shown the financial structure of the plans and their provider networks. This variation in financial structure can lead patients to have health plans aligned with their financial needs, but not with their underlying nonfinancial preferences. Compounding the challenge is the fact that managed care organizations have historically used a combination of population-level budget impact models, cost-effectiveness analyses, medical necessity criteria, and current medical consensus to make coverage decisions. This approach to creating and presenting health plan options does not consider heterogeneity in patient and family preferences and values, as it treats populations as uniform. Similarly, it does not consider that there are some situations in which patients are price-insensitive. We seek to highlight the challenges posed by presenting health plans to patients in strictly financial terms, and to call for more consideration of nonfinancial patient preferences in the health plan design and selection process.

AbstractThe landmark United States healthcare reform law – the Affordable Care Act – provides an opportunity to study the dynamics of implementation for complex, politically contentious policies. Matland’s Ambiguity-Conflict Model suggests that bottom-up models will dominate in such cases. I exploit variation across states in the implementation of online health insurance marketplaces to test whether the federal- (top-down) or state-managed (bottom-up) implementation model produced better outcomes. Specifically, the study examines if state, federal or partnership exchanges were most effective at offering generous plans for consumers based on premiums, deductibles and copayments in 2014, the first year of operation. The results unambiguously indicate that state exchanges were most successful. The findings provide evidence for what Matland suspected – that bottom-up models, by providing more discretion to local implementers to adapt to contexts and build coalitions, are superior for high-conflict, high-ambiguity policies.

Abstract ITP is a rare but serious platelet disorder. It has been associated with fatal hemorrhage and reduced life expectancy (Cohen et al., Arch Intern Med, 2000). The incidence of ITP has been reported in two population-based studies in Europe (Neylon et al., Br J Haem, 2003; Frederiksen and Schmidt, Blood, 1999). However, there are no recent high quality studies that we are aware of regarding the burden of this disease (i.e., prevalence) in the US by gender and age group, and so we undertook this study in IHCIS (Integrated Healthcare Information Services), a US managed care database comprised of over 38 million patients from 30 health plans. ICD-9 code 287.3 (primary thrombocytopenia) was used as a proxy for an ITP diagnosis. Patients were required to have at least one diagnosis code in 2004 and a second diagnosis code in 2003, 2004 or 2005 to help minimize rule-out diagnoses. Continuous enrolment for a defined period of time also was required. Projected 2006 cases were obtained by multiplying the 2004 prevalence proportions by July 1, 2006 US population estimates (http://www.census.gov/ipc/www/usinterimproj). The projected number of patients with ITP in the US in 2006 was estimated to be 85,000 to 108,000, depending on the stringency of the inclusion criteria (i.e., whether the second occurrence of 287.3 in a patient record had to be within six months of the first). Slightly more of these cases were among women (56%) compared to men, and adults were diagnosed more frequently than those aged 0–15. This is the first study to estimate US prevalence counts using a managed care population, which includes both inpatients and outpatients. However, there are several limitations: ICD-9 code 287.3 is not exclusive to ITP. Segal et al. (Am J Hem, 2004) reported that sensitivity and specificity based on a single occurrence of this code was 100% and 89%, respectively, among inpatients, and 84% and 66%, respectively, among outpatients; our study required two code occurrences. Our estimate also assumes that the prevalence rate has remained constant from 2004 to present. Lastly, Frederiksen and Schmidt reported that the incidence of ITP was higher among older individuals. Therefore, we may be under-estimating the true prevalence of this disease in the general population because the elderly are somewhat under-represented in the IHCIS database.

e13592 Background: To date, there has been a paucity of information in the literature describing the epidemiology of mCRPC within the prostate cancer population. We present a real-world data study describing characteristics and mortality of patients with mCRPC within an administrative claims database of an insured population within the United States. Methods: In an administrative claims database of ≈18,000,000 covered lives, adult male patients were included if they had ≥1 claim for prostate cancer (ICD-9: 185 or 233.4; ICD-10: C61 or D075), underwent pharmacologic or surgical castration, and had a code for metastatic disease during the identification period (January 1, 2008–March 31, 2018). The index date was the first metastatic claim; 6 months of continuous enrollment (CE) prior to (baseline period) and after (follow-up period) the index date was required. Patients with metastatic claims in the baseline period were excluded. Patients were followed until the earliest of: death (unless prior to the 6-month CE), end of study period, or disenrollment. A claims-based algorithm was employed to identify locally advanced and distant mCRPC patients in the prostate cancer study population. Mortality data were sourced from the Social Security Administration Medicare data, and a claims algorithm. Results: 343,089 patients were identified with a claim for prostate cancer; of those, 3690 mCRPC cases (1.1%) were identified using the claims-based algorithm and met the study inclusion criteria. Median age was 75 years. Insurance type included commercial plans (27%) and Medicare (73%). Castration type included pharmacologic (99%) and surgical (1%). First claims for metastases were most commonly in the bone (65%) or lymph nodes (15%), with 20% in other sites. The study population averaged a Charlson comorbidity index score of 3.05 at baseline, with 16% of patients receiving a score of ≥5. The most common baseline comorbidities were hypertension (67%), urinary disease (58%), dyslipidemia (52%), and cardiac disease (45%). Median follow-up time among the mCRPC group was 538 days, during which 1834 deaths occurred; 50% of the population experienced mortality during the study period. Conclusions: This study provides valuable insights into the epidemiology, clinical characteristics, prevalence rate, and mortality of patients with mCRPC. Given the high mortality proportion of this disease, the development of novel therapies to prolong life in patients with mCRPC is warranted.

Background Twitter is a potentially valuable tool for public health officials and state Medicaid programs in the United States, which provide public health insurance to 72 million Americans. Objective We aim to characterize how Medicaid agencies and managed care organization (MCO) health plans are using Twitter to communicate with the public. Methods Using Twitter’s public application programming interface, we collected 158,714 public posts (“tweets”) from active Twitter profiles of state Medicaid agencies and MCOs, spanning March 2014 through June 2019. Manual content analyses identified 5 broad categories of content, and these coded tweets were used to train supervised machine learning algorithms to classify all collected posts. Results We identified 15 state Medicaid agencies and 81 Medicaid MCOs on Twitter. The mean number of followers was 1784, the mean number of those followed was 542, and the mean number of posts was 2476. Approximately 39% of tweets came from just 10 accounts. Of all posts, 39.8% (63,168/158,714) were classified as general public health education and outreach; 23.5% (n=37,298) were about specific Medicaid policies, programs, services, or events; 18.4% (n=29,203) were organizational promotion of staff and activities; and 11.6% (n=18,411) contained general news and news links. Only 4.5% (n=7142) of posts were responses to specific questions, concerns, or complaints from the public. Conclusions Twitter has the potential to enhance community building, beneficiary engagement, and public health outreach, but appears to be underutilized by the Medicaid program.

Among industrialized nations the United States is relatively unique in relying on a mix of public and private financing and delivery of healthcare: federal and federal-state programs, such as Medicare and Medicaid; employment-based health insurance (primarily HMOs); and state-subsidized insurance pools for high-risk individuals. In recent years, however, there have been efforts to apply the principles of private employment-based health insurance to the other forms of healthcare, and there is speculation that rising healthcare costs can only be addressed by further extending capitated payment plans. This suggests that U.S. healthcare may increasingly be organized according to market principles. For some, this represents a historic departure from an emphasis on public responsibility for healthcare and a sacrifice of the value principles embodied in health relationships between patient and provider. But defenders of HMOs and a larger role for markets argue that managed care allows for a more rational allocation of scarce healthcare resources by minimizing inefficient low-benefit–high-cost care. More individuals receive essential care if inessential care is eliminated. HMOs are also said to encourage non-HMOs to provide lower priced healthcare.

Abstract Nursing home social services departments (NH SS-Ds) are involved in a myriad of duties i.e., from care manager, patient advocate to counselor. But it is unclear how much variation there is across departments. Begging the question, what are the most common core functions of NH SS-Ds in the United States? A nationally representative cross-sectional sample of 922 NH SS-Ds completed a survey on-line or via mail. They were asked to indicate the extent their department was involved in 46 job functions. The listing of functions was inspired by the literature and pilot tested. The most common core functions would include those whereby at least 2/3s of the respondents would report “always/usually” being involved. 32 of the 46 functions were rated as “always/usually” and therefore qualified as the most common core functions. The five most common were discussing with staff the discharges of long-term as well as short-stay residents; arranging services for residents returning to the community; creating care plans; and mediating issues between residents. There were only two items whereby less than 10% of departments were “always/usually” involved – working with volunteers and helping feed residents. This survey tool successfully represented core SS-D functions as remarkable similarity across SS-Ds in the US existed. Responsibilities associated with care planning and care transitions were heavily featured, thus reflecting recent federal guidelines changes. The study’s results are pertinent to researchers, educators as well as nursing home administrators for role clarification and identification of training domains.

ABSTRACT Aim To create a non-clinical care education alternative for low-middle-income country (LMIC) medical students in an acute care surgery (ACS) service in the United States. Materials and methods An observational 30-day rotation with retrospective evaluation for an international medical student occurred at a level one trauma center in the United States. Trauma morning report was used as an educational model based on some elements of the American College of Surgeons Committee on Trauma, Resources for Optimal Care of the Injured. Results Trauma morning report was held daily for the student’s 30-day experience. The trauma patients’ primary and secondary survey, images, trauma bay, and operative management were all reviewed daily. Patients’ prehospital and hospital courses were completely evaluated by the performance improvement team. The functional status, physical therapy, familial support networks, economic and health insurance record, and rehabilitation disposition were reviewed. Prior to discharge, socioeconomic barrier analysis was conducted to provide safe outpatient care plans. Education by attending surgeons for the multidisciplinary team, which was integrated by students, residents, fellows, faculty, social workers, physical therapists, advanced nurse practitioners, performance improvement coordinator, and nurse trauma manager, was conducted daily on a selected topic. Conclusion Trauma morning report served as an observational education in multidisciplinary trauma systems (TS) for international students. The experience in the United States provides a new perspective on systems-based trauma care for international students. Clinical significance The educational alternative exposed is a pathway for medical students from LMIC to increase their clinical experience, ACS knowledge, and trauma care system-based understanding. The students who opt for this kind of experience may choose a specialization in surgery, increase their research productivity, and improve the development of emergency medical services TS in their respective countries. How to cite this article Silva JCR, Gupta R, Gracias V, Peck G. Nonclinical, Observational Trauma Rotations in the United States provide International Students Multidisciplinary Trauma Program and Systems Education. Panam J Trauma Crit Care Emerg Surg 2017;6(1):8-12.

Background In 2016, over 11 million individuals were admitted to prisons and jails in the United States. Because the majority of these individuals will return to the community, addressing their health needs requires coordination between community and correctional health care providers. However, few systems exist to facilitate this process and little is known about how physicians perceive and manage these transitions. Objective The goal of this study was to characterize physicians’ views on transitions both into and out of incarceration and describe how knowledge of a patient’s criminal justice involvement impacts patient care plans. Methods Semi-structured interviews were conducted between October 2018 and May 2019 with physicians from three community clinics in Hennepin County, Minnesota. Team members used a hybrid approach of deductive and inductive coding, in which a priori codes were defined based on the interview guide while also allowing for data-driven codes to emerge. Results Four themes emerged related to physicians’ perceptions on continuity of care for patients with criminal justice involvement. Physicians identified disruptions in patient-physician relationships, barriers to accessing prescription medications, disruptions in insurance coverage, and problems with sharing medical records, as factors contributing to discontinuity of care for patients entering and exiting incarceration. These factors impacted patients differently depending on the direction of the transition. Conclusions Our findings identified four disruptions to continuity of care that physicians viewed as key barriers to successful transitions into and out of incarceration. These disruptions are unlikely to be effectively addressed at the provider level and will require system-level changes, which Medicaid and managed care organizations could play a leading role in developing.

AbstractObjectiveAlthough hospital emergency preparedness efforts have been recognized as important, there has been growing pressure on cost containment, as well as consolidation within the US health care system. There is little data looking at what health care emergency preparedness functions have been, could be, or should be centrally coordinated at a system level.MethodsWe developed a questionnaire for academic health systems and asked about program funding, resources provided, governance, and activities. The questionnaire also queried managers’ opinions regarding the appropriate role for the system-level resources in emergency response, as well as about what is most helpful at the system-level supporting preparedness.ResultsFifty-two of 97 systems (54%) responded. The most frequently occurring system-wide activities included: creating trainings or exercise templates (75%), promoting preparedness for employees in the system (75%), providing access to specific subject matter experts (73%), and developing specific plans for individual member entities within their system (73%). The top resources provided included a common mass notification system (71%), arranging for centralized contracts for goods and services (71%), and providing subject matter expertise (69%).ConclusionsCurrently, there is wide variation in the resources, capabilities, and programs used to support and coordinate system-level emergency preparedness among academic health systems. (Disaster Med Public Health Preparedness. 2018;12:574–577)

AbstractAlthough the United States has been impacted by numerous devastating disasters over the last 10 years, there have been only limited efforts between the governmental and non-profit/voluntary organizations to meet the multiple disaster health and mental health needs of the community. Too often, responding organizations compete to provide services, duplicate efforts, and frequently under-estimate the need for services.Recent efforts have been undertaken by The American Red Cross and other groups to resolve this issue. Governmental and community-based organizations have been invited to participate in planning sessions to pre-identify roles and responsibilities, as well as to exchange key information about the services each group can and does provide.These efforts have lead to an increased awareness of the potential problems and the development of cohesive plans to provide medical and emotional support services to impacted communities. This has led to improved care for those with serious injuries or psychological crisis, while those with less critical problems have been managed appropriately without needing to be immediately referred to overcrowded emergency departments or physician's offices.

The healthcare industry of the United States is undergoing extensive change to meet the needs of the Affordable Care Act of 2010. Organizations need to comply with a new macro-regulatory environment and establish institutionally based strategies that meet mandated standards and processes. The Act represents a shift from employer-sponsored insurance plans to a system where, depending upon subjective evaluations of what is on offer, consumers can shop around and purchase insurance plans listed in a federal or state marketplace. This means that healthcare providers are under intense political and public scrutiny. The new competitive environment may accelerate the shift from care-focused to efficiency-focused management initiatives within the healthcare industry and is viewed by some as an opportunity for contextual ambidexterity and conflict to emerge. In addition to establishing compliance programs to manage employees’ ethical conduct in an effort to meet the narrow and deterministic demands of governmental pressure, organizations may also introduce ethical programs that reflect organizational commitment, individual integrity, and the willingness to admit mistakes and be creative in problem-solving exercises.

Health care systems across the United States are considering community health worker (CHW) services for high-risk patients, despite limited data on how to build and sustain effective CHW programs. We describe the process of providing CHW services to 5,289 at-risk patients within a state-run health system. The program includes 30 CHWs, six care coordinators, the Director of Care Coordination, the Medical Director, a registered nurse, mental health specialists, and legal specialists. CHWs are organized into geographic and specialized teams. All CHWs receive basic training that includes oral and mental health; some receive additional disease-specific training. CHWs develop individualized care coordination plans with patients. The implementation of these plans involves delivery of a wide range of social service and coordination support. The number of CHW contacts is determined by patient risk. CHWs spend about 60% of their time in an office setting. To deliver the program optimally, we had to develop multiple CHW job categories that allow for CHW specialization. We created new technology systems to manage operations. Field issues resulted in program changes to improve service delivery and ensure safety. Our experience serves as a model for how to integrate CHWs into clinical and community systems.

Abstract Objective Consensus that enhanced teamwork is necessary for efficient and effective primary care delivery is growing. We sought to identify how electronic health records (EHRs) facilitate and pose challenges to primary care teams as well as how practices are overcoming these challenges. Methods Practices in this qualitative study were selected from those recognized as patient-centered medical homes via the National Committee for Quality Assurance 2011 tool, which included a section on practice teamwork. We interviewed 63 respondents, ranging from physicians to front-desk staff, from 27 primary care practices ranging in size, type, geography, and population size. Results EHRs were found to facilitate communication and task delegation in primary care teams through instant messaging, task management software, and the ability to create evidence-based templates for symptom-specific data collection from patients by medical assistants and nurses (which can offload work from physicians). Areas where respondents felt that electronic medical record EHR functionalities were weakest and posed challenges to teamwork included the lack of integrated care manager software and care plans in EHRs, poor practice registry functionality and interoperability, and inadequate ease of tracking patient data in the EHR over time. Discussion Practices developed solutions for some of the challenges they faced when attempting to use EHRs to support teamwork but wanted more permanent vendor and policy solutions for other challenges. Conclusions EHR vendors in the United States need to work alongside practicing primary care teams to create more clinically useful EHRs that support dynamic care plans, integrated care management software, more functional and interoperable practice registries, and greater ease of data tracking over time.

Fifty-five hospitals in the United States have been designated Ebola treatment centers (ETCs) by their state and local health authorities. Designated ETCs must have appropriate plans to manage a patient with confirmed Ebola virus disease (EVD) for the full duration of illness and must have these plans assessed through a CDC site visit conducted by an interdisciplinary team of subject matter experts. This study determined the clinical laboratory capabilities of these ETCs. ETCs were electronically surveyed on clinical laboratory characteristics. Survey responses were returned from 47 ETCs (85%). Forty-one (87%) of the ETCs planned to provide some laboratory support (e.g., point-of-care [POC] testing) within the room of the isolated patient. Forty-four (94%) ETCs indicated that their hospital would also provide clinical laboratory support for patient care. Twenty-two (50%) of these ETC clinical laboratories had biosafety level 3 (BSL-3) containment. Of all respondents, 34 (72%) were supported by their jurisdictional public health laboratory (PHL), all of which had available BSL-3 laboratories. Overall, 40 of 44 (91%) ETCs reported BSL-3 laboratory support via their clinical laboratory and/or PHL. This survey provided a snapshot of the laboratory support for designated U.S. ETCs. ETCs have approached high-level isolation critical care with laboratory support in close proximity to the patient room and by distributing laboratory support among laboratory resources. Experts might review safety considerations for these laboratory testing/diagnostic activities that are novel in the context of biocontainment care.

Abstract Objective To identify factors that impede payer engagement in a health information exchange (HIE), along with organizational and policy strategies that might effectively address the impediments. Materials and Methods Qualitative analysis of semi-structured interviews with leaders from 17 varied payer organizations from across the country (e.g., large, national payers; state Blues plans; local Medicaid managed care plans). Results We found a large gap between payers’ vision of what optimal HIE should be and the current approach to HIE in the United States. Notably, payers sought to be active participants in HIE efforts – both providing claims data and accessing clinical data to support payer HIE use cases. Instead, payers were often asked by HIE efforts only to provide financial support without the option to participate in data exchange, or, when given the option, their data needs were secondary to those of providers. Discussion Efforts to engage payers in pursuit of more robust and sustainable HIE need to better align their value proposition with payer HIE use cases. This will require addressing provider concerns about payer access to clinical data. Policymakers should focus on creating the conditions for broader payer engagement by removing common obstacles, such as low provider engagement in HIE. Conclusion Despite variation in the extent to which payers engaged with current HIE efforts, there was agreement on the vision of optimal HIE and the facilitators of greater payer engagement. Specific actions by those leading HIE efforts, complemented by policy efforts nationally, could greatly increase payer engagement and enhance HIE sustainability.

There are ≈40 million acres of turfgrass lawns throughout the United States, most of which are managed under chemical-intensive pest and fertilizer programs. “Organic lawn care” is being adopted more widely; however, unlike the formally defined policies and regulations that govern organic agriculture, the label organic lawn management has not been formally defined and is used to describe a variety of practices. Neighborhoods, cities, states, and provinces across North America are adopting policies regulating the use of pesticides and fertilizers in the landscape. In addition, a small but growing number of public institutions and individual consumers are successfully adopting alternative lawn care methods, including organic lawn care. Although perceived as environmentally friendly, the effects of organic management on insect diversity and pest management remain understudied. Organic lawn management may lead to increased lawn plant diversity, which in agroecosystems has enhanced ecological services provided by beneficial insect species. Effects of vegetative diversity on lawn pest management are less clear. Vegetative complexity and increased plant diversity in urban landscapes may enhance insect predator efficacy. The diversity of predatory insects varies between turfgrass varieties in response to prey populations. Mortality of insectivorous and granivorous ground beetles (Carabidae) while not directly impacted by pest management programs in turfgrass may be indirectly impacted by a reduction in the prevalence of plant species that provide alternative food resources. Previous studies have focused on herbivorous insects as well as predatory and parasitic insects that feed on them. Future studies should assess how lawn plant diversity resulting from organic management practices might impact insect communities in turfgrass.

Background: The necessity of aggressive pain management in the hospital setting is becoming increasingly evident. It has been shown to improve patient outcomes, and is now an avenue for Medicare to assess reimbursement. In this cohort analysis, we compared the March 2008 to the December 2012 Hospital Consumer Assessment of Health Plans Survey (HCAHPS) reports in order to determine if pain management has improved in the United States after this national standardized survey was created. Objective: To evaluate whether pain perception would improve in the 2012 report relative to the 2008 report. Study Design: Statistical analyses were conducted with the HCAHPS report to compare pain control in regards to hospital type, hospital ownership, and individual hospitals. Using the question, “How often is your pain controlled?,” T-tests were used to compare each hospital type. Hospital ownerships were assessed via analysis of variance (ANOVA) testing. T-tests were conducted to track the difference of hospital performance between the 2008 and the 2012 report. Paired management data were obtained from hospitals that participated in both reports and were assessed using paired T-tests. Setting: This survey was administered to a random sample of adult inpatients between 48 hours and 6 weeks after discharge from any hospital reporting to Centers for Medicare and Medicaid (CMS) across the US. Limitations: Limitations of this study include response bias, recall bias, and there may be bias related to types of people likely to respond to a survey, but this is inherent to data that is collected on a voluntary response. Additionally, a 3% increase in the number of patients rating their pain as always well-controlled, while statistically significant, admittedly may not be clinically significant. In addition, the raw data collected is adjusted for the effects of patient-mix. The statistical analyses performed to derive the final quarterly HCAHPS reports are unavailable to us and therefore we cannot comment on how individual factors such as age, sex, race, and education or the interaction of the aforementioned affect responses about the patient’s perception on how well their pain was controlled between 2008 and 2012. Results: Two thousand three hundred and ninety five hospitals reported pain management data in both 2008 and 2012. In 2012, hospitals improved their ability to “always control a patients pain” by 3.07% (P < 0.0001) in comparison to the baseline March 2008 report, which was statistically significant. According to the 2012 data, the discrepancy in pain management between acute care hospitals and critical access hospitals was 3.33% which was statistically significant (P < 0.05). Government hospitals were shown to manage pain better at baseline, but all 3 types of ownership improved their pain scores between the 2 reports which was shown to be statistically significant (P < 0.01). Discussion: The HCAHPS survey is a national public standardized report used as a way to compare care in the United States. Patient pain perception has improved between the 2008 and 2012 reports. Further studies are needed to evaluate critical care hospitals. Key words: HCAHPS, pain scores, patient perception, national comparison of hospitals, Agency for Healthcare Research and Quality (AHRQ), acute care hospitals, critical access hospitals, pain management:

On a foggy Monday morning in late September 2010 in Kiel, Germany, I received a phone call from Berlin. “Do you have any plans for November through summer of next year?” the voice inquired. One of the two German Marshall Fund congressional fellows for the 2010–2011 round had suddenly dropped out and a replacement was needed. The call came five months after I had been initially rejected for the fellowship, and while my life had certainly moved on (I had begun work on my PhD dissertation at the University of Kiel and had expected to stay in Northern Germany for two or three years), I quickly regained my composure, asked for time to discuss this with my dissertation director as well as with my parents, and shortly thereafter accepted the selection. Exactly how I managed to cram the amount of work required for moving overseas into four weeks instead of the usual four to six months remains blurry. Eventually, however, I was able to tie up the loose ends in Germany, get the appropriate work visa for the United States, and even participate in a prestigious, long-planned naval reserve exercise that the German Navy's chief of naval operations had invited me to attend.

Background The outbreak of coronavirus disease 2019 (COVID-19) rippled across the world from Wuhan, China, to the shores of the United States within a few months. Hospitals and intensive care units were suddenly faced with a “tsunami” warning requiring instantaneous implementation and escalation of disaster plans. Evidence Review An evidence-based question was developed and an extensive review of the literature was completed, resulting in a structured plan for the intensive care units to manage a surge of patients critically ill with COVID-19 in March 2020. Twenty-five sources of evidence focusing on pandemic intensive care unit and COVID-19 management laid the foundation for the team to navigate the crisis. Implementation The Critical Care Services task force adopted recommendations from the CHEST consensus statement on surge capacity principles and other sources, which served as the framework for the organized response. The 4 S’s became the focus: space, staff, supplies, and systems. Development of algorithms, workflows, and new processes related to treating patients, staffing shortages, and limited supplies. New intensive care unit staffing solutions were adopted. Evaluation Using a framework based on the literature reviewed, the Critical Care Services task force controlled the surge of patients with COVID-19 in March through May 2020. Patients received excellent care, and the mortality rate was 0.008%. The intensive care unit team had the needed respiratory and general supplies but had to continually adapt to shortages of personal protective equipment, cleaning products, and some medications. Sustainability The intensive care unit pandemic response plan has been established and the team is prepared for the next wave of COVID-19.

Abstract KEY MESSAGE Standardization of care for subspecialty patients require centralization and support across multi-disciplinary groups within the Kaiser Permanente medical group, which is a large health maintenance organization (HMO) in the United States. BACKGROUND Prior to the development of a Pediatric Neuro-Oncology program, Southern California Kaiser Permanente pediatric neuro-oncology patients were routinely referred to respective regional academic centers for consultation. The process was not standard across the region, resulting in additional costs and differences in treatment recommendations, potentially affecting outcomes. METHODS A Pediatric Neuro-Oncology program was established, July 2017, based at the Kaiser Permanente Los Angeles Medical Center (LAMC), consisting of pediatric neuro-oncology, pediatric neurosurgery, pediatric neuro-radiology, pediatric radiation oncology, and pediatric neuro-oncology case management. RESULTS A Pediatric Neuro-Oncology tumor board was established to meet on a bi-monthly basis. Pediatric neuro-oncology patients across the Southern California now have their magnetic resonance imaging (MRI) reviewed by the same pediatric neuro radiologists. Neuropathology is standardized and sent to Children’s Hospital Los Angeles and reviewed at the molecular neuropathology tumor board attended by the pediatric neuro-oncologist. Cases discussions regarding the patients include the regional pediatric neurosurgeons, the pediatric radiation oncologists, and the pediatric neuro-oncologist, and treatment plans are recommended and recorded by the case manager. CONCLUSIONS Centralization of care has allowed for more consistent and standard care across the Southern California Region, but requires support from multi-disciplinary groups.

In this issue of Journal of Disaster Research, we introduce nine papers on societal responses to recent catastrophic disasters with special focus on long-term recovery processes in Japan and the United States. As disaster impacts increase, we also find that recovery times take longer and the processes for recovery become more complicated. On January 17th of 1995, a magnitude 7.2 earthquake hit the Hanshin and Awaji regions of Japan, resulting in the largest disaster in Japan in 50 years. In this disaster which we call the Kobe earthquake hereafter, over 6,000 people were killed and the damage and losses totaled more than 100 billion US dollars. The long-term recovery from the Kobe earthquake disaster took more than ten years to complete. One of the most important responsibilities of disaster researchers has been to scientifically monitor and record the long-term recovery process following this unprecedented disaster and discern the lessons that can be applied to future disasters. The first seven papers in this issue present some of the key lessons our research team learned from the studying the long-term recovery following the Kobe earthquake disaster. We have two additional papers that deal with two recent disasters in the United States – the terrorist attacks on World Trade Center in New York on September 11 of 2001 and the devastation of New Orleans by the 2005 Hurricane Katrina and subsequent levee failures. These disasters have raised a number of new research questions about long-term recovery that US researchers are studying because of the unprecedented size and nature of these disasters’ impacts. Mr. Mammen’s paper reviews the long-term recovery processes observed at and around the World Trade Center site over the last six years. Ms. Johnson’s paper provides a detailed account of the protracted reconstruction planning efforts in the city of New Orleans to illustrate a set of sufficient and necessary conditions for successful recovery. All nine papers in this issue share a theoretical framework for long-term recovery processes which we developed based first upon the lessons learned from the Kobe earthquake and later expanded through observations made following other recent disasters in the world. The following sections provide a brief description of each paper as an introduction to this special issue. 1. The Need for Multiple Recovery Goals After the 1995 Kobe earthquake, the long-term recovery process began with the formulation of disaster recovery plans by the City of Kobe – the most severely impacted municipality – and an overarching plan by Hyogo Prefecture which coordinated 20 impacted municipalities; this planning effort took six months. Before the Kobe earthquake, as indicated in Mr. Maki’s paper in this issue, Japanese theories about, and approaches to, recovery focused mainly on physical recovery, particularly: the redevelopment plans for destroyed areas; the location and standards for housing and building reconstruction; and, the repair and rehabilitation of utility systems. But the lingering problems of some of the recent catastrophes in Japan and elsewhere indicate that there are multiple dimensions of recovery that must be considered. We propose that two other key dimensions are economic recovery and life recovery. The goal of economic recovery is the revitalization of the local disaster impacted economy, including both major industries and small businesses. The goal of life recovery is the restoration of the livelihoods of disaster victims. The recovery plans formulated following the 1995 Kobe earthquake, including the City of Kobe’s and Hyogo Prefecture’s plans, all stressed these two dimensions in addition to physical recovery. The basic structure of both the City of Kobe’s and Hyogo Prefecture’s recovery plans are summarized in Fig. 1. Each plan has three elements that work simultaneously. The first and most basic element of recovery is the restoration of damaged infrastructure. This helps both physical recovery and economic recovery. Once homes and work places are recovered, Life recovery of the impacted people can be achieved as the final goal of recovery. Figure 2 provides a “recovery report card” of the progress made by 2006 – 11 years into Kobe’s recovery. Infrastructure was restored in two years, which was probably the fastest infrastructure restoration ever, after such a major disaster; it astonished the world. Within five years, more than 140,000 housing units were constructed using a variety of financial means and ownership patterns, and exceeding the number of demolished housing units. Governments at all levels – municipal, prefectural, and national – provided affordable public rental apartments. Private developers, both local and national, also built condominiums and apartments. Disaster victims themselves also invested a lot to reconstruct their homes. Eleven major redevelopment projects were undertaken and all were completed in 10 years. In sum, the physical recovery following the 1995 Kobe earthquake was extensive and has been viewed as a major success. In contrast, economic recovery and life recovery are still underway more than 13 years later. Before the Kobe earthquake, Japan’s policy approaches to recovery assumed that economic recovery and life recovery would be achieved by infusing ample amounts of public funding for physical recovery into the disaster area. Even though the City of Kobe’s and Hyogo Prefecture’s recovery plans set economic recovery and life recovery as key goals, there was not clear policy guidance to accomplish them. Without a clear articulation of the desired end-state, economic recovery programs for both large and small businesses were ill-timed and ill-matched to the needs of these businesses trying to recover amidst a prolonged slump in the overall Japanese economy that began in 1997. “Life recovery” programs implemented as part of Kobe’s recovery were essentially social welfare programs for low-income and/or senior citizens. 2. Requirements for Successful Physical Recovery Why was the physical recovery following the 1995 Kobe earthquake so successful in terms of infrastructure restoration, the replacement of damaged housing units, and completion of urban redevelopment projects? There are at least three key success factors that can be applied to other disaster recovery efforts: 1) citizen participation in recovery planning efforts, 2) strong local leadership, and 3) the establishment of numerical targets for recovery. Citizen participation As pointed out in the three papers on recovery planning processes by Mr. Maki, Mr. Mammen, and Ms. Johnson, citizen participation is one of the indispensable factors for successful recovery plans. Thousands of citizens participated in planning workshops organized by America Speaks as part of both the World Trade Center and City of New Orleans recovery planning efforts. Although no such workshops were held as part of the City of Kobe’s recovery planning process, citizen participation had been part of the City of Kobe’s general plan update that had occurred shortly before the earthquake. The City of Kobe’s recovery plan is, in large part, an adaptation of the 1995-2005 general plan. On January 13 of 1995, the City of Kobe formally approved its new, 1995-2005 general plan which had been developed over the course of three years with full of citizen participation. City officials, responsible for drafting the City of Kobe’s recovery plan, have later admitted that they were able to prepare the city’s recovery plan in six months because they had the preceding three years of planning for the new general plan with citizen participation. Based on this lesson, Odiya City compiled its recovery plan based on the recommendations obtained from a series of five stakeholder workshops after the 2004 Niigata Chuetsu earthquake. <strong>Fig. 1. </strong> Basic structure of recovery plans from the 1995 Kobe earthquake. <strong>Fig. 2. </strong> “Disaster recovery report card” of the progress made by 2006. Strong leadership In the aftermath of the Kobe earthquake, local leadership had a defining role in the recovery process. Kobe’s former Mayor, Mr. Yukitoshi Sasayama, was hired to work in Kobe City government as an urban planner, rebuilding Kobe following World War II. He knew the city intimately. When he saw damage in one area on his way to the City Hall right after the earthquake, he knew what levels of damage to expect in other parts of the city. It was he who called for the two-month moratorium on rebuilding in Kobe city on the day of the earthquake. The moratorium provided time for the city to formulate a vision and policies to guide the various levels of government, private investors, and residents in rebuilding. It was a quite unpopular policy when Mayor Sasayama announced it. Citizens expected the city to be focusing on shelters and mass care, not a ban on reconstruction. Based on his experience in rebuilding Kobe following WWII, he was determined not to allow haphazard reconstruction in the city. It took several years before Kobe citizens appreciated the moratorium. Numerical targets Former Governor Mr. Toshitami Kaihara provided some key numerical targets for recovery which were announced in the prefecture and municipal recovery plans. They were: 1) Hyogo Prefecture would rebuild all the damaged housing units in three years, 2) all the temporary housing would be removed within five years, and 3) physical recovery would be completed in ten years. All of these numerical targets were achieved. Having numerical targets was critical to directing and motivating all the stakeholders including the national government’s investment, and it proved to be the foundation for Japan’s fundamental approach to recovery following the 1995 earthquake. 3. Economic Recovery as the Prime Goal of Disaster Recovery In Japan, it is the responsibility of the national government to supply the financial support to restore damaged infrastructure and public facilities in the impacted area as soon as possible. The long-term recovery following the Kobe earthquake is the first time, in Japan’s modern history, that a major rebuilding effort occurred during a time when there was not also strong national economic growth. In contrast, between 1945 and 1990, Japan enjoyed a high level of national economic growth which helped facilitate the recoveries following WWII and other large fires. In the first year after the Kobe earthquake, Japan’s national government invested more than US$ 80 billion in recovery. These funds went mainly towards the repair and reconstruction of infrastructure and public facilities. Now, looking back, we can also see that these investments also nearly crushed the local economy. Too much money flowed into the local economy over too short a period of time and it also did not have the “trickle-down” effect that might have been intended. To accomplish numerical targets for physical recovery, the national government awarded contracts to large companies from Osaka and Tokyo. But, these large out-of-town contractors also tended to have their own labor and supply chains already intact, and did not use local resources and labor, as might have been expected. Essentially, ten years of housing supply was completed in less than three years, which led to a significant local economic slump. Large amounts of public investment for recovery are not necessarily a panacea for local businesses, and local economic recovery, as shown in the following two examples from the Kobe earthquake. A significant national investment was made to rebuild the Port of Kobe to a higher seismic standard, but both its foreign export and import trade never recovered to pre-disaster levels. While the Kobe Port was out of business, both the Yokohama Port and the Osaka Port increased their business, even though many economists initially predicted that the Kaohsiung Port in Chinese Taipei or the Pusan Port in Korea would capture this business. Business stayed at all of these ports even after the reopening of the Kobe Port. Similarly, the Hanshin Railway was severely damaged and it took half a year to resume its operation, but it never regained its pre-disaster readership. In this case, two other local railway services, the JR and Hankyu lines, maintained their increased readership even after the Hanshin railway resumed operation. As illustrated by these examples, pre-disaster customers who relied on previous economic output could not necessarily afford to wait for local industries to recover and may have had to take their business elsewhere. Our research suggests that the significant recovery investment made by Japan’s national government may have been a disincentive for new economic development in the impacted area. Government may have been the only significant financial risk-taker in the impacted area during the national economic slow-down. But, its focus was on restoring what had been lost rather than promoting new or emerging economic development. Thus, there may have been a missed opportunity to provide incentives or put pressure on major businesses and industries to develop new businesses and attract new customers in return for the public investment. The significant recovery investment by Japan’s national government may have also created an over-reliance of individuals on public spending and government support. As indicated in Ms. Karatani’s paper, individual savings of Kobe’s residents has continued to rise since the earthquake and the number of individuals on social welfare has also decreased below pre-disaster levels. Based on our research on economic recovery from the Kobe earthquake, at least two lessons emerge: 1) Successful economic recovery requires coordination among all three recovery goals – Economic, Physical and Life Recovery, and 2) “Recovery indices” are needed to better chart recovery progress in real-time and help ensure that the recovery investments are being used effectively. Economic recovery as the prime goal of recovery Physical recovery, especially the restoration of infrastructure and public facilities, may be the most direct and socially accepted provision of outside financial assistance into an impacted area. However, lessons learned from the Kobe earthquake suggest that the sheer amount of such assistance may not be effective as it should be. Thus, as shown in Fig. 3, economic recovery should be the top priority goal for recovery among the three goals and serve as a guiding force for physical recovery and life recovery. Physical recovery can be a powerful facilitator of post-disaster economic development by upgrading social infrastructure and public facilities in compliance with economic recovery plans. In this way, it is possible to turn a disaster into an opportunity for future sustainable development. Life recovery may also be achieved with a healthy economic recovery that increases tax revenue in the impacted area. In order to achieve this coordination among all three recovery goals, municipalities in the impacted areas should have access to flexible forms of post-disaster financing. The community development block grant program that has been used after several large disasters in the United States, provide impacted municipalities with a more flexible form of funding and the ability to better determine what to do and when. The participation of key stakeholders is also an indispensable element of success that enables block grant programs to transform local needs into concrete businesses. In sum, an effective economic recovery combines good coordination of national support to restore infrastructure and public facilities and local initiatives that promote community recovery. Developing Recovery Indices Long-term recovery takes time. As Mr. Tatsuki’s paper explains, periodical social survey data indicates that it took ten years before the initial impacts of the Kobe earthquake were no longer affecting the well-being of disaster victims and the recovery was completed. In order to manage this long-term recovery process effectively, it is important to have some indices to visualize the recovery processes. In this issue, three papers by Mr. Takashima, Ms. Karatani, and Mr. Kimura define three different kinds of recovery indices that can be used to continually monitor the progress of the recovery. Mr. Takashima focuses on electric power consumption in the impacted area as an index for impact and recovery. Chronological change in electric power consumption can be obtained from the monthly reports of power company branches. Daily estimates can also be made by tracking changes in city lights using a satellite called DMSP. Changes in city lights can be a very useful recovery measure especially at the early stages since it can be updated daily for anywhere in the world. Ms. Karatani focuses on the chronological patterns of monthly macro-statistics that prefecture and city governments collect as part of their routine monitoring of services and operations. For researchers, it is extremely costly and virtually impossible to launch post-disaster projects that collect recovery data continuously for ten years. It is more practical for researchers to utilize data that is already being collected by local governments or other agencies and use this data to create disaster impact and recovery indices. Ms. Karatani found three basic patterns of disaster impact and recovery in the local government data that she studied: 1) Some activities increased soon after the disaster event and then slumped, such as housing construction; 2) Some activities reduced sharply for a period of time after the disaster and then rebounded to previous levels, such as grocery consumption; and 3) Some activities reduced sharply for a while and never returned to previous levels, such as the Kobe Port and Hanshin Railway. Mr. Kimura focuses on the psychology of disaster victims. He developed a “recovery and reconstruction calendar” that clarifies the process that disaster victims undergo in rebuilding their shattered lives. His work is based on the results of random surveys. Despite differences in disaster size and locality, survey data from the 1995 Kobe earthquake and the 2004 Niigata-ken Chuetsu earthquake indicate that the recovery and reconstruction calendar is highly reliable and stable in clarifying the recovery and reconstruction process. <strong>Fig. 3.</strong> Integrated plan of disaster recovery. 4. Life Recovery as the Ultimate Goal of Disaster Recovery Life recovery starts with the identification of the disaster victims. In Japan, local governments in the impacted area issue a “damage certificate” to disaster victims by household, recording the extent of each victim’s housing damage. After the Kobe earthquake, a total of 500,000 certificates were issued. These certificates, in turn, were used by both public and private organizations to determine victim’s eligibility for individual assistance programs. However, about 30% of those victims who received certificates after the Kobe earthquake were dissatisfied with the results of assessment. This caused long and severe disputes for more than three years. Based on the lessons learned from the Kobe earthquake, Mr. Horie’s paper presents (1) a standardized procedure for building damage assessment and (2) an inspector training system. This system has been adopted as the official building damage assessment system for issuing damage certificates to victims of the 2004 Niigata-ken Chuetsu earthquake, the 2007 Noto-Peninsula earthquake, and the 2007 Niigata-ken Chuetsu Oki earthquake. Personal and family recovery, which we term life recovery, was one of the explicit goals of the recovery plan from the Kobe earthquake, but it was unclear in both recovery theory and practice as to how this would be measured and accomplished. Now, after studying the recovery in Kobe and other regions, Ms. Tamura’s paper proposes that there are seven elements that define the meaning of life recovery for disaster victims. She recently tested this model in a workshop with Kobe disaster victims. The seven elements and victims’ rankings are shown in Fig. 4. Regaining housing and restoring social networks were, by far, the top recovery indicators for victims. Restoration of neighborhood character ranked third. Demographic shifts and redevelopment plans implemented following the Kobe earthquake forced significant neighborhood changes upon many victims. Next in line were: having a sense of being better prepared and reducing their vulnerability to future disasters; regaining their physical and mental health; and restoration of their income, job, and the economy. The provision of government assistance also provided victims with a sense of life recovery. Mr. Tatsuki’s paper summarizes the results of four random-sample surveys of residents within the most severely impacted areas of Hyogo Prefecture. These surveys were conducted biannually since 1999,. Based on the results of survey data from 1999, 2001, 2003, and 2005, it is our conclusion that life recovery took ten years for victims in the area impacted significantly by the Kobe earthquake. Fig. 5 shows that by comparing the two structural equation models of disaster recovery (from 2003 and 2005), damage caused by the Kobe earthquake was no longer a determinant of life recovery in the 2005 model. It was still one of the major determinants in the 2003 model as it was in 1999 and 2001. This is the first time in the history of disaster research that the entire recovery process has been scientifically described. It can be utilized as a resource and provide benchmarks for monitoring the recovery from future disasters. <strong>Fig. 4.</strong> Ethnographical meaning of “life recovery” obtained from the 5th year review of the Kobe earthquake by the City of Kobe. <strong>Fig. 5.</strong> Life recovery models of 2003 and 2005. 6. The Need for an Integrated Recovery Plan The recovery lessons from Kobe and other regions suggest that we need more integrated recovery plans that use physical recovery as a tool for economic recovery, which in turn helps disaster victims. Furthermore, we believe that economic recovery should be the top priority for recovery, and physical recovery should be regarded as a tool for stimulating economic recovery and upgrading social infrastructure (as shown in Fig. 6). With this approach, disaster recovery can help build the foundation for a long-lasting and sustainable community. Figure 6 proposes a more detailed model for a more holistic recovery process. The ultimate goal of any recovery process should be achieving life recovery for all disaster victims. We believe that to get there, both direct and indirect approaches must be taken. Direct approaches include: the provision of funds and goods for victims, for physical and mental health care, and for housing reconstruction. Indirect approaches for life recovery are those which facilitate economic recovery, which also has both direct and indirect approaches. Direct approaches to economic recovery include: subsidies, loans, and tax exemptions. Indirect approaches to economic recovery include, most significantly, the direct projects to restore infrastructure and public buildings. More subtle approaches include: setting new regulations or deregulations, providing technical support, and creating new businesses. A holistic recovery process needs to strategically combine all of these approaches, and there must be collaborative implementation by all the key stakeholders, including local governments, non-profit and non-governmental organizations (NPOs and NGOs), community-based organizations (CBOs), and the private sector. Therefore, community and stakeholder participation in the planning process is essential to achieve buy-in for the vision and desired outcomes of the recovery plan. Securing the required financial resources is also critical to successful implementation. In thinking of stakeholders, it is important to differentiate between supporting entities and operating agencies. Supporting entities are those organizations that supply the necessary funding for recovery. Both Japan’s national government and the federal government in the U.S. are the prime supporting entities in the recovery from the 1995 Kobe earthquake and the 2001 World Trade Center recovery. In Taiwan, the Buddhist organization and the national government of Taiwan were major supporting entities in the recovery from the 1999 Chi-Chi earthquake. Operating agencies are those organizations that implement various recovery measures. In Japan, local governments in the impacted area are operating agencies, while the national government is a supporting entity. In the United States, community development block grants provide an opportunity for many operating agencies to implement various recovery measures. As Mr. Mammen’ paper describes, many NPOs, NGOs, and/or CBOs in addition to local governments have had major roles in implementing various kinds programs funded by block grants as part of the World Trade Center recovery. No one, single organization can provide effective help for all kinds of disaster victims individually or collectively. The needs of disaster victims may be conflicting with each other because of their diversity. Their divergent needs can be successfully met by the diversity of operating agencies that have responsibility for implementing recovery measures. In a similar context, block grants made to individual households, such as microfinance, has been a vital recovery mechanism for victims in Thailand who suffered from the 2004 Sumatra earthquake and tsunami disaster. Both disaster victims and government officers at all levels strongly supported the microfinance so that disaster victims themselves would become operating agencies for recovery. Empowering individuals in sustainable life recovery is indeed the ultimate goal of recovery. <strong>Fig. 6.</strong> A holistic recovery policy model.

Abstract Untoward events involving radioactive material, either accidental or intentional, are potentially devastating. Hematologists and oncologists are uniquely suited to help manage radiation victims, as myelosuppression is a frequent complication of radiation exposure. In the aftermath of a large event, such as a nuclear detonation, there may be a national call for surge capacity that involves hematologists/oncologists across the country in the disaster response. In preparation, the National Marrow Donor Program and American Society for Blood and Marrow Transplantation have established the Radiation Injury Treatment Network (RITN), a voluntary consortium of transplant centers, donor centers, and umbilical cord blood banks. RITN is partnered with the Office of the Assistant Secretary for Preparedness and Response in the United States Department of Health and Human Services to develop treatment guidelines, educate healthcare professionals, coordinate situation response, and provide comprehensive evaluation and care for radiation injury victims. We outline the current plans for event response and describe scenarios, including catastrophic events that would require extensive support from hematologists/oncologists across the country. In addition, we highlight important reference resources and discuss current efforts to develop medical countermeasures against radiation toxicity. Practitioners and institutions across the country are encouraged to become involved and participate in the planning.

<p><strong>Objectives: </strong>To examine within-state geographic heterogeneity in hypertension prevalence and evaluate associations between hypertension prevalence and small area contextual characteristics for Black and White South Carolina Medicaid enrollees in urban vs rural areas. <strong></strong></p><p><strong>Design: </strong>Ecological <strong></strong></p><p><strong>Setting: </strong>South Carolina, United States. <strong></strong></p><p><strong>Main Outcome Measure: </strong>Hypertension prevalence </p><p><strong>Methods: </strong>Data representing adult South Carolina Medicaid recipients enrolled in fiscal year 2013 (N=409,907) and ZIP Code Tabulation Area (ZCTA)-level contextual measures (racial segregation, rurality, poverty, educational attainment, unemployment and primary care physician adequacy) were linked in a spatially referenced database. Optimized Getis-Ord hotspot mapping was used to visualize geographic clustering of hypertension prevalence. Spatial regression was performed to examine the association between hypertension prevalence and small-area contextual indicators. <strong></strong></p><p><strong>Results: </strong>Significant (alpha=.05) hotspot spatial clustering patterns were similar for Blacks and Whites. Black isolation was significantly associated with hypertension among Blacks and Whites in both urban (Black, b=1.34, P&lt;.01; White, b=.66, P&lt;.01) and rural settings (Black, b=.71, P=.02; White, b=.70, P&lt;.01). Primary care physician adequacy was associated with hypertension among urban Blacks (b=-2.14, P&lt;.01) and Whites (b=-1.74, P&lt;.01). <strong></strong></p><p><strong>Conclusions: </strong>The significant geographic overlap of hypertension prevalence hotspots for Black and White Medicaid enrollees provides an opportunity for targeted health intervention. Provider adequacy findings suggest the value of ACA network adequacy standards for Medicaid managed care plans in ensuring health care accessibility for persons with hypertension and related chronic conditions. <em>Ethn Dis. </em>2016;26(3):331-338; doi:10.18865/ed.26.3.331 </p>

IntroductionThere are 60 Poison Centers in the United States that manage over 2.5 million poison exposure calls each year. A poison center can be reached 24 hours a day by dialing a national 800 hotline. Poison Centers are staffed by Specialists in Poison Information who are highly trained in clinical toxicology and are very skilled in telephone triage.DiscussionATSDR and the Poison Centers in HHS/FEMA Region 6 developed draft guidance for incorporating Poison Centers into the National Response Plan. That framework was used to incorporate Poison Centers into the gulf oil spill response of 2010. The National Poison hotline was promoted to provide medical support for those with health effects or health questions related to the spill. During the response the surveillance capabilities of the National Poison Data System (NPDS) were highlighted. The Louisiana Poison Center (LPC) and the other gulf states Poison Centers provided information on health effects related to the spill. Information was provided by the LPC to the Louisiana Department of Health and Hospitals, Office of Public Health Section of Epidemiology and Environmental Toxicology, public information officer to assist in briefing the Governor, the Louisiana Governors Office of Homeland Security and Emergency Preparedness to post to the Virtual Louisiana website, as well as ATSDR, CDC, EPA, and other agencies participating in the gulf response unified command. Poison Centers, for the first time, participated in a response on a national level, providing medical support for those with symptoms or medical questions related to the spill. In addition to assisting in the medical care of those exposed to substances related to the oil spill and the response efforts, Poison Centers also responded to questions about air and water quality and seafood safety.ConclusionPoison Centers are a valuable resource to assist in emergency response plans.

Background: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) first reached the United States in January 2020. Located in New York City (NYC), MSK Kids, at Memorial Sloan Kettering Cancer Center services, is one of the largest pediatric cancer centers in the U.S., caring for children, teenagers, and young adults with cancer, immune deficiencies, and blood disorders. Methods: Implementation for infection mitigation and ongoing care of patients included: (1) the creation of a strategic planning team of physicians, advanced practice providers, nurses, and administrators to develop guidance and workflows, (2) continuous reassessment of patients’ needs for hospital services and visit frequency, (3) the use of telemedicine to replace in-person visits, (4) the use of satellite regional centers to manage patients living outside NYC, (5) pre-screening of patients prior to visits for risks and symptoms of coronavirus disease 2019 (COVID-19) infection, (6) day-of-service screening for risks or symptoms of COVID-19 infection, (7) surveillance testing of children and their caregivers, and (8) creation of cohort plans for the management of COVID-19 positive and uninfected patients within the same institution, in both the outpatient and inpatient settings. Results: We describe the timeline for planning mitigation during the first weeks of the pandemic, and detail in a stepwise fashion the rationale and implementation of COVID-19 containment efforts in the context of a large pediatric oncology program. Discussion: Our experience offers a model on which to base strategic planning efforts at other pediatric oncology centers, for continued preparedness to combat the threat posed by SARS-CoV-2 worldwide.

Background: In late 2012, Hurricane Sandy struck the eastern United States. Healthcare infrastructure in New York City—including long-term care facilities (LTCFs)—was affected significantly. The authors examined the impact of the storm on LTCFs 2 years after the event, using a qualitative approach consisting of a semistructured interview focused on preparedness and response. Important insights regarding preparedness and response may be lost by quantitative analysis or outcome measurement alone. During Sandy, individuals at LTCFs experienced the event in important subjective ways that, in aggregate, could lead to valuable insights about how facilities might mitigate future risks. The authors used data from a semistructured interview to generate hypotheses regarding the preparation and response of LTCFs. The interview tool was designed to help develop theories to explain why LTCF staff and administrators experienced the event in the way they did, and to use that data to inform future policy and research. Methods: Representatives from LTCFs located in a heavily affected area of New York City were approached for participation in a semistructured interview. Interviews were digitally recorded and transcribed. Recurrent themes were coded based on time period (before, during, or after the storm) and content. A grounded theory approach was used to identify important themes related to the participants’ experiences.Results: A total of 21 interviews were conducted. Several overarching themes were identified, including a perception that facilities had not prepared for an event of such magnitude, of inefficient communication and logistics during evacuation, and of lack of easily identifiable or appropriate resources after the event. Access to electrical power emerged as a key identifier of recovery for most facilities. The experience had a substantial psychological impact on LTCF staff regardless of whether they evacuated or sheltered in place during the storm.Conclusion: Representatives from LTCFs affected by Sandy experienced the preparation, response, and recovery phases of the event with a unique perspective. Their insights offer evidence which can be used to generate testable hypothesis regarding similar events in the future, and can inform policy makers and facility administrators alike as they prepare for extreme weather events in similar settings. Results specifically suggest that LTCFs develop plans which carefully address the unique qualities of extreme weather events, including communication with local officials, evacuation and transfer needs in geographic areas with multiple facilities, and plans for the safe transfer of residents. Emergency managers at LTCFs should consider electrical power needs with the understanding that in extreme weather events, power failures can be more protracted than in other types of emergencies.

Health care delivery and benefits in the United States are changing. This article provides a basic description of the present-day components, managed care constructs, and impact of medical/hospital program/ benefit designs on pharmacy programs.

As their expansion slows in the United States, managed care organizations will continue to enter new markets abroad. Investors view the opening of managed care in Latin America as a lucrative business opportunity. As public-sector services and social security funds are cut back, privatized, and reorganized under managed care, with the support of international lending agencies such as the World Bank, the effects of these reforms on access to preventive and curative services will hold great importance throughout the developing world. Many groups in Latin America are working on alternative projects that defend health as a public good, and similar movements have begun in Africa and Asia. Increasingly, this organizing is being recognized not only as part of a class struggle but also as part of a struggle against economic imperialism—which has now taken on the new appearance of rescuing less developed countries from rising health care costs and inefficient bureaucracies through the imposition of neoliberal managed-care solutions exported from the United States.

Since 1995, states have played an increasingly active role as regulators of managed care health plans. However, there is little consistency from state to state in the laws that govern managed care plans. This paper analyzes this inconsistency within the framework of the economic and political theories of regulatory choice. An empirical model is developed to test whether these theories can explain the presence of two laws regulating women's access to obstetrician-gynecologists (OB/GYNs). The results suggest that these theories together do help to clarify why certain states enacted the regulations. The regulations were more likely to be present in states with a relatively high number of OB/GYNs and female legislators, and Democratic control of government.

The issue of risk selection is especially important for states that enroll blind and disabled beneficiaries of Supplemental Security Income (SSI) in Medicaid managed care. SSI beneficiaries have persistent needs for care, have a wide variety of chronic conditions, and often need atypical and complex services. Risk selection occurs when the health care needs of beneficiaries enrolled in a specific plan differ systematically from the needs of the overall beneficiary population and payments do not reflect those needs. We assess the extent of risk selection among managed care plans for SSI beneficiaries over the first three years of Tennessee's Medicaid managed care program, TennCare. Using claims data containing fee-for-service expenditures prior to enrollment in managed care, we find substantial evidence of persistent risk selection among plans. Results are robust to most alternative measures of risk selection for most plans.

The result ERISA compels us to reach means that the Corcorans [who lost their unborn child allegedly as a result of United Healthcare’s negligent determination that hospitalization was not medically necessary] have no remedy, state or federal, for what may have been a serious mistake. This is troubling....In the words of its sponsor, Senator Jacob Javits, the Employee Retirement Income Security Act (ERISA) was enacted in 1974 “to maintain the voluntary growth of private [pension and employee benefit] plans while at the same time making needed structural reforms in such areas as vesting, funding, termination, etc. so as to safeguard workers against loss of their earned or anticipated benefits....” Ironically, one of ERISA’s provisions—its indeterminate provision for the preemption of state law—has probably created more uncertainty about the adequacy and security of health care benefits than any other piece of legislation. Neither ERISA nor any other federal statute comprehensively regulates the content of employer provided health care plans, including benefits provided through managed care organizations (MCOs).

In the face of escalating Medicaid costs and anticipated reductions in federal Medicaid spending, states are increasingly converting from fee-for-service (FFS) to managed health care systems. The interrelated issues of enrollment and auto-assignment are fundamental to the overall success or failure of Medicaid managed care programs. The purpose of this article is to suggest how policy makers, consumer advocates, and providers should address these issues. My major premise is that implementation of managed care will proceed more smoothly if states adopt enrollment strategies that promote voluntary selection of health plans by Medicaid consumers, minimize the likelihood of auto-assignment, and mitigate the negative consequences of mandatory assignment of consumers to managed care organizations (MCOs).States seeking to implement Medicaid managed care must apply for a waiver from the secretary of the Department of Health and Human Services (DHHS). Two different types of waivers are available to implement Medicaid managed care.