OBTAINABLE RESOURCES

Artificial Intelligence In Health Care

Each year, medical diagnosis errors affect the health of millions of Americans and cost billions of dollars. Machine learning technologies can help identify hidden or complex patterns in diagnostic data to detect diseases earlier and improve treatments. A report from the U.S. Government Accountability Office (GAO), the congressional watchdog agency, identified such technologies in use and development, including some that improve their own accuracy by learning from new data. Developing and adopting these technologies has challenges, however, such as the need to demonstrate real-world performance in diverse clinical settings. GAO policy options, like improving data access and collaboration, may help address challenges. Several machine learning (ML) technologies are available in the U.S. to assist with the diagnostic process. The resulting benefits include earlier detection of diseases; more consistent analysis of medical data; and increased access to care, particularly for underserved populations. GAO identified a variety of ML-based technologies for five selected diseases: certain cancers, diabetic retinopathy, Alzheimer’s disease, heart disease, and COVID-19 with most technologies relying on data from imaging such as x-rays or magnetic resonance imaging (MRI). These ML technologies have generally not been widely adopted. Academic, government, and private sector researchers are working to expand the capabilities of ML-based medical diagnostic technologies. The report can be obtained here.

National Strategy To Support Family Caregivers

A report that recently was released is entitled, the 2022 National Strategy to Support Family Caregivers. It provides detailed information about nearly 350 actions federal agencies will take over the next three years to support the nation’s 53 million family caregivers. The National Strategy includes more than 150 actions that state and local governments, public health departments, philanthropies, and community-based, faith-based, and nonprofit organizations should take, recognizing that all these groups have a fundamental role to play in supporting family caregivers. The National Strategy was created to support family caregivers of all ages, from youth to grandparents, and regardless of where they live or what caregiving looks like for them and their loved ones. It was developed jointly by the advisory councils created by the RAISE Family Caregiving Act (P.L. 115-119) and the Supporting Grandparents Raising Grandchildren Act (P.L. 115-196), with extensive input from the public, including family caregivers and the individuals they support. It will be updated in response to public comments and will evolve with the caregiving landscape. A 60-day comment period opened on October 1, 2022. The report and the opportunity to submit comments are here.

Accelerating The Use Of Findings From Patient-Centered Outcomes Research

Patient-centered outcomes research (PCOR) studies consider the questions and outcomes that are meaningful to patients to compare the effectiveness of different prevention, diagnostic, and treatment options. PCOR also increases patient involvement in their care by providing them an opportunity to evaluate the quality, outcomes, and effectiveness of health care treatments and interventions, especially in areas where there is poor existing clinical evidence. The National Academies of Sciences, Engineering, and Medicine Board on Healthcare Services hosted a series of public workshops to explore ways of accelerating the use of PCOR findings in clinical practice to improve health and health care. Workshop discussions touched on the role of community health workers in helping care providers see and understand the whole picture of patient lives, the need for community engagement to ensure research is conducted and applied to practice equitably, and ways of measuring the impact of efforts to disseminate and implement new practices based on PCOR. This report summarizes the discussions that took place at these workshops. The document can be obtained here.

NORMAL BLINDNESS: LOOKING BUT FAILING TO SEE

Looked But Failed to See (LBFTS) errors occur when observers fail to notice a clearly visible item. They can happen across a wide range of tasks and settings, from driving and medical image perception to laboratory visual search tasks, overlooking typos in a paper, or failing to see a cyclist in an intersection. LBFTS can be thought of as a form of “normal blindness.” Although obviously far less severe than clinical blindness, it is so universal that its costs are substantial at a societal level. An article published in the September 2022 issue of the journal Trends in Cognitive Sciences outlines a new, unified account of such errors, arguing that processes that function well in most situations are guaranteed to produce a steady stream of LBFTS errors under some circumstances. The authors advance the proposition that normal blindness is the by-product of the limited-capacity prediction engine that is the human visual system. Processes that evolved to allow individuals to move through the world with ease are virtually guaranteed to cause missing certain significant stimuli, especially in important tasks like driving and medical image perception.

Although various LBFTS situations may seem like distinct phenomena, it can be argued that based on recent work, they all can be seen as products of the same normal mechanisms of attention and object recognition. Specifically: (i) observers only select a subset of what they could process on each fixation (although they are not blind to the rest of the visual input); (ii) even the items that are selected by attention will be missed if too little time is given to their processing; (iii) the processes that give rise to routine visual awareness persuade us that we have seen more than we have actually seen; and (iv) attentional guidance (attentional set) can guide observers away from targets as well as toward them. Taken together, these factors produce a state of ‘normal blindness’ that has significant implications. A framework is shown in which multiple types of LBFTS errors arise from the same underlying processes. A relatively complex task is used in the form of a cartoon as an example. 

HEALTH REFORM DEVELOPMENTS

A central aim of governmental efforts to improve individual and community health status in the U.S. is to remove inequities. Many kinds of social determinants influence the extent to which all segments of the population benefit from having equal access to high quality health care services. One factor affecting the ability to obtain services has to do with one’s residential location. For example, a  report issued in September 2022 from the American Hospital Association highlights the variety of  causes that resulted in 136 rural hospital closures from 2010 to 2021, and a record 19 closures in 2020 alone. Many longstanding pressures are involved, such as low reimbursement, staffing shortages, low patient volume, and regulatory barriers, as well as the continued financial challenges associated with the COVID-19 pandemic. The report outlines several pathways for rural hospitals to achieve financial sustainability, including additional federal support, flexible models of care, decreased regulatory  burden, partnership arrangements, and state Medicaid expansion. The AHA also continues to urge Congress to extend the Medicare-dependent Hospital and enhanced Low-volume Adjustment programs, which are set to expire this month. The programs provide vital support for geographically isolated rural hospitals with low patient volumes.  

Apart from having accessibility to hospitals, other examples can be provided about unequal use of health care services. A data brief from the Office of the Inspector General at the Department of Health and Human Services (HHS) in September 2022 reveals that the COVID-19 pandemic created unprecedented challenges for how Medicare beneficiaries access health care. The Centers for Medicare & Medicaid Services (CMS) took a number of actions to expand access to telehealth for Medicare beneficiaries temporarily. More than 28 million, about two in five, Medicare beneficiaries used telehealth during the first year of the pandemic. CMS increased the types of services that beneficiaries could use via telehealth, from 118 to 264 service types. Beneficiaries in urban areas were more likely than those in rural areas to use telehealth. In total, 45% of beneficiaries in urban areas used telehealth during the first year of the pandemic. They accounted for more than 24 million of the 54 million Medicare beneficiaries living in urban areas. In contrast, just 33% percent of beneficiaries in rural areas used telehealth. They accounted for more than three million of the more than 11 million Medicare beneficiaries living in rural areas. Reasons for this disparity pertain to rural populations being less likely than residents in urban areas to have access to broadband connectivity. Rural health care providers also may face challenges providing telehealth to their patients because equipment and internet connectivity can be too expensive. 

Poverty And Health Insurance Coverage

The U.S. Census Bureau announced on September 13, 2022 that real median household income in 2021 was not statistically different than 2020. The official poverty rate of 11.6% also was not statistically different between 2020 and 2021. The Supplemental Poverty Measure (SPM) rate in 2021 was 7.8%, a decrease of 1.4 percentage points from 2020. Meanwhile, the percentage of individuals with health insurance coverage for all or part of 2021 was 91.7% (compared to 91.4% in 2020.) An estimated 8.3% of the population, or 27.2 million, did not have health insurance at any point during 2021, according to findings from the 2022 Current Population Survey Annual Social and Economic Supplement (CPS ASEC). That amount compared with an estimated 8.6% of the population, or 28.3 million, who did not have health insurance at any point during 2020. In 2021, private health insurance coverage continued to be more prevalent than public coverage, at 66.0% and 35.7%, respectively. Some individuals may have more than one coverage type during the calendar year. Of the subtypes of health insurance, employer-based insurance was the most common, covering 54.3% of the population for some or all of the  calendar year. 

Constitutionality Of Affordable Care Act Continues To Foster Litigation

A federal judge in Texas agreed this month with plaintiffs that requiring insurers to cover the costs of medications for HIV pre-exposure prophylaxis (PrEP) infringed on their religious rights, effectively eliminating a central tenet of the Affordable Care Act (ACA). Under the ACA, most health plans are required to pay for a range of preventive services. The decision came in response to Braidwood Management v. Becerra (formerly Kelley v. Becerra). Plaintiffs argued that the ACA requirement for insurers to pay for certain preventive services was unconstitutional, because it encouraged behavior that clashed with their personal and religious beliefs, such as  services related to reproductive and sexual health.

OBTAINABLE RESOURCES

Addressing Structural Racism, Bias, And Health Communication Regarding Obesity

The National Academies of Sciences, Engineering, and Medicine's Roundtable on Obesity Solutions convened a three-part workshop series that explored how structural racism; weight bias and stigma; and health communication intersect with obesity, gaps in the evidence base, and challenges and opportunities for long-term, systems-wide strategies needed to reduce the incidence and prevalence of obesity. Through diverse examples across different levels and sectors of society, the workshops explored how to leverage the connections between these three drivers and innovative data-driven and policy approaches to inform actionable priorities for individuals, organizations, and policymakers to make lasting systems change. The workshop report can be obtained at

Addressing Structural Racism, Bias, and Health Communication as Foundational Drivers of Obesity: Proceedings of a Workshop Series |The National Academies Press.

The Demographic Outlook: 2022 To 2052

The size of the U.S. population and its age and sex composition affect federal spending, revenues, deficits, debt, and the economy. In a new report, the Congressional Budget Office (CBO) describes its population projections that underlie the baseline budget projections and economic forecast that CBO published in May 2022 and the long-term budget projections that the agency published in July 2022. In CBO’s projections, the population increases from 335 million individuals in 2022 to 369 million in 2052, expanding by 0.3% per year, on average. (In this report, population refers to the Social Security area population—the relevant population for the calculation of Social Security payroll taxes and benefits. The population also is projected to become older, on average, as growth in the number of individuals age 65 or older outpaces that of younger age groups. The civilian noninstitutionalized population grows in numbers in CBO’s projections, from 264 in 2022 to 298 million in 2052. (This measure of the population includes only individuals age 16 or older. The agency uses it to project the size of the labor force.) The prime working age population (ages 25 to 54) grows at an average annual rate of 0.2% over that period, slower than its average over the 1980–2021 period (1.0%). In CBO’s current projections, the population is smaller and grows more slowly, on average, than CBO projected last year. Fertility rates are expected to be lower than the agency projected last year, reducing the size and growth of the population that is under 24 years old over the 30-year projection period. The report can be obtained at

https://www.cbo.gov/system/files/2022-07/57975-demographic-outlook.pdf.

Innovating Undergraduate Education: Lessons From The Pandemic

Innovating undergraduate education must take into consideration the current expectation among college-bound high school students of a return to the traditional. Simply stated, after the challenges of build-the-airplane-while-you-fly-it remote learning and all its attendant problems, students are expecting a return to the face-to-face education of yesteryear.  According to the firm Eduventures, however, the United States is at an inflection point with traditional-aged undergraduate education: Either it is possible to breathe a post-pandemic sigh of relief and go back to an undergraduate education steeped in tradition and circumscribed by the campus and its in-person interactions or a leap can be made to reinvigorate undergraduate education by innovating the experience based on pandemic learnings. The company believes that the latter will help higher education institutions provide relevant education for tomorrow’s so-called “traditional undergraduates.” Ye,t truly innovating undergraduate education requires a considered examination of what pandemic-related technology and pedagogy worked and didn’t work. It also requires a demonstration of value to students who currently yearn for tradition. More information can be obtained at Innovating Undergraduate Education: Lessons from the Pandemic (encoura.org)

HEALTH REFORM DEVELOPMENTS

A central aim of governmental efforts to improve individual and community health status in the U.S. is to remove inequities. Many kinds of social determinants influence the extent to which all segments of the population benefit from having equal access to high quality health care services. One factor affecting the ability to obtain services has to do with one’s residential location. For example, a  report issued in September 2022 from the American Hospital Association highlights the variety of  causes that resulted in 136 rural hospital closures from 2010 to 2021, and a record 19 closures in 2020 alone. Many longstanding pressures are involved, such as low reimbursement, staffing shortages, low patient volume and regulatory barriers, as well as the continued financial challenges associated with the COVID-19 pandemic. The report outlines several pathways for rural hospitals to achieve financial  sustainability, including additional federal support, flexible models of care, decreased regulatory  burden, partnership arrangements and state Medicaid expansion. The AHA also continues to urge    Congress to extend the Medicare-dependent Hospital and enhanced Low-volume Adjustment programs, which are set to expire this month. The programs provide vital support for geographically isolated rural hospitals with low patient volumes. 

Apart from having accessibility to hospitals, other examples can be provided about unequal use of health care services. A data brief from the Office of the Inspector General at the Department of Health and Human Services (HHS) in September 2022 reveals that the COVID-19 pandemic created unprecedented challenges for how Medicare beneficiaries access health care. The Centers for Medicare &   Medicaid Services (CMS) took a number of actions to expand access to telehealth for Medicare beneficiaries temporarily. More than 28 million, about two in five, Medicare beneficiaries used telehealth during the first year of the pandemic. CMS increased the types of services that beneficiaries could use via telehealth, from 118 to 264 service types. Beneficiaries in urban areas were more likely than those in rural areas to use telehealth. In total, 45% of beneficiaries in urban areas used telehealth during the first year of the pandemic. They accounted for more than 24 million of the 54 million Medicare beneficiaries living in urban areas. In contrast, just 33% percent of beneficiaries in rural areas used telehealth. They accounted for more than 3 million of the more than 11 million Medicare  beneficiaries living in rural areas. Reasons for this disparity pertain to rural populations being less likely than residents in urban areas to have access to broadband connectivity. Rural health care providers also may face challenges providing telehealth to their patients because equipment and internet connectivity can be too expensive.

Poverty And Health Insurance Coverage

The U.S. Census Bureau announced on September 13, 2022 that real median household income in 2021 was not statistically different than 2020. The official poverty rate of 11.6% also was not statistically   different between 2020 and 2021. The Supplemental Poverty Measure (SPM) rate in 2021 was 7.8%, a decrease of 1.4 percentage points from 2020. Meanwhile, the percentage of individuals with health   insurance coverage for all or part of 2021 was 91.7% (compared to 91.4% in 2020.) An estimated 8.3% of the population, or 27.2 million, did not have health insurance at any point during 2021, according to findings from the 2022 Current Population Survey Annual Social and Economic Supplement (CPS ASEC). That amount compared with an estimated 8.6% of the population, or 28.3 million, who did not have health insurance at any point during 2020. In 2021, private health insurance coverage continued to be more prevalent than public coverage, at 66.0% and 35.7%, respectively. Some individuals may have more than one coverage type during the calendar year. Of the subtypes of health insurance, employer-based insurance was the most common, covering 54.3% of the population for some or all of the  calendar year.

Constitutionality Of Affordable Care Act Continues To Foster Litigation

A federal judge in Texas agreed this month with plaintiffs that requiring insurers to cover the costs of medications for HIV pre-exposure prophylaxis (PrEP) infringed on their religious rights, effectively eliminating a central tenet of the Affordable Care Act (ACA). Under the ACA, most health plans are required to pay for a range of preventive services. The decision came in response to Braidwood Management v. Becerra (formerly Kelley v. Becerra). Plaintiffs argued that the ACA requirement for insurers to pay for certain preventive services was unconstitutional, because it encouraged behavior that clashed with their personal and religious beliefs, such as  services related to reproductive and sexual health.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Disparities In Activity And Traffic Fatalities By Race/Ethnicity

Traffic fatalities remain a major public health challenge despite progress made during recent decades. A study described in the August 2022 issue of the American Journal of Preventive Medicine developed exposure-based estimates of fatalities per mile traveled for pedestrians, cyclists, and light-duty vehicle occupants. Exposure to traffic fatality differs by race/ethnicity group and by mode, indicating that adjustment for differential exposure is needed when estimating disparities. The authors found that fatality rates per 100 million miles traveled are systematically higher for Black and Hispanic Americans for all modes and notably higher for vulnerable modes (e.g., Black Americans died at more than four times the rate for White Americans while cycling, 33.71 [95% CI: 21.84, 73.83] compared with 7.53 [95% CI: 6.64, 8.69], and more than two times the rate while walking, 40.92 [95% CI: 36.58, 46.44] compared with 18.77 [95% CI: 17.30, 20.51]). These fatalities are a substantial and preventable public health challenge in the U.S.

Chronic Conditions Among Adults Aged 18─34 Years — United States, 2019

According to the July 29, 2022 issue of Morbidity and Mortality Weekly Reports, in 2019, 53.8% of adults aged 18─34 years had at least one chronic condition, and 22.3% had more than one condition. CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) to measure prevalence of 11 chronic conditions among adults aged 18–34 years overall and by selected characteristics, and to measure prevalence of health-related risk behaviors by chronic condition status. The most prevalent conditions were obesity (25.5%), depression (21.3%), and high blood pressure (10.7%). Differences in the prevalence of having a chronic condition were most noticeable between young adults with a disability (75.8%) and without a disability (48.3%) and those who were unemployed (62.3%) and students (45.8%). Addressing conditions in young adulthood can help slow disease progression and improve well-being across the life span. Coordinated efforts might help improve the availability of evidence-based policies and interventions.

HEALTH TECHNOLOGY CORNER

Pan-Cancer Integrative Histology-Genomic Analysis Via Multi-Modal Deep Learning

The rapidly emerging field of computational pathology has demonstrated promise in developing objective prognostic models from histology images. Most prognostic models, however, either are based on histology or genomics alone and do not address how these data sources can be integrated to develop joint image-omic prognostic models. Additionally, identifying explainable morphological and molecular descriptors from these models that govern such prognosis is of interest. As reported on August 8, 2022 in the journal Cancer Cell, researchers at Brigham and Women’s Hospital in Boston used multimodal deep learning to examine pathology whole-slide images and molecular profile data jointly from 14 cancer types. A multimodal deep learning algorithm is able to fuse these heterogeneous modalities to predict outcomes and discover prognostic features that correlate with poor and favorable outcomes. Investigators presented all analyses for morphological and molecular correlates of patient prognosis across the 14 cancer types.

Effects Of Posture And Gastroparesis On Drug Dissolution In The Human Stomach

The oral route is the most common choice for drug administration because of several advantages, such as convenience and high patient compliance, and the demand and investment in research and development for oral drugs continue to grow. The rate of dissolution and gastric emptying of the dissolved active pharmaceutical ingredient (API) into the duodenum is modulated by gastric motility, physical properties of the pill, and the contents of the stomach, but current in vitro procedures for assessing dissolution of oral drugs are limited in their ability to recapitulate this process. A paper on August 9, 2022 in the journal Physics of Fluids describes how researchers at Johns Hopkins employed a biomimetic in silico simulator based on the realistic anatomy and morphology of the stomach to investigate and quantify the effect of body posture and stomach motility on drug bioavailability. Simulations show that changes in posture can potentially have a significant (up to 83%) effect on the emptying rate of the API into the duodenum.

DEVELOPMENTS IN HIGHER EDUCATION

The higher education realm plays a major role in producing the health workforce. Both the number and kinds of competently-prepared health professionals are dependent on the following considerations: the ability to attract student applicants with a solid background in science and mathematics to a wide range of academic programs at various degree levels, and the resources needed to cover the costs of education in health professions schools. Working Paper No. 30275 that was published in July 2022 by the National Bureau of Economic Research (NBER) sheds light on the latter issue by indicating that an increasing tension between the perceived necessity of a college degree and the challenge of paying for it has led to a proliferation of financial aid policies in the U.S. and around the world. More students are receiving more aid today, and more different types of aid, than ever before. Moreover, half a century of policy experimentation has led to an equally impressive accumulation of research evidence, facilitated by methodological advances and the widespread availability of student-level administrative data.

The authors present the economic rationale for financial aid, a summary of how aid works in the U.S. context, and common methodological challenges in studying it. They review the evidence from both inside and outside the U.S. on the causal impact of a variety of financial aid policies and programs on students’ college decisions, attainment, and post-college outcomes, and summarize the overarching themes with respect to margins of impact, mechanisms, and heterogeneity. They point out in their analysis that seemingly small bureaucratic details can dramatically alter students’ behavioral response to a given dollar of subsidy. Complex and uncertain eligibility and application procedures, such as those historically required to access Pell Grants, can prevent aid from effectively reaching those who most need it. One conclusion reached is the possibility that student aid programs could cause some students harm by inducing them into low-quality institutions when their time might have been better spent in the labor market, or by inducing them to take on debt for programs that don’t pay off.

Government Accountability Office (GAO) Analysis Of Student Loans

When the Patient Protection and Affordable Care Act (ACA) became law in March 2010, several of its provisions involving costs had to be offset. One proposed remedy was to use profits generated by having the federal government take over student lending. Although the Department of Education originally estimated federal Direct Loans made in the last 25 years would generate billions in income for the federal government, its current estimates show these loans will cost the government billions. According to a report issued on July 29, 2022 by the Government Accountability Office (GAO), these loans originally were estimated to produce $114 billion in income for the government. Although actual costs cannot be known until the end of the loan terms, as of fiscal year 2021 these loans are estimated to cost the federal government $197 billion. This swing of $311 billion was driven both by programmatic changes and by reestimates using revised assumptions (e.g., economic factors and loan performance) as additional data became available.

Proposed Rule On Nondiscrimination On The Basis Of Sex In Education Programs

The July 12, 2022 issue of the Federal Register, the official U.S. federal government journal, contains a hefty 190-pages of triple-column text describing a proposed new rule concerning Title IX regulations affecting how campuses deal with sexual harassment, assault, and discrimination. The U.S. Department of Education proposes to amend the regulations implementing Title IX of the Education Amendments of 1972 (Title IX). Current regulations are viewed as not best fulfilling the requirement of Title IX that schools and institutions that receive Federal financial assistance eliminate discrimination on the basis of sex in their education programs or activities. The Department therefore proposes that the current regulations should be amended to provide greater clarity regarding the scope of sex discrimination, including recipients’ obligations not to discriminate based on sex stereotypes; sex characteristics; pregnancy or related conditions; sexual orientation; and gender identity. A comment period ends on September 12, 2022.

HEALTH REFORM DEVELOPMENTS

Health reform is a term that closely relates to the word litigation. For example, UnitedHealth Group (United), owner of the largest health insurance company in the United States, proposes to acquire Change Healthcare (Change), the leading source of key technologies that United’s health insurance rivals depend on to compete with United. A trial in the U.S. District Court in Washington, DC is underway as of August 1, 2022 to prevent the UnitedHealth Group from doing so. The proposed merger is opposed by the U.S. Department of Justice, along with the states of Minnesota and New York, on the basis that it would harm competition in commercial health insurance markets and also in the market for a vital technology used to process claims and reduce health care costs.

By ensuring accuracy, avoiding overpayments, and reducing administrative waste, Change’s technologies save United’s rivals tens of billions of dollars each year and reduce health care costs. Change also has access to vast amounts of competitively sensitive data about United’s rivals, data that reveal how their plans are designed and how they calculate payments to providers, for example, and holds “unfettered” rights to use much of this information.

Constitutionality Of Affordable Care Act Continues To Foster Litigation

The Patient Protection and Affordable Care Act, more commonly referred to as the Affordable Care Act (ACA), became law in March 2010. Since its inception, many ACA provisions have been controversial. The courts have been called upon several times to resolve disputes by litigants. For example, Section 2713 pertains to health insurance coverage of certain preventive services that have been approved by the U.S. Preventive Services Task Force (PSTF), a congressionally established private body of experts; the Advisory Committee on Immunization Practices (ACIP); and the Health Resources and Services Administration (HRSA). As an illustration, opponents of Section 2713 are against the provision of coverage of contraceptives and preexposure prophylaxis (a medication that prevents HIV) on religious or other grounds.

The case Leal v. Becerra filed in December 2020 in federal district court in Amarillo, TX resulted in the rejection of a claim by plaintiffs that 2713 unconstitutionally delegates to HRSA the power to adopt legal requirements binding on private parties, a power the Constitution vests in Congress. In the ongoing case Kelley v. Becerra, plaintiffs appealed this decision to the Fifth Circuit federal court in Fort Worth, TX in February 2021. They challenge the constitutionality of the ACA’s provisions and mandates issued pursuant to this grant of authority to the PSTF, ACIP, and HRSA. Specifically, they object to paying for health insurance plans that cover contraceptives, preexposure prophylaxis drugs, and other preventive-care services for religious reasons plus related preventive-care coverage that they neither want nor need. Instead, all plaintiffs express a desire to purchase on the open market insurance policies that meet their needs and are free from the requirements of the provisions and their resulting mandates.

Enhanced Nursing Home Five-Star Quality Rating System Launched By CMS

The Centers for Medicare & Medicaid Services on July 27, 2022 launched its enhanced Nursing Home Five-Star Quality Rating System, which integrates data these facilities report on their weekend staffing rates for nurses and information on annual turnover among nurses and administrators. The updated Star Ratings increase transparency aimed at improving the quality of nursing homes so residents obtain the reliable, quality care they deserve. CMS research shows that higher nurse turnover is associated with lower quality of care. It is believed that nurses who have worked at a facility longer are more likely to know residents well enough to recognize small health changes and act before they become larger issues. Similarly, administrators with longer tenures help create stable leadership that can lead to more consistent policies and protocols that are tailored to serve residents better. Last January, CMS began posting weekend staffing and turnover rates on Medicare’s Care Compare website. The agency now is incorporating that information into the consumer-friendly Nursing Home Five-Star Quality Rating System. New nurse staffing information includes registered nurses, licensed practical nurses, vocational nurses, and nurse aides who work under the direction of licensed nurse staff and provide much of the day-to-day care for nursing home residents, such as eating, bathing, grooming, and toileting. Ratings are updated quarterly.

MAJOR LEGISLATION ENACTED

The budget reconciliation process was used by the Senate on October 7, 2022 to pass the Inflation Reduction Act. Vice President Kamala Harris cast the tie-breaking 51-50 party-line vote. The House followed suit five days later by passing this $437 billion tax, climate, and health package by a similar party-line vote of 220-207 vote. The legislation was signed into law by President Joseph Biden. A White House celebratory event is scheduled for September 6, 2022.

Apart from health-related provisions, enactment will result in new taxes on large, profitable corporations, increased spending over a decade on new workers and technology at the Internal Revenue Service, and tax subsidies aimed at combating climate change. Some major health features are as follows:

• The Medicare program is granted authority to set the price of certain high-expenditure prescription drugs, in both Part B and Part D. Prices on a narrow set of 10 drugs can be negotiated starting in 2026 with a potential expansion to 20 medicines in 2029.

• Out-of-pocket Part D spending by beneficiaries will be capped at $2,000 per year, beginning in 2025.

• Individuals who received Affordable Care Act subsidies through the 2021 American Rescue Plan will be able to depend on obtaining another three years of those benefits.

• Insulin costs will be capped at $35 per month for Medicare recipients.

• Along with Medicaid program participants, beginning in 2023 seniors will be eligible to receive certain vaccines free.

Apart from the Inflation Reduction Act, the House also approved legislation to extend further Medicare telehealth flexibilities first instituted in response to the COVID-19 pandemic. H.R. 4040, the Advancing Telehealth Beyond COVID-19 Act of 2022 was passed on July 27, 2022. This bill modifies the extension of certain Medicare telehealth flexibilities after the end of the COVID-19 public health emergency. It provides that certain flexibilities continue to apply until December 31, 2024, if the emergency period ends before that date. More specifically, this legislation allows:

• Beneficiaries to continue to receive telehealth services at any site, regardless of type or location (e.g., the beneficiary's home).

• Occupational therapists, physical therapists, speech-language pathologists, and audiologists to continue to furnish telehealth services.

• Federally qualified health centers and rural health clinics to continue to serve as the distant site (i.e., the location of the health care practitioner).

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Stress And The Acceleration Of Immune Aging

Stress in the form of traumatic events, job strain, everyday stressors, and discrimination can accelerate aging of the immune system, potentially increasing an individual’s risk of cancer, cardiovascular disease, and illness from infections such as COVID-19. As reported on June 13, 2022 in the Proceedings of the National Academy of Sciences of the USA, a study by researchers at the University of Southern California indicates that exposure to stress is a risk factor for poor health and accelerated aging. Immune aging plays a role in immune health and tissue specific aging, and may contribute to elevated risk for poor health among individuals who experience high psychosocial stress. Individuals with higher stress scores had older-seeming immune profiles, with lower percentages of fresh disease fighters and higher percentages of worn-out white blood cells. The association between stressful life events and fewer ready to respond, or naive, T cells remained strong even after controlling for education, smoking, drinking, BMI and race or ethnicity.

Disparities In Activity And Traffic Fatalities By Race/Ethnicity

Traffic fatalities remain a major public health challenge, A study reported on June 7, 2022 in the American Journal of Preventive Medicine develops exposure-based estimates of fatalities per mile traveled for pedestrians, cyclists, and light-duty vehicle occupants and describes disparities by race/ethnicity, including a sub-analysis of fatality rates during darkness and in urban areas. Exposure to traffic fatality differs by race/ethnicity group and by mode, indicating that adjustment for differential exposure is needed when estimating disparities. Investigators found that fatality rates per 100 million miles traveled are systematically higher for Black and Hispanic Americans for all modes and notably higher for vulnerable modes (e.g., Black Americans died at more than four times the rate for White Americans while cycling, 33.71 [95% CI: 21.84, 73.83] compared with 7.53 [95% CI: 6.64, 8.69], and more than twice the rate while walking, 40.92 [95% CI: 36.58, 46.44] compared with 18.77 [95% CI: 17.30, 20.51]).

HEALTH TECHNOLOGY CORNER

E-Nose Sniffs Out Mixtures Of Volatile Organic Compounds (VOCs)

Clean air and the detection of pollution are of utmost importance for human health. As paint thinner, ink, and adhesives dry, they can release volatile organic compounds (VOCs), which can have a negative impact on health. A typical common air pollutant among these VOCs is xylene, an important chemical feedstock finding widespread use not only in the large-scale synthesis of various polymers, such as polyethylene terephthalate (PET) and parylene, but also in the rubber and leather industries. It exists as three isomers with the same elements, but slightly different arrangements. Because the isomers are so similar, they are difficult to monitor separately. The detection and discrimination of these isomers are quite important for environmental monitoring and medical care. As reported in an article published on June 8, 2022 in the journal ACS Sensors, researchers have developed an electric nose (“e-nose”) with porous metal-organic framework (MOF) films that can distinguish xylene isomer mixtures accurately.

Identification Of A Brain Circuit For Addiction Remission

Drug addiction is a public health crisis for which new treatments are needed urgently. In rare cases, regional brain damage can lead to addiction remission. These cases may be used to identify therapeutic targets for neuromodulation. Substance use disorders in the U.S. are a leading cause of death among young individuals. Treatments such as deep brain stimulation hold promise for helping them overcome addiction, but questions remain about what brain areas should be targeted. Researchers are gaining new insights from patients who are no longer addicted to nicotine after experiencing a brain lesion, such as a stroke. Using a new technique known as lesion network mapping, researchers at Brigham and Women’s Hospital in Boston, MA have mapped addiction remission to entire brain circuits rather than specific brain regions, pointing to new targets for treatment. The results are published on June 13, 2022 in the journal Nature Medicine. A goal is to take larger steps towards improving existing therapies for addiction and open the door for remission.

HEALTH REFORM DEVELOPMENTS

An aspect of the troika known as health care access, cost, and quality that does not often receive the attention it warrants is scope of practice laws in the states. Substantial amounts of time and money are spent throughout the U.S. by members of certain professions to enhance their scope of practice. Their efforts are opposed by members of other professions who devote similar amounts of energy to preventing these groups from succeeding. The main rationale for this staunch resistance is to protect the safety of patients. Nonetheless, once additional states loosen restrictions and allow other professions to expand their scope of practice, eventually hundred of thousands of patients will have been treated by the newcomers. If the outcome is that none or a neglible amount of them were endangered in any way, then an argument that the public is at a serious risk of injury as a result of changing practice laws begins to lose some of its power to persuade legislators.

For example, Colorado Governor Jared Polis on June 7, 2022 signed into law HB 22-1233, making that state the 10th one to allow optometrists to perform laser procedures. The legislation, which goes into effect on August 10 of this year, also will allow the practice of optometry to include several interventions that include eyelid injections and use of local anesthetic. Despite opposition from the American Academy of Pediatrics, Colorado Medical Society, Colorado Society of Eye Physicians & Surgeons, and the American Society of Plastic Surgeons, the optometrists were successful in convincing legislators that experience in nine other states has shown that patient safety concerns should not be a factor in preventing optometrists from enhancing their scope of practice. Moreover, since care by ophthalmologists is not readily available throughout the state, access by patients to vision care will be improved. Similarly, other professions that engage in efforts to enhance their scope of practice on the basis of being able to provide safe care and address the problem of underserved areas include: nurse practitioners v. physicians; dental hygienists/therapists v. dentists; psychologists v. psychiatrists; and nurse anesthetists v. anesthesiologists.

Medicare Prospective Payment Systems And Proposed Policy Changes

Medicare is a highly important federal health program that is instrumental in meeting the needs of millions of beneficiaries. As it continues to increase in size over the decades, it also undergoes constant change. A recent example of how modifications tend to occur can be found in the May 10, 2022 issue of the Federal Register, the official journal of the federal government of the U.S. This particular edition contains a proposed rule that would affect several different functions, including the Hospital Inpatient Quality Reporting (IQR) Program and Hospital-Acquired Condition (HAC) Reduction Program. Detailed in small print at three columns per page, the proposed rule covers 639 pages and is drenched in a torrent of acronyms, e.g., Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Interested parties were invited to comment on the proposed rule and the deadline for doing so was no later than 5 p.m. EDT on June 17, 2022. Hundreds of respondents have expressed their views.

Examples of some concerns are that if the rule is implemented, the Centers for Medicare & Medicaid Services (CMS) will be able to suppress hospital data and measures of preventable hospital-cause harm, such as falls resulting in serious injuries. A related issue is that the 10-measure Patient Safety and Adverse Events Composite (PSI 90) would be hidden from public data files and would not appear on the CMS Hospital Compare website. Also, worst-performing hospitals no longer would be subject to a reduction in Medicare reimbursement. An overall concern is that the ability to identify providers with patient safety problems will be compromised seriously.

Public’s Confidence In Federal Government Employees

As exemplified by a recent proposed Medicare rule on May 10, 2022 that required 639 pages of triple-columned pages to describe, at some juncture program staff will have to synthesize all the public comments that arrive and decide the extent to which these views will affect the contents of that rule. Clearly, federal agencies have a significant impact on the lives of U.S. inhabitants. Meanwhile, according to a report on June 6 of this year from the Pew Research Center, the share of Americans who have a great deal or fair amount of confidence in career employees at federal agencies has declined among Democrats and Republicans since 2018. A decline in appreciation for the work these employees do probably will not act as a major disincentive to finding some joy in carrying out their daily tasks.

APPROPRIATIONS PROCESS IS UNDERWAY

The major federal legislative task of crafting a series of spending bills that can be enacted into law has begun. Similar to previous years, the prospect of completing work by the end of the present fiscal year on September 30 does not appear to be especially promising. A more likely outcome is that a continuing resolution (CR) will be necessary to fund the federal government beyond the end of the fiscal year this coming September 30. Given that 2022 involves conducting a national election, all House members and one-third of Senate members will be campaigning with a hope of staying in office. The result could be that reaching agreement on the 12 annual spending bills will have to be postponed until a lame-duck session after the November elections.

No budget is in place this year because a budget resolution that sets overall limits in spending has not been adopted. That step should have been completed in April. Instead, a shortcut budget in the form of a deeming resolution was produced recently in the House of Representatives that provides for a spending cap of $1.6 trillion to be enforced when bills reach the House floor. That amount is enough to begin work on the one dozen separate pieces of legislation. The House Appropriations Committee then can use this overall number, known as a “302(a)” after its section in the 1974 budget law to divide it into a dozen “302(b)” subcommittee allocations. Apart from disagreements over defense and non-defense spending amounts, controversy also can be anticipated regarding how much the spending bills will contribute to increasing the federal budget deficit.

Typical battles occur annually regarding efforts to achieve parity between defense and non-defense expenditures, which led to many lengthy delays in finalizing legislation for the current fiscal year. The result was that comparable increases were provided in both the defense and non-defense accounts. It usually proves to be quite difficult to resolve such differences.

The House Appropriations Committee has updated its markup schedule with an aim of acting on each of the 12 spending bills before the end of June 2022. A plan is to bring plans to the House floor in July. Senate appropriators seem less inclined to proceed on a similar timetable. Members of that chamber can be expected to focus on total defense versus non-defense spending levels, with Republicans advocating for an increase in defense spending that exceeds the rate of inflation. Now that inflation is at its highest peak in several decades, it should prove highly challenging to reach an agreement on a spending package that aligns with that elevated level.

ASAHP belongs to the Health Professions and Nursing Education Coalition (HPNEC), which submitted outside witness testimony on May 26, 2022 to reiterate fiscal year 2023 funding priorities to the House Labor, Health and Human Services, Education, and Related Agencies (Labor-HHS) Appropriations Subcommittee. The Coalition advocates adequate and continued support for authorized health professions and nursing workforce development programs. The subcommittee is encouraged to adopt at least $1.51 billion for Titles VII and VIII programs of the Health Resources & Services Administration (HRSA).

REIFICATION OF A HEALTH BEDROCK

Demography is a useful tool for projecting social challenges that must be addressed in the future. Whether through steady increases in the number of births that occur in the U.S. or through immigration, this country’s population will continue to grow. Perhaps more importantly, both numerically and proportionately, increased growth will occur among individuals ages 65 and older. This cohort also will be distinguished by the disproportionate existence of various chronic co-morbidities that will strain the nation’s ability to address health and health-related social needs pertaining to problems, such as dementia. Three major sectors in the health sphere can play important roles in undertaking improvements in the years that lie ahead.

Higher Education Institutions in the health professions must continue to place an emphasis on ensuring that education programs will enable students to work cooperatively and effectively in team-based care with members of other professions. These schools play a fundamental role in the production of adequate numbers of graduates to serve as faculty, researchers, and clinicians. The latter group should be equipped with the ability to furnish high quality care to a broad spectrum of patients with dementia that differ according to key factors, including age, gender, race/ethnicity, culture, health literacy, and digital competency. A necessary set of skills will involve the provision of person-centered care that includes taking into account patient preferences, their life history, and opportunities to advise them about ways of achieving dementia risk reduction.

Clinical Settings will entail service delivery by health care providers working in conjunction with informal caregivers in the home environment. Both as part of their formal educational preparation and in providing patient care, a necessary skill will be an ability to offer education for the informal group to become competent in providing care to in-home patients. These individuals should be able to support medication management within the home setting, especially since improper pharmaceutical use is associated with an increase in fall risks among individuals living with dementia. Caring for this kind of patient is distinctive insofar as they may experience progressive declines in physical, cognitive, and emotional functioning. Because some caregivers themselves are in advanced age brackets, they may be at risk of stress-related declines in physical and mental health status.

Policymakers work in government programs, such as Medicare and Medicaid, and health insurance companies in the private sector. Recognizing the burdens placed on informal caregivers in the home setting, there needs to be increased opportunities for these individuals to benefit from respite services. The WHO in 2019 published its first evidence-based guideline on dementia risk reduction, which currently must be implemented into policy and practice. Direct and indirect costs of dementia will continue to soar unless changes are made in the way care is delivered. A greater understanding is needed of how cognitive impairment affects care delivery costs in the context of the Medicare home health benefit. Health insurance coverage options are complicated and confusing. Additional efforts are required to make this information more understandable for all concerned parties.

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Muscle-Building Exercise, Weapon Carrying, And Physical Fighting

Since the COVID pandemic began, gun violence and school violence have been on the rise while there has been an emphasis on muscularity as today’s body ideal for many boys. A new study published on May 12, 2022 in the Journal of Interpersonal Violence has revealed a link between the two. Cross-sectional data from the 2019 Youth Risk Behavior Survey (U.S.) were analyzed (N = 4120). Three forms of weapon carrying (general, on school grounds, gun carrying) and two forms of physical fighting (general, on school grounds) were assessed. Over 75% of participants reported engaging in muscle-building exercise. One in five (19.8%) participants reported any general weapon carrying in the past 30 days, 3.3% reported any weapon carrying at school in the past 30 days, 6.5% reported any gun carrying in the past 12 months, 28% reported any general physical fighting in the past 12 months, and 10.7% reported any physical fighting at school in the past 12 months.

Evaluation Of Age Patterns Of COVID-19 Mortality By Race And Ethnicity In The U.S.

As reported on May 17, 2022 in JAMA Network Open, reductions in COVID-19 mortality among older populations are remarkable. From March 2020 to October 2021, declines in death rates for the various racial and ethnic and sex combinations were especially large among those aged 80 to 84 years and those 85 years or older. Despite the availability of effective vaccines, COVID-19 mortality rose among younger adults. Possible factors underpinning these changing patterns are higher vaccination prevalence and less exposure to infection among older individuals. This advantage may have increased over time as younger individuals returned to work and other activities and the Delta variant emerged. Limitations included the use of provisional mortality data and the exclusion of other racial and ethnic groups owing to data quality issues. The rise in mortality rates among young adults underscores the value of increasing the lagging vaccination rate in this population.

HEALTH TECHNOLOGY CORNER

Machine Learning-Based In-Hospital COVID-19 Disease Outcome Predictor (CODOP)

Scientists have developed and validated CODOP, an algorithm to help identify who is most at risk of dying from COVID-19 when admitted to a hospital, according to a report of a study published on May 17, 2022 in eLife. This machine learning-based tool was trained, tested, and validated with six cohorts encompassing 29,223 COVID patients from more than 150 hospitals in Spain, the USA, and Latin America during 2020-22. CODOP uses 12 clinical parameters commonly measured at hospital admission for reaching high discriminative ability up to nine days before clinical resolution, it is well calibrated, and it enables an effective dynamic risk stratification during hospitalization. Furthermore, CODOP maintains its predictive ability independently of the virus variant and the vaccination status. The performance of this tool in heterogeneous and geographically disperse patient cohorts and the easiness of use strongly suggest its clinical utility, particularly in resource-limited countries.

Scent Dogs Detect Coronavirus Reliably From Skin Swabs

Results of a study published in May 2022 in BMJ Global Health involve estimating scent dogs’ diagnostic accuracy in identification of individuals infected with SARS-CoV-2 in comparison with reverse transcriptase polymerase chain reaction (RT-PCR). Researchers conducted a randomised triple-blinded validation trial, and a real-life study at the Helsinki-Vantaa International Airport, Finland. This controlled investigation comprised four identical sets of 420 parallel samples (from 114 individuals tested positive and 306 negative by RT-PCR), randomly presented to each dog over seven trial sessions. The validation experiments had an overall accuracy of 92% (95% CI 90% to 93%), a sensitivity of 92% (95% CI 89% to 94%) and a specificity of 91% (95% CI 89% to 93%) compared with RT-PCR. One finding highlights the importance of continuous retraining as new variants emerge. Using scent dogs may present a valuable approach for rapid screening of large numbers of individuals.

HEALTH REFORM DEVELOPMENTS

Individual health status can be enhanced by having adequate insurance coverage and ready availability of health care services. A new report from the National Center for Health Statistics (NCHS) presents coverage estimates of health for the civilian noninstitutionalized U.S. population based on data from the 2021 National Health Interview Survey (NHIS). These estimates are being published before final editing and final weighting so that access to the most recent information can be provided. Estimates are disaggregated by age group, sex, family income (as a percentage of the federal poverty level [FPL]), race and ethnicity, and state Medicaid expansion status. With three years of comparable data available starting with the redesigned NHIS in 2019, this report is able to provide data on trends, similar to reports using 2018 and earlier data. Estimates of health insurance coverage based on data from 2021 are provided, along with selected trends from 2019–2021.

In 2021, 30.0 million individuals of all ages (9.2%) were uninsured at the time of interview. This amount was lower than, but not significantly different from 2020, when 31.6 million persons of all ages (9.7%) were uninsured. In 2021, among adults aged 18–64, 13.5% were uninsured at the time of interview, 21.7% had public coverage, and 66.6% had private health insurance coverage. Among children aged 0–17 years, 4.1% were uninsured, 44.3% had public coverage, and 53.8% had private health insurance coverage. Among non-Hispanic White adults aged 18–64, the percentage who were uninsured decreased from 10.5% in 2019 to 8.7% in 2021. The percentage of individuals under age 65 with exchange-based coverage increased from 3.7% in 2019 to 4.3% in 2021.

Adverse Events In Hospitals

A separate item in this issue of the newsletter discusses the topic of health care quality. A Report in Brief that became available in May 2022 from the Office of Inspector General of the U.S. Department of Health and Human Services (HHS) indicates that 25% of Medicare patients experienced patient harm during their hospital stays in October 2018. Patient harm includes adverse events and temporary harm events. Among that group of patients, 12% experienced adverse events, which are events that led to longer hospital stays, permanent harm, life-saving intervention, or death. Also, 13% of patients experienced temporary harm events, which required intervention, but did not cause lasting harm, prolong hospital stays, or require life-sustaining measures. Temporary harm events sometimes were serious and could have caused further harm if providers had not treated patients promptly.

The most common type of harm event was related to medication (43%), such as patients experiencing delirium or other changes in mental status. The remaining events related to patient care (23%), such as pressure injuries; to procedures and surgeries (22%), such as intraoperative hypotension; and to infections (11%), such as hospital-acquired respiratory infections. Physician-reviewers determined that 43% of harm events were preventable, with preventable events commonly linked to substandard or inadequate care provided to the patient. Reviewers determined that 56% of harm events were not preventable and occurred even though providers followed proper procedures. Events were determined not preventable for several reasons, including that the patients were found to be highly susceptible to the events because of their poor health status.

Prices Paid To Hospitals By Private Health Plans

Findings from a new report by the RAND Corporation show that in 2020, across all hospital inpatient and outpatient services (including both facility and related professional charges), employers and private insurers paid 224% of what Medicare would have paid for the same services at the same facilities. That percentage is a reduction from the 247% figure reported for 2018 in the previous study owing to an increase in the volume of claims from states with prices below the previous mean price. Prices for common outpatient services performed in ambulatory surgery centers (ASCs) averaged 162% of Medicare payments, but if paid using Medicare, payment rates for hospital outpatient departments (HOPDs) would have averaged 117%. Although relative prices are lower for ASC claims priced according to HOPD rules, HOPD prices are higher than ASC prices. Little variation in prices is explained by each hospital’s share of patients covered by Medicare or Medicaid. A larger portion of price variation is explained by hospital market power. Prices for COVID-19 hospitalization were similar to prices for overall inpatient admissions and averaged 241% of Medicare.

FEDERAL REGULATION AND MORTALITY IN THE 50 STATES

As long as U.S. mortality rates continue to be an object of interest, it is worth considering the extent to which activities of the federal government have the potential to influence such rates. Congress regularly passes laws pertaining to health care that are enacted, while federal agencies have the responsibility of specifying in detailed language exactly how such laws should be implemented. An excellent source for discovering what unfolds in the sphere of regulations is the Federal Register, the official journal of the federal government. Published every weekday, except on federal holidays, it contains government agency rules, proposed rules, and public notices. Previous research speculates that some regulations are counterproductive in the sense that they increase (rather than decrease) mortality risk, but few empirical studies have measured the extent to which this phenomenon holds across the regulatory system as a whole. A study described in the March 2022 issue of the journal Risk Analysis was intended to estimate the effect of U.S. federal regulation on state-level mortality.

Investigators found that a 1% increase in federal regulation of state economies is associated with an increase in an index of state mortality of between 0.53% and 1.35%. The findings are robust to the form of mortality measure, choice of covariates, and the inclusion/exclusion of various regions, states, and industries. They also provided an update of the “cost-per-life saved cutoff,” which is the counterproductive risk threshold for expenditures. Financial outlays in excess of $38.6 million (2019 dollars) per life saved can be expected to increase mortality risk. Examples are provided of how unintended consequences of regulations can increase mortality in some cases. Fuel efficiency regulations have resulted in some automakers producing smaller cars, which can be more dangerous in an accident. The increased cost of flying as a result of Department of Homeland Security regulations may have induced individuals to drive instead, thereby increasing traffic accidents. Also, if individual expenditures on health are at all effective at reducing mortality risk and if regulatory costs are sizeable, it follows that regulatory costs induce some deaths. By extension, even regulations with a primary aim of reducing mortality can have the opposite effect if costs are excessive relative to benefits.

SPECIES OF ARTIFICIAL INTELLIGENCE (AI)

Charles Darwin in 1859 set the stage for the emergence of artificial intelligence (AI) when stating in the final sentence of his book Origin of Species, “from so simple a beginning endless forms most beautiful and most wonderful have been, and are being, evolved.” According to an article with the title, “From So Simple a Beginning:” Species of Artificial Intelligence that was published in the Spring 2022 issue of the journal Daedalus, artificial intelligence has a decades-long history exhibiting alternating enthusiasm and disillusionment for the field’s scientific insights, technical accomplishments, and socioeconomic impact. Recent achievements involve renewed claims for the transformative and disruptive effects of AI. Exponential increases in computing power, open-source software, available data, and embedded services have been crucial to this success. Yet, there is growing unease around whether the behavior of these systems can be rendered transparent, explainable, unbiased, and accountable. The author argues that artificial general intelligence (AGI)—able to range across widely differing tasks and contexts—is unlikely to be developed, or emerge, any time soon.

From driving cars to controlling critical infrastructure, from diagnosing illnesses to recommending content for entertainment, AI is ubiquitous. When in 2011 IBM announced a new age of cognitive computing with Watson, it was asked, why not turn Watson into a physician, but task transfer and generalization have turned out to be quite difficult. A physician’s general problem-solving is full of task and context changes. Rather than replicating accomplished physicians, IBM’s Watson Health has turned out AI assistants that can perform routine tasks. Recent possession of symbolic language and discovery of mathematics and formal systems of computation have provided tools to build and explore new AI systems, a broad repertoire of approaches and methods that remains essential. AI systems with their ability to represent and discover patterns in high dimensional data have as yet low dimensional embedding in the physical and digital worlds they inhabit. This thin tissue of grounding, of being in the world, represents the single largest challenge to realizing AGI, systems able to range across widely differing tasks and contexts reflectively.

AESCHYLUS AND HEALTH CARE QUALITY

An essay on the topic of death by Michel de Montaigne serves as a reminder about the manner in which the famous ancient Greek playwright Aeschylus met his fateful demise. Warned in a prophesy that he would die after being struck by a falling object, he took to the great outdoors to reduce the likelihood of such an outcome. While he was sitting by the sea, an eagle soaring aloft that had just captured a tortoise committed the error of mistaking the tragedian’s shiny bald pate for a rock. In order to crack the shell of its quarry, the bird unfortunately dropped it on the playwright’s head.

Similarly, health care is a sphere where many examples can be found of actions resulting in outcomes that differ from what originally was anticipated. Long-term efforts to achieve health reform have focused on access, cost, and quality. Three articles published in the April 29, May 5, and May 12, 2022 issues of the New England Journal of Medicine represent a scorecard for assessing how successful various initiatives have been in enhancing health care quality.

A premise is that to improve quality, the system must be fixed. As attractive as that notion may appear, the author indicates that some 30 years later, the fix itself is a massive system. As reimbursement models shift toward value-based payment, quality improvement (QI) no longer is just about being better, but also about documenting improvement to maximize payment. An entire industry has arisen to support the optimization and demonstration of performance. For example, CMS’s Merit-Based Incentive Payment System (MIPS) for ambulatory care settings found that clinicians and administrators invested about 200 hours per year to meet each physician’s MIPS requirements. That these hours could be spent in countless other ways, especially caring for patients, raises an obvious question: Is the system created to fix the system even working? Moreover, despite innumerable metrics and vast research assessing their worth, it still is not clear that what matters is being measured nor whether the tools to do so exist.

Another example involves CMS’s Hospital Readmissions Reduction Program (HRRP). In 2019, hospitals caring for a high percentage of Black patients were disproportionately likely to incur financial penalties. Hospitals serving the highest-risk patients incurred the largest penalties under the HRRP, independent of quality of care. Ironically, billions of dollars thus are being transferred from poorly resourced hospitals or those serving the sickest patients to well-resourced facilities, thereby worsening the disparities policymakers claim to be trying to fix.

Furthermore, a perception that practice variation signals quality deficiencies remains foundational to the pursuit of “high value” care. If value is defined as quality divided by cost, then measuring value faces all the same problems as measuring quality—flawed risk adjustment, metric gaming, and omission of the many aspects of quality that defy measurement. A good question is why continue to embrace these flawed constructs, particularly when it is not clear that the current regulatory approach effectively serves patients or clinicians?

MENTAL HEALTH FOCAL POINT

Glaring problems, such as an unacceptably high mortality rate stemming from drug overdoses, growing evidence of increased suicide ideation among some U.S. population subgroups, along with increases in gun violence and eating disorders have stimulated a bipartisan effort on Capitol Hill to have mental health legislation passed that addresses such problems effectively. For example, the rate of overdose deaths among U.S. teenagers nearly doubled in 2020, the first year of the COVID pandemic, and rose another 20% in the first half of 2021 compared with the 10 years before the pandemic, even as drug use remained generally stable during the same period. It is the first time in recorded history that the teen drug death rate has seen an exponential rise, according to new UCLA research that was published in April 2022 in the Journal of American Medical Association, even though rates of illicit drug use among teens are at all-time lows. The month of May 2022 featured the introduction of H.R. 7666, the Restoring Hope for Mental Health and Well-Being Act of 2022. The bill went from the Subcommittee on Health of the Committee on Energy and Commerce to the full committee on a vote of 32-0 and was passed as amended on a vote of 55-0 on May 18, 2022. This comprehensive legislative approach includes provisions to: • Have the Secretary of the Department of Health and Human Services (HHS) establish an office to coordinate work relating to behavioral health crisis care across the operating divisions and agencies of the Department, including the Substance Abuse and Mental Health Services Administration, the Centers for Medicare & Medicaid Services, and the Health Resources and Services Administration • Establish a behavioral health crisis coordinating office within the Substance Abuse and Mental Health Services Administration (SAMHSA) • Reauthorize the Garrett Lee Smith Memorial Act Suicide Prevention Program; the Maternal Mental Health Screening and Treatment Grant Program; grants to support American Indian and Alaska Native communities with mental health and substance use disorder prevention, treatment, and recovery services; and the Behavioral Health Workforce Education and Training Program • Require self-funded, non-federal governmental plans to comply with mental health parity laws In the Senate, a bipartisan effort also is underway to reauthorize a bill focusing on mental health care. Initially, the Mental Health Reform Act of 2015 was incorporated into the 21st Century Cures Act, which passed Congress in 2016. That 2016 law, P.L. 114-255, needs to be updated. An aim is to report out a comprehensive reauthorization bill in this session of Congress that establishes an Office of the Assistant Secretary for Mental Health; improves children’s access to mental health care by providing grants to integrate behavioral health care into primary care offices; promotes coordination of mental health benefits, increases recruitment of a diverse mental health workforce by expanding SAMHSA’s Minority Fellowship Program; and promotes access to mental health services by authorizing $25 million to support states' ability to enforce existing mental health parity laws.

AESCHYLUS AND HEALTH CARE QUALITY

An essay on the topic of death by Michel de Montaigne serves as a reminder about the manner in which the famous ancient Greek playwright Aeschylus met his fateful demise. Warned in a prophesy that he would die after being struck by a falling object, he took to the great outdoors to reduce the likelihood of such an outcome. While he was sitting by the sea, an eagle soaring aloft that had just captured a tortoise committed the error of mistaking the tragedian’s shiny bald pate for a rock. In order to crack the shell of its quarry, the bird unfortunately dropped it on the playwright’s head.

Similarly, health care is a sphere where many examples can be found of actions resulting in outcomes that differ from what originally was anticipated. Long-term efforts to achieve health reform have focused on access, cost, and quality. Three articles published in the April 29, May 5, and May 12, 2022 issues of the New England Journal of Medicine represent a scorecard for assessing how successful various initiatives have been in enhancing health care quality.

A premise is that to improve quality, the system must be fixed. As attractive as that notion may appear, the author indicates that some 30 years later, the fix itself is a massive system. As reimbursement models shift toward value-based payment, quality improvement (QI) no longer is just about being better, but also about documenting improvement to maximize payment. An entire industry has arisen to support the optimization and demonstration of performance. For example, CMS’s Merit-Based Incentive Payment System (MIPS) for ambulatory care settings found that clinicians and administrators invested about 200 hours per year to meet each physician’s MIPS requirements. That these hours could be spent in countless other ways, especially caring for patients, raises an obvious question: Is the system created to fix the system even working? Moreover, despite innumerable metrics and vast research assessing their worth, it still is not clear that what matters is being measured nor whether the tools to do so exist.
Another example involves CMS’s Hospital Readmissions Reduction Program (HRRP). In 2019, hospitals caring for a high percentage of Black patients were disproportionately likely to incur financial penalties. Hospitals serving the highest risk patients incurred the largest penalties under the HRRP, independent of quality of care. Ironically, billions of dollars thus are being transferred from poorly resourced hospitals or those serving the sickest patients to well-resourced facilities, thereby worsening the disparities policymakers claim to be trying to fix.

Furthermore, a perception that practice variation signals quality deficiencies remains foundational to the pursuit of “high value” care. If value is defined as quality divided by cost, then measuring value faces all the same problems as measuring quality—flawed risk adjustment, metric gaming, and omission of the many aspects of quality that defy measurement. A good question is why continue to embrace these flawed constructs, particularly when it is not clear that the current regulatory approach effectively serves patients or clinicians?