John Colbert

October 29, 2018

HEALTH REFORM DEVELOPMENTS

John Colbert

October 29, 2018

REFLECTIONS ON AN EXPERIMENT IN DEMOCRACY of the newsletter refers to the federal election in November 2018 that will determine the composition of both the House and the Senate, beginning in 2019. As in previous contests that have been conducted since 2010, the Patient Protection and Affordable Care Act (ACA) of 2010 has the potential to influence the outcome. Not a single Republican in either chamber voted in favor of the ACA when it became law. Many candidates of that political party also chose to focus on its negative aspects when vying for office in the elections of 2012, 2014, and 2016. From the time of its inception, multiple attempts also have been made in Congress to repeal and replace this legislation.

Upon assuming the majority in both chambers and taking control of the White House after the 2016 election, Republicans appeared to be in a strong position to achieve their objective of eliminating this law. They came close to doing so in 2017, but the ACA remains in effect and many Democrats are using that fact as a basis for attacking Republicans in the upcoming November 2018 election. A key feature of the ACA is that it eliminated the ability of insurance companies to prohibit patients with preexisting conditions either from obtaining coverage or by requiring them to pay exorbitantly priced premiums for such protection. The Democrat’s message in the present election cycle is: Republicans intend to return to the days when insurers possessed such power and Democrats pledge to prevent them from doing so.

Employers’ Reimbursement Arrangements To Provide Health Coverage For Employees
Meanwhile, the Departments of Labor, Health and Human Services, and the Treasury proposed new rules in the October 29, 2018 issue of the Federal Register pertaining to how employers may use health reimbursement arrangements (HRAs) to provide health coverage to employees. The rule would expand the uses of HRAs to include payment of premiums for individual market coverage in some instances. The Departments estimate that the proposed changes would have an impact on coverage for approximately 10.7 million individuals, decrease the number of uninsured by 800,000, and cost the federal government approximately $30 billion in lost tax revenue from 2020-2028. The proposed rule was issued in compliance with an October 2017 Executive Order on “Promoting Healthcare Choice and Competition Across the United States,” suggesting that these changes would help make coverage more affordable for small to mid-sized employers and provide employees with more coverage options. Public Comments can be submitted for 60 days after publication of the rule.

Access To Health Care For Low-Income Adults With & Without Medicaid Expanded Eligibility
Low-income adults in states that expanded Medicaid under the Affordable Care Act were less likely to report having any unmet medical needs compared with those in non-Medicaid expansion states, according to a Government Accountability Office (GAO) report released on October 15, 2018. Among other findings:

About 26 percent of low-income adults in Medicaid expansion states reported having unmet medical needs compared to 40 percent in non-expansion states.
About 9.4 percent of low-income individuals in Medicaid expansion states said that they passed up needed medical care in the past 12 months because they couldn't afford it compared to 20 percent in non-expansion states.
About 82 percent of low-income adults had a usual place of care in Medicaid expansion states compared to 68 percent in non-expansion states.

Health and Workplace Benefits Survey (WBS) Results
The EBRI/Greenwald & Associates Health and Workplace Benefits Survey (WBS) of 1,025 workers in the United States ages 21–64 was conducted in June 2018. Among its main findings: (1) Workers rank health care as the most critical issue in the nation, (2) One-half of workers describe the health care system as poor (22 percent) or fair (28 percent), (3) Confidence about the health care system is mixed and declines looking into the future, and (4) Thirty-four percent of workers say they are confident that they are able to afford health care without financial hardship today, but this percentage decreases to just 30 percent when they consider the next 10 years.

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MICROBIOME’S OMNIPRESENT UNSEEN GUESTS

John Colbert

October 29, 2018

Trends Archives

Much of health care is delivered at the level of treating acknowledged symptoms, but it is what exists at less visible layers, such as the human microbiome housing several trillion microbial cells, that can be of critical importance. Patients and their caregivers in the clinical setting engage in transactions in which one group arrives with a concatenation of symptoms while the other group is confronted with the task of interpreting these signs correctly in order to develop an effective treatment plan.

An example of the value of comprehending and appreciating layers of increasing complexity is afforded by a painting completed by Salvador Dali in 1956 called Nature Morte Vivante, which in English translates into “Living Still Life.” Influenced by Nobel Laureate physicist Werner Heisenberg’s work in quantum mechanics, the title is a play on words characterized by the basic notion of something being perfectly still, yet continuing to be in motion simultaneously. The seeming paradox is explained by the fact that although an object may not appear to be moving, it is composed of millions of atoms that are in rapid motion.

A closer look at the canvas reveals other features that may not appear to be obvious upon cursory examination. Mathematics did not escape Dali’s attention as evidenced by his employment of the Fibonacci sequence, a generator of spiral images that appear throughout the painting. He associated the spiral with a key element of nature and became even more intrigued by it when he learned of the masterpiece 852-word article, highly unusual for its brevity, by James Watson and Francis Crick that was published in the April 25, 1953 issue of the journal Nature. These researchers suggested a spiral structure (a helix) for the salt of deoxyribose nucleic acid (DNA), one “with novel features of considerable biological interest.”

This helix would revolutionize genetics. Essentially no recognition was given, however, of the work of chemist Rosalind Franklin, whose x-ray diffraction studies in crystallography provided the imagery that inspired Watson and Crick. Assuming that Dali was unaware of her contribution, it is likely that he would have been fascinated to learn about this hidden layer of meaning that subsequently accrued to the enormous advantage of her newly more world famous colleagues.

Allied health clinicians and their patients often interact on the basis of seeking and providing relief from symptoms involving aches, pain, discomfort, and physical immobility. Additional layers that lack such clarity are semiotics (non-language features reflecting patient and caregiver differences based on age, sex, gender, race/ethnicity, and health literacy), genomics, proteomics, metabolomics, and the microbiome. The latter unseen guests continue to attract a significant amount of attention as demonstrated by the following examples of papers in the professional literature: Disruption of maternal gut microbiota during gestation alters offspring microbiota and immunity (Microbiome, July 2018), The gut microbiota and dysbiosis in autism spectrum disorders (Current Neurology and Neuroscience Reports, November 2018), and Researchers link gut bacteria to heart transplant success or failure (Journal of Clinical Investigation Insight, October 4, 2018).

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DEVELOPMENTS IN HIGHER EDUCATION

John Colbert

September 25, 2018

Trends Archives

Passage of legislation by Congress and enactment into law when signed by the President of the United States are events that attract considerable attention in the media. Equally important in the life of any legislation is what eventually occurs in the regulatory arena. On August 14 of this year, the Secretary of the Department of Education proposed to rescind the gainful employment (GE) regulations, which added to the Student Assistance General Provisions requirements for programs that prepare students for gainful employment in a recognized occupation. The Department plans to update the College Scorecard, or a similar web-based tool, to provide program-level outcomes for all higher education programs at all institutions that participate in the programs authorized by Title IV of the Higher Education Act of 1965, which would improve transparency and inform student enrollment decisions through a market-based accountability system. A key step in the process is to invite comments about such proposals.

Several associations representing college leaders, educators, and professionals responded on September 13, 2018. They advised the Department to revise rather than eliminate the existing rule. A concern is that rescinding the existing rule prior to developing additional alternatives would leave a meaningful gap between oversight of gainful employment programs and the period when additional information could influence prospective students’ decisions. By rescinding the regulations entirely, the Department will forego an opportunity to strengthen and improve them and abandon a meaningful oversight tool. The result, according to the Department’s own estimates, would be $4.5 billion in Pell Grant funding going to programs that otherwise would not be eligible under existing regulations. Considering the importance of Pell Grants and the difficulties involved in providing sufficient funding to meet student needs, it is viewed as troubling that the Department is considering a move that would significantly increase the cost of Pell Grants by directing those additional funds to programs that demonstrate poor returns for students.

Negotiated Rulemaking To Revise Regulations Involving Accreditation
The Department of Education on July 31, 2018 published a notice in the Federal Register announcing its intention to convene a negotiated rulemaking committee to revise regulations regarding accreditation and the recognition of accrediting organizations. The goal is to reduce current compliance requirements, concentrating accreditors’ efforts on educational quality and strengthening commitment to innovation. In preparation, the Department of Education held the first of three public hearings on September 6, 2018. At the hearing, which was held in Washington, DC, testimony was provided by representatives of think tanks, consumer advocacy groups, college presidents, and several accreditation representatives. Comments made on that occasion indicated that: (1) the agenda for the negotiated rulemaking is too large for one committee; (2) the Department needs to strengthen regulations, not reduce them; (3) competency-based education in the context of regular and substantive interaction should be addressed; and (4) institutional mission needs to be protected.

Federal Funding Support For Higher Education In Fiscal Year 2019
Fiscal Year 2019 begins on October 1, 2018. A budget proposal for the new fiscal year released last February signaled an intention by the Trump Administration to consolidate multiple income-contingent repayment plans for student borrowers into a single plan, eliminate Public Service Loan Forgiveness, and end subsidized student loans. It also would expand Pell Grant eligibility to short-term non-degree programs, end the Supplemental Educational Opportunity Grant, and overhaul the Federal Work-Study program. Congress subsequently chose to do otherwise.

A funding agreement reached by House and Senate negotiators reflects an effort to increase spending on student aid, career and technical education, and university-based research. The spending bill for the new fiscal year would increase the Education Department's total budget to $71.5 billion -- a second year in a row Congress has boosted funding, despite efforts by the Administration to reduce spending. The maximum Pell Grant would be raised by $100 to $6,195 in the agreement. Perkins Career and Technical Education grants will receive $1.26 billion, representing a $70 million increase from the previous year. Funding aimed at fixing the Public Service Loan Forgiveness program was extended to an amount of $350 million.

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FULFILLING A QUEST FOR PATIENT-CENTERED CARE

Patient-centered care is an important aspect of service delivery, but more efforts are needed to achieve its full potential. Read More

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

Charles Gulas, Dean of the Walker College of Health Professions at Maryville University of Saint Louis, is featured in this issue of TRENDS. Read More

FISCAL YEAR 2019 FUNDING PICTURE BRIGHTENS

For the first time in 15 years, Congress manages to complete a funding package for health and education prior to the start of the next fiscal year on October 1. Read More

HEALTH REFORM DEVELOPMENTS

Some states seek workforce requirements for certain Medicaid recipients, a challenge is mounted to stop an expansion of short-term health insurance plans, and savings are produced by accountable care organizations. Read More

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

Prevalence Of Chronic Pain And High-Impact Chronic Pain Among Adults—United States
Daily Use Of Marijuana Among Non-College Young Adults
Micromotor Pills As A Dynamic Oral Delivery Platform
Using Biomimicry To Develop Solutions For Human Health Problems Read More

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

Creating A Policy Environment To Address Social Determinants Of Health
Population Health: Translation Of Research To Policy
Achieving Rural Health Equity And Well-Being: Proceedings Of A Workshop Read More

HURRICANE METHUSELAH MOVES STEADILY TOWARD U.S. SHORES

HOW LAWS, REGULATIONS, SELF-REGULATORY PRACTICES, AND FINANCIAL SUBSIDIES AFFECT U.S. HEALTH CARE

John Colbert

September 25, 2018

Trends Archives

Compared to other western nations, the U.S. is assigned low grades based on the amount of money spent on health care and the results that are achieved. A typical analysis shows that lacking a public commitment to universal health care, this nation instead is a product of bio-scientific free enterprise – technologically sophisticated, extremely expensive, but inaccessible to the poor. A contrasting account can be found in a paper in the University of Texas Public Law & Legal Theory, Research Paper Series (#581), which will be a chapter in a book scheduled for publication in 2019. Its author, William Sage, indicates that beginning over 20 years ago, the poor performance of the American health care system has been slowly revealed. For nearly as long, steps that might improve that performance have been identified, but little has changed. The answer to why there has been a lack of significant progress lies in large part to an accumulation of laws, regulations, self-regulatory practices, and financial subsidies which locks U.S. health care into inefficient, unfair patterns and practices. While most of these provisions were well-intentioned when developed, this “deep legal architecture” now serves mainly to prevent meaningful competition in medical markets and to distort or limit collective investment in the nation’s health.

Noting that the United States wastes a vast amount of money each year on ineffective, overpriced, poorly delivered, and inaccessible medical care, the author offers three lessons that seem most important to summarize. First, the various ideological “brands” associated with national health reform must realign themselves to the task of facilitating decentralized, incremental improvement rather than asserting a national political consensus on setting limits. Second, in addition to continuing routine enforcement of the antitrust laws, the U.S. Department of Justice and the Federal Trade Commission should pursue longer-term strategies intended to reverse the distortions currently burdening competition. Third, America’s spendthrift health care system is particularly problematic because it leads the political process to medicalize problems such as poverty, lack of education, and substandard housing while over-investing in medical care and under-investing in non-medical social services that would be less costly, more effective, and more accessible to disadvantaged segments of the population.

Return to September 2018 trends

HURRICANE METHUSELAH MOVES STEADILY TOWARD U.S. SHORES

John Colbert

September 25, 2018

Trends Archives

Just as Hurricane Florence battered the Carolinas in September of this year, a more powerful storm from a quite different perspective continues its steady movement toward the United States and other nations around the globe, with enormous and unprecedented implications for the health sector of the economy. According to the U.S. Census Bureau, the year 2030 marks an important demographic turning point in this country’s history because by that year, all baby boomers will be older than age 65. This transition will expand the size of the older population so that one in every five residents will be retirement age. Moreover, aging of baby boomers (whose members were born between 1946 and 1964) means that in less than two decades, older individuals are projected to outnumber children for the first time in U.S. history. By 2035, there will be 78.0 million persons 65 years and older compared to 76.7 million under the age of 18.

As the population ages, the ratio of older adults to working-age adults, also known as the old-age dependency ratio, is projected to rise. By 2020, there will be just over three-and-a-half working-age adults for every retirement-age person. By 2060, that ratio will fall to just under two-and-a-half working-age adults for every retirement-age person. The non-Hispanic White alone population is projected to shrink over the coming decades, from 199 million in 2020 to 179 million in 2060, even as the U.S. population continues to grow. Their decline is driven by falling birth rates and a rising number of deaths over time among non-Hispanic Whites as that population sub-group ages. The racial and ethnic composition of younger birth cohorts is expected to change more quickly than for older cohorts. In 2060, over 36.4% of children are projected to be non-Hispanic White alone compared with 55.1% of older adults. Key policy issues that must be addressed: meeting the health care needs of an older cohort that disproportionately will be affected by chronic disease, assuring the availability of an adequate supply of competently-prepared health practitioners, and determining how to pay for health and health-related social services.

Return to September 2018 trends

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

John Colbert

September 25, 2018

Trends Archives

Creating A Policy Environment To Address Social Determinants Of Health
The National Alliance To Impact The Social Determinants of Health (NASDOH) in working to build systematically and pragmatically a common understanding of the importance of addressing social needs as part of an overall approach to health improvement has released a new white paper to create a supportive policy environment to address social determinants of health. The document introduces NASDOH’s plans to bring clarity to the current understanding of the issues, challenges, and opportunities for the health care system to address social determinants in concert with communities and the public and private sector. NASDOH encourages public and private sector leaders to support progress by promoting collaboration and innovation around social determinants of health interventions in five areas of focus: (1) Promoting a supportive policy environment at all levels of government and in the private sector, (2) Framing the issue in a way that promotes action, (3) Elevating shared learnings across communities, (4) Leveraging shared approaches to measurement and evaluation, and (5) Encouraging data and technology innovation. The paper can be obtained here.

Population Health: The Translation Of Research To Policy
The Robert Wood Johnson Foundation Health & Society Scholars (HSS) program was designed to build the nation’s capacity for research, leadership, and policy change, while addressing the multiple determinants of population health. One of its goals was to produce a cadre of scientific leaders who could contribute to this research and spearhead action to improve overall population health and eliminate health inequities. A report takes a case study approach using six diverse examples of science to policy translation generated by Scholars in the HSS program from 2003 to 2016. Because the HSS program was discontinued in 2017, the Milbank Memorial Fund published these case studies in the hope that many audiences, including students, would use them to learn about the connection between research, decision making, and policy. The case studies are on the following topics:

Healthy and Unhealthy Food Sources in New York City,
Fragile Health and Fragile Wealth,
Medical Marijuana as a Strategy to Reduce Opioid Overdose Deaths? Lessons from a Study of State Medical Marijuana Laws,
How Practitioners Bring Population Health Ideas Into Other Policy Sectors: Lessons from Transportation,
Forefront Suicide Prevention’s Wheel of Change: Catalyzing a Social Movement to Prevent Suicide, and
Exposure to Heat Waves: Making Film and Policy.

The report can be obtained here.

Achieving Rural Health Equity And Well-Being: Proceedings Of A Workshop
Rural counties make up about 80 percent of the land area of the United States, but they contain less than 20 percent of the U.S. population. The relative sparseness of the population in rural areas is one of many factors that influence the health and well-being of rural Americans. Rural areas have histories, economies, and cultures that differ from those of cities and from one rural area to another. Understanding these differences is critical to taking steps to improve health and well-being in rural areas and to reduce health disparities among rural populations. To explore the impacts of economic, demographic, and social issues in rural communities and to learn about asset-based approaches to addressing the associated challenges, the National Academies of Sciences, Engineering, and Medicine held a workshop on June 13, 2017. A publication that summarizes the presentations and discussions from the workshop can be obtained here.

Return to September 2018 trends

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

John Colbert

September 25, 2018

Trends Archives

Use Of Yoga, Meditation, And Chiropractors Among U.S. Adults: 2012-2017
A report from the National Center for Health Statistics (NCHS) in November 2018 examines changes over time in the percentage of adults who used yoga, meditation, and chiropractors in the past 12 months, as well as variation by sex, age, race, and Hispanic origin. Among adults aged 18 and over, increases were seen from 2012 to 2017 in the use of yoga, meditation, and chiropractors. Yoga was the most commonly used complementary health approach among U.S. adults in 2012 (9.5%) and 2017 (14.3%). In 2017, women were more likely to use yoga, meditation, and chiropractors in the past 12 months compared with men. Non-Hispanic white adults were more likely to use yoga, meditation, and chiropractors compared with Hispanic and non-Hispanic black adults. In 2012, seeing a chiropractor was as popular as yoga, followed by meditation, but in 2017, meditation became the 2nd most-used approach ahead of chiropractic.

Increasing Medication Adherence Could Improve Care And Save Health Care Costs
Non-adherence to medication represents a major problem that limits the effectiveness of treatment and adds to the burden of illness and cost of health care. About half of all patients do not take their medication as prescribed, according to a September 2018 report from the National Council for Behavioral Health’s Medical Director Institute. Estimates indicate that medication non-adherence costs the health care delivery system $100 billion to $300 billion annually due to more frequent use of high-cost services, additional prescriptions to offset non-adherence, and interventions to address relapses. The report discusses medication non-adherence in chronic conditions, mental health, and substance use disorders, and offers some possible solutions. If many of these solutions were to be adopted by 2025, a projection is made that the health system would save $2 billion a year from reduced hospital costs alone. Apart from improving communication between patients and providers, some more high-tech solutions include apps and robots.

HEALTH TECHNOLOGY CORNER

Robotic Arm May Help To Rehabilitate Chronic Stroke Victims’ Communication Deficits
Apropos of the article about silos in Health Silo Disruption and Eradication of this issue of TRENDS, treatment in one domain (motor function) may benefit performance in another untreated domain (communication) in individuals with acquired aphasia, the loss of ability to understand or express speech. Research published in Frontiers in Neurology on October 22, 2018 shows that robotic arm rehabilitation in chronic stroke patients with aphasia may promote speech and language function recovery. The rehabilitation in this study targeted the right arm since study participants each had suffered a left hemisphere stroke leading to a deficit in motor function on their right side. The research team observed small, but consistent improvement on measures assessing speech articulation and overall language processing in aphasia. It is believed some treatment approaches may encourage plasticity and reorganization that can span multiple domains. Although this initial finding should be interpreted cautiously, it remains exciting to consider the possibility that stroke rehabilitation in one domain would improve performance in another domain.

Obesity Provides Unexpected Enhancement Of Anticancer Medications
Obesity is associated with increased mortality and reduced longevity, but counter-intuitive findings occasionally suggest evidence of an obesity paradox. An article published in the journal Nature Medicine on November 16, 2018 indicates that overweight patients sometimes respond better than other patients to powerful drugs that harness the immune system to fight tumors. Called checkpoint inhibitors, the drugs block the activation of PD-1, a protein on the surface of immune sentinels called T cells. The body naturally triggers PD-1 to dampen immune responses, but tumors also can stimulate PD-1 to protect themselves. Lifting this molecular “brake” allows the T cells to attack the cancer cells. PD-1 inhibitors have caused untreatable tumors to vanish for years in patients with melanoma, lung cancer, and some other cancer types. Although there is heightened immune dysfunction and tumor progression, there also is greater anti-tumor efficacy and survival after checkpoint blockade that targets some pathways activated in obesity.

return to trends september 2018

HEALTH REFORM DEVELOPMENTS

John Colbert

September 25, 2018

Trends Archives

Efforts have been made over the past several decades to achieve meaningful health reform. The number “three” figures prominently in such attempts. One version focuses on: increasing access to health care, improving quality, and reducing costs. Pursuing any one of these aims often has the unwanted outcome of making it difficult to realize the other two. Another version based on the number three is known as the Triple Aim, which consists of improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care.

Worth noting is that it occasionally proves challenging at times to obtain a clear picture of what is transpiring when reports from different sources present conflicting information. As an illustration, the U.S. Census Bureau earlier this month indicated that the uninsured rate from 2016-2017 remained statistically unchanged, while private polling data suggest an increased uninsured rate of 1-2 percent. Meanwhile, the most recent attempt of a comprehensive nature to make improvements in the realm of health care is represented by the Patient Protection and Affordable Care Act (usually referred to as the ACA or Obamacare) that became law in 2010. Since then, several policy initiatives of a more incremental nature have been proposed. Recent examples are described on this page of each issue of TRENDS, along with updates as they occur. Some developments that continue to materialize are discussed below.

Medicaid Work Requirements
Many individuals who previously did not have health insurance were able to obtain coverage when the federal-state Medicaid program was expanded to include them. Some states currently are planning to add work requirements for able-bodied adults who receive coverage. Michigan recently submitted a waiver application that would require enrollees in the age bracket 19-62 either to work, attend job-training, or volunteer at least 80 hours per month to retain coverage. If approved, the proposal will become effective in 2020 and may affect as many as 540,000 beneficiaries. Because of 12 possible exemptions that would apply to particular groups, such as family caretakers and pregnant women, the actual number may prove to be lower. If the waiver application is approved, Michigan is in line to become the fifth state to be able to impose work requirements. Utah and Wisconsin are among some other states that also are seeking waiver approvals.

Exploring The Fate Of Short-Term, Limited-Duration Health Insurance Plans
The Trump Administration was successful in having a final rule issued on August 1, 2018 to help individuals struggling to afford health coverage find new, more affordable options. The rule allows for the sale and renewal of short-term, limited-duration plans that cover longer periods than the previous maximum period of less than three months. Such coverage now can cover an initial period of less than 12 months, and taking into account any extensions, a maximum duration of no longer than 36 months in total. A case filed in mid-September 2018 in Washington, DC is aimed at stopping the expansion of short-term health plans because opponents view them as not requiring provision of the same essential health benefits as ACA-compliant plans and possibly jeopardizing the ability of individuals with pre-existing conditions to find coverage. In contrast, proponents believe that short-term, limited-duration insurance will benefit: individuals who are between jobs, students taking time off from school, and middle-class families without access to subsidized ACA plans. Compared to the federal final rule, Oklahoma released guidance on September 7, 2018 to limit the sale of short-term, limited-duration plans to six months.

Medicare Savings Achieved By Accountable Care Organizations (ACOs)
An estimate from the Center for Medicare & Medicaid Services (CMS) indicates that Medicare ACOs underperformed during the first few years of implementation, generating a gross savings of $954 million. This estimate is contested by a report commissioned by the National Association of Accountable Care Organizations (NAACOS), which claims that the Medicare Shared Savings Program (MSSP) produced more than $1.84 billion in gross savings between 2013 and 2015. According to NAACOS, as of January 2018, there are 561 Medicare ACOs serving more than 12.3 million beneficiaries with hundreds more commercial and Medicaid ACOs serving millions of additional patients.

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FISCAL YEAR 2019 FUNDING PICTURE BRIGHTENS

John Colbert

September 25, 2018

Trends Archives

A principal function of Congress is to provide funds to support a broad array of government activities in time for the start of a new fiscal year each October 1. Except for 2018, that particular task has proven to be exceptionally challenging. During the past 15 years, two kinds of obstacles have stood in the path of appropriating money in a timely manner. The first is differences between Democrats and Republicans, while the second is a basic disagreement that proves difficult to reconcile between the Senate and the House of Representatives.

Some candidates in elections of yesteryear were fond of using a campaign theme song called “Sunny Days Are Here Again.” Unlike those earlier funding cycles, 2018 truly represents a most welcome departure from more cloudy times to a present sunny day. Especially gratifying is that this turn of events affects one of the largest of the 12 categories of funding, the Departments of Labor, Health and Human Services, Education, and Related Agencies (Labor-HHS). The House Appropriations Committee on September 13, 2018 filed a two-bill Appropriations “minibus” funding bill, which was approved by a joint House and Senate Conference Committee. The Conference Report includes the Department of Defense and the Labor- HHS Appropriations bills for fiscal year 2019. This package also includes a short-term “Continuing Resolution (CR),” which will provide continued funding to keep the federal government operating until all yearly funding bills can be signed into law. The CR merely extends current levels of funding for federal agencies until December 7, 2018.

Some appropriation highlights that await being finalized by having bills signed into law are:

Includes vital funding for the National Institutes of Health – $39 billion, an increase of $2 billion.
Funds programs to protect against health threats such as pandemics and bio-threats, providing $7.9 billion for the Centers for Disease Control and Prevention (CDC) and $2 billion to prepare for and prevent public health and social services emergencies with programs such as biomedical research, acquisition of medical supplies and vaccines, and hospital preparedness grants.
Saves taxpayers $50 million in future appropriations by creating the first Infectious Diseases Rapid Response Reserve Fund, where funds only become available for use in the event of a future public health emergency.
Helps to combat the opioid epidemic by providing $6.7 billion, a historic level of funding, for programs that fight, treat, and stop substance abuse and support access to mental health services. Includes $5.7 billion for the Substance Abuse and Mental Health Services Administration, a $584 million increase. Funds activities authorized under the 21st Century Cures Act and other addiction and recovery programs.
As described on page five of this issue of TRENDS, furnishes support for students who are studying for careers in the health professions.

return to trends september 2018

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

John Colbert

September 25, 2018

Trends Archives

By Susan N. Hanrahan, ASAHP President

In my message in the November 2017 issue, I indicated that I will be asking some of you to send a photo and answer a series of “fun” questions to be shared with our membership so that we can continue our collegiality through our newsletter. The 6th of many profiles this year is presented as follows:

Name and Title: Charles J Gulas, Dean, Walker College of Health Professions, Professor of Physical Therapy

Place of Birth: Cleveland Ohio

University: Maryville University of Saint Louis

How long have you been in your position? Started at Maryville as an adjunct in 1999, Director of Clinical Education, and Director of Physical Therapy Program, 2000 and 2001, Dean in 2004.

What’s the value of a university education? Teaches students to be critical thinkers, reflective learners, be creative and ignite passions.

What is the value of ASAHP? Updated information, and Networking, Networking and Networking!!

Your philosophy on education in seven words: Facilitating Thinking to Expand Creativity and Passion.

If I could teach in another field, which one and why? Botany/landscaping because I love plants, or Cyber- security because I am fascinated by how our information is tracked.

Before I retire I want to: Teach abroad.

In college, I was known for: Undergraduate days organizing protests.

What music is playing in my car/office? No music in office... in car Sirius On Broadway or 80’s hits

The last book I read for fun was: “small great things” by Jodi Picoult

My favorite trip was: Greek Islands

If I could travel anywhere it would be: Africa safari

Four people I’d take to coffee or have a glass of wine with: Gertrude Stein, Abraham Lincoln, Claude Monet, Ignatius de Loyola

The best advice I ever received was: Always Be Present.

My hobby is: Gardening, Travel

My passion is: Experiencing life with fascinating people.

My pet peeve is: Having to wait for coffee to be brewed at Starbuck’s.

A perfect day is: When I am challenged to learn something new.

Cats or dogs? Either are nice to visit.

E-book or hardback? Depends on the day, but loving my Kindle more.

Beach or mountains? Beach

I wish I could: Have more time to be outdoors.

Only my friends know: How much I love chocolate, and do need time to be alone.

My favorite saying is: No good deed goes unpunished!

Return to TRENDS September 2018

FULFILLING A QUEST FOR PATIENT-CENTERED CARE

John Colbert

September 25, 2018

Trends Archives

Much emphasis is placed today on the importance of putting patients first as exemplified by the common use of related terms, such as patient-centered care and shared decision-making. Application of these terms represents worthy objectives. Repeated often enough, however, such language may be equivalent to the reification of a metaphor, with the implication that objectives are being fulfilled satisfactorily, while the reality of the actual situation may suggest otherwise.

Patient-centered care is a term highlighted when the Patient Protection and Affordable Care Act (PPACA), more popularly known as Obamacare, became law in March 2010. A new care model in the form of Patient-Centered Medical Homes (PCMH) and establishment of a Patient-Centered Outcomes Research Institute (PCORI) were created by that landmark piece of legislation. Regarding the former, a declared outcome by the American Academy of Pediatrics in 2002 for the 21st century was that “every child deserves a medical home.” Although for more than a decade efforts to improve the health care experiences and outcomes of high-risk pediatric populations have centered on the redesign of health care settings to deliver PCMH care, results show that more work is needed to reach fruition.

According to an article published in the October 2018 issue of the journal Medical Care, just over one-third of children with special health care needs reported experiencing PCMH concordant care and there was high variation across components. Disparities in access to PCMH care also were significant from the perspective of children’s demographic characteristics, with minority children faring worse in access to this care compared with their white counterparts.

Although they do not always agree on bracketed years, demographers find utility in generating population categories based on age, producing the following kinds of groups by birth year: Post-War Cohort (1928-1945), Baby Boomers (1946-1964), Generation X (1965-1979), Millennials (1980-1994), and Generation Z (1995- 2015). Health professionals also may benefit to some degree as a result of this taxonomy by seeking and acquiring greater knowledge about and increased sensitivity toward members of these groups from the standpoint of being able to provide more appropriate, targeted kinds of care for them.

Regardless of age bracket, shared characteristics cut across each classification, such as religiosity, adherence to prescribed treatment, and patient resilience. Also, within each group, members can be differentiated on the basis of their individual outlook, how they experience pain, reliance on family support, and desire to return to a pre-health problem stage involving employment or leisure activities.

A particularly important attribute is affective behavior consisting of verbal and non-verbal displays of emotion, mood, and other feeling states that contribute to impression formation when patients and their health care givers interact with one another. Differences stemming from age, gender, and race/ethnicity may play a decisive role in determining just how effective that interaction will prove to be.

Return to September 2018 trends

SOCIAL SECURITY AND PAYING FOR HEALTH CARE

John Colbert

August 27, 2018

Trends Archives

As guaranteed pension plans continue to disappear in the lives of most workers, many retirees will rely heavily on Social Security monthly payments. Numerically, the ranks of the so-called “Baby Boomer” generation reaching the age of 65 increase by an average 10,000 individuals every day, a growth spurt that will continue over a 19-year period that began on January 1, 2011. The Social Security program assumes great importance in the lives of patients who rely on Medicare to address their health care wants and needs.

Participation in Medicare can entail high out-of-pocket costs for some beneficiaries that relate to the nature of their health problems. Approximately one in five Medicare beneficiaries has serious physical or cognitive limitations that require personal care services and supports. A March 2017 report from the National Center for Health Statistics (NCHS) examines health care access and utilization among adults with multiple chronic conditions (MCC). As the number of these conditions increases, the health care costs for those so diagnosed also will grow. The program is expensive and money is spent unevenly: 10% of enrollees represent 63% of expenditures. The 5% who die each year account for 30% of costs, often involving intensive care that prolongs life with no hope of recovery.

The adequacy of retirement income – from Social Security benefits and other sources – can be reduced quite substantially by personal health care expenditures. As reported in a study published in October 2017 by the Center for Retirement Research at Boston College, data for the period 2002-2014 were used to calculate post-out-of-pocket benefit ratios, defined as the share of either Social Security benefits or total income available for non-medical spending. The results show that average out-of-pocket spending (excluding long-term care) was $4,274 per year in 2014, with approximately two-thirds ($2,965) spent on premiums.

In 2014, the average retiree had only 65.7 percent of Social Security benefits remaining after this spending and only 82.2 percent of total income. Nearly one-fifth (18 percent) of retirees had less than 50 percent of their 2014 Social Security income remaining after out-of-pocket spending, with six percent of retirees falling below 50 percent of total income. A conclusion drawn from this analysis is that with less than two -thirds of Social Security benefits available for non-medical consumption, and limited income outside of Social Security for much of the aged population, many retirees likely feel that making ends meet is difficult. Meanwhile, Medicare spending per beneficiary is expected to resume its decades-long rise by the end of the present decade, which will exert even more pressure on retirees’ budgets.

A shortfall in Social Security financing poses a significant challenge for policymakers. The Medicare program also is on a short financial leash since its trust fund rapidly is running dry. Alternatives for shoring up these two sets of accounts are not pleasant to contemplate because they entail some mixture of either lowering annual benefit levels or imposing higher tax rates. Finding remedies for certain problems can be deferred for only so long. Eventually, Congress will be compelled to tackle them. No option exists in shifting a portion of the burden to the states. Many of them have crises in the form of significantly underfunded pension and health benefit systems for current and future retired public service employees.

return to trends july - august 2018

AVAILABLE RESOURCES ACCESSIBLE ELECTRONICALLY

John Colbert

August 27, 2018

Trends Archives

Matching Patients And Their Records
Despite widespread adoption of electronic health records and increasing exchange of health care data, the benefits of interoperability and health information technology have been hampered by the inability to match patients and their records reliably. The Pew Charitable Trusts contracted with the RAND Corporation to investigate "patient-empowered" approaches to record matching — solutions that have some additional, voluntary role for patients beyond simply furnishing demographics to their health care providers — and to select a promising solution for further development and pilot testing. A report recommends adopting a three-stage approach that aims to: improve the quality of identity information; establish new smartphone app functionality to facilitate bidirectional exchange of identity information and health care data between patients and providers; and create advanced functionality to improve value further. The report also suggests that because the solution contains multiple components involving diverse stakeholders, a governance mechanism likely will be needed to provide leadership, track pilot tests, and evaluation, along with convening key parties to build consensus where consensus is needed. The report can be obtained at https://www.rand.org/pubs/research_reports/RR2275.html.

Reasonable Patient Care Under Uncertainty
An article published on August 2, 2018 in the journal Health Economics discusses how limited ability to predict illness and treatment response may affect the welfare achieved in patient care. The discussion covers both decentralized clinical decision-making and care that adheres to clinical practice guidelines. The author explains why predictive ability has been limited, calling attention to questionable methodological practices in the research that supports evidence‐based medicine. Research is summarized on identification whose objective is to yield credible prediction of patient outcomes. Recognizing that uncertainty will continue to afflict medical decision making, basic decision theory is applied to suggest reasonable decision criteria with well‐understood welfare properties. The article can be obtained at https://onlinelibrary.wiley.com/doi/epdf/10.1002/hec.3803.

Patient-Centered Medical Homes And Accountable Care Organizations
Patient-centered medical homes (PCMHs) and accountable care organizations (ACOs) often were considered to be competing models for reforming health care delivery. It increasingly has become apparent, however, that one helps the other, according to the main finding from the new Patient- Centered Primary Care Collaborative (PCPCC) 2018 evidence report, “Advanced Primary Care: A Key Contributor to Successful ACOs,” the first study of its kind to look at how the role of advanced primary care, such as the PCMH, may contribute to the success or failure of ACOs. While these two leading models are transforming health care delivery and payment, little research has been done on how these models interact to promote lower costs and better quality for populations. Using qualitative and quantitative methods, researchers at the Robert Graham Center and IBM Watson Health found that: The attributes of successful ACO’s are necessary to transform the practice of primary care, successful ACO’s are more likely to be built on the basis of high- quality primary care, Medicare ACOs with a higher proportion of PCMH primary care physicians were more likely to generate savings, and Medicare ACOs with a higher proportion of PCMH primary care physicians demonstrated higher quality scores, including on a significant number of process and outcome measures. The report was published with support from the Milbank Memorial Fund for the fifth time. The document can be obtained at https://www.milbank.org/wp-content/uploads/2018/08/advanced_primary_care_report_080118.pdf.

return to trends july - august 2018

PRESIDENT’S CORNER—ASAHP MEMBER FOCUS

John Colbert

August 27, 2018

Trends Archives

By Susan N. Hanrahan, ASAHP President

In my message in the November 2017 issue, I indicated that I will be asking some of you to send a photo and answer a series of “fun” questions to be shared with our membership so that we can continue our collegiality through our newsletter. The 6th of many profiles this year is presented as follows:

Name and Title: Barbara Jacobsmeyer, EVP – President, Inpatient Hospitals at Encompass Health

Place of Birth: St. Louis, MO

Industry: Encompass Health, formerly called HealthSouth

How long have you been in your position? 11 years with the company and 1 1⁄2 years in current role

What’s the value of a university education? Well-rounded educational experience

What is the value of ASAHP? Focus on allied health professionals and common challenges and opportunities in the field to work on as a group. Great that it now includes the employer side so we can work together on these opportunities.

Before I retire I want to: Leave a legacy of mentoring other successful women executives. My favorite trip was: Mediterranean cruise

The best advice I ever received was: “People don’t care how much you know until they know how much you care.”

My hobby is: Running and playing golf.

My passion is: Education on heart disease and stroke My pet peeve is: Smacking gum.

A perfect day is: When I wake up.

Cats or dogs? Dogs – 2

E-book or hardback? E-book

Beach or mountains? Beach

I wish I could: Sing.

Only my friends know I: Can’t sing.

My favorite saying is: Hope is not a strategy.

Return to TRENDS July - August 2018

AFFORDABLE CARE ACT DEVELOPMENTS

John Colbert

August 27, 2018

Trends Archives

International comparisons developed by entities such as the Organization for Economic Co-Operation and Development (OECD), which consists of 36 member nations, rank the United States as highest in health care spending, but doing considerably less well in achieving positive health outcomes for patients. Concerns about the cost of health care have resonated for decades on Capitol Hill, with the result that both legislative and regulatory initiatives either of an incremental or a broad sweeping nature (e.g., the Affordable Care Act) have been implemented in an effort to curtail health care spending. Nonetheless, the challenge continues to exist. A factor contributing to the cost dilemma stems from the regulatory environment as discussed below.

Cost And Consequences Of Complying With Hospital Regulatory Requirements
On July 31 of this year, the Senate Committee on Health, Education, Labor & Pensions (HELP) held a hearing to discuss reducing administrative spending in health care. The event was the third in a series of hearings focused on curbing health care costs. Witnesses included the president and CEO of a state hospital and nursing home association, the president and CEO of America’s Health Insurance Plans (AHIP), an economics professor from Harvard University, and an advisor to the American Action Forum. HELP Committee Chairman Lamar Alexander (R-TN) made reference to a 2017 report from the American Hospital Association (AHA), noting that hospitals and health care providers must comply with 629 different regulatory requirements from four federal agencies. Along with these agency require- ments, providers must follow other state and federal regulations. The AHA report indicates that compliance with non-clinical regulatory requirements collectively costs providers almost $39 billion a year. A typical community hospital, for example, must employ 23 full-time workers just to comply with Medicare regulations.

Individual Insurance Performance In 2018
An analysis from the Kaiser Family Foundation shows that despite significant challenges, the individual market remains stable and insurers generally are profitable. Insurer financial results from 2018 – after the Administration’s decision to cease cost-sharing subsidy payments, but before the repeal of the individual mandate penalty in the tax overhaul goes into effect – showed no sign of a market collapse. Premium and claims data support the notion that 2017 premium increases were necessary as a one-time market correction to adjust for a sicker-than-expected risk pool, and premium increases in 2018 were in large part compensating for policy uncertainty and the termination of cost-sharing subsidy payments. Without these policy changes, it is likely that insurers generally would have required only modest premium increases in 2018. Low loss ratios and higher margins indicate that some insurers over- corrected in 2018, raising premiums more than was necessary to cover claims and administrative costs and earn a reasonable profit. Even though repeal of the individual mandate penalty and expansion of loosely regulated insurance options will tend to drive premiums up in 2019, increases will be mitigated by this over-correction, and in some cases, premiums even will decline. Some insurers have exited the market in recent years, but in 2019, some insurers are reentering markets they previously had departed.

Final Rule Issued On Short-Term, Limited-Duration Insurance Coverage
The Departments of Health and Human Services, Labor, and the Treasury on August 1, 2018 issued a final rule to help individuals struggling to afford health coverage find new, more affordable options. The rule allows for the sale and renewal of short-term, limited-duration plans that cover longer periods than the previous maximum period of less than three months. Such coverage now can cover an initial period of less than 12 months, and taking into account any extensions, a maximum duration of no longer than 36 months in total. This action has an objective of helping increase choices for beneficiaries faced with escalating premiums and dwindling options in the individual insurance market. Short-term, limited-duration insurance, which is not obliged to comply with federal market requirements governing individual health insurance coverage, is aimed at benefiting consumers who are involved in a transition between different coverage options, such as an individual who is between jobs or a student taking time off from school, as well as for middle-class families without access to subsidized ACA plans.

return to trends july - august 2018

QUICK STAT (SHORT, TIMELY, AND TOPICAL)

John Colbert

August 27, 2018

Trends Archives

Causes Of Death In The United States
Data from the National Center for Health Statistics are based on information from all death certificates filed in the 50 states and the District of Columbia in 2016. Causes of death classified by the International Classification of Diseases, Tenth Revision are ranked according to the number of deaths assigned to rankable causes. Statistics are based on the underlying cause of death. In 2016, the 10 leading causes of death were, in rank order: Diseases of heart; Malignant neoplasms; Accidents (unintentional injuries); Chronic lower respiratory diseases; Cerebrovascular diseases; Alzheimer’s disease; Diabetes mellitus; Influenza and pneumonia; Nephritis, nephrotic syndrome, and nephrosis; and Intentional self-harm (suicide). They accounted for 74% of all deaths occurring in the United States. It is of special interest to reflect on the extent to which these conditions stem from human behavior and lifestyle choices rather than from infections or any other external causative agents.

Application Of A Tool To Identify Undiagnosed Hypertension — United States, 2016
Approximately 11 million U.S. adults with a usual source of health care have undiagnosed hypertension, placing them at increased risk for cardiovascular events. Using data from the National Health and Nutrition Examination Survey (NHANES), CDC developed the Million Hearts Hypertension Prevalence Estimator Tool, which allows health care delivery organizations to predict their patient population’s hypertension prevalence based on demographic and comorbidity characteristics. Organizations can use this tool to compare predicted prevalence with their observed prevalence to identify potential underdiagnosed hypertension. This study applied the tool using medical billing data alone and in combination with clinical data collected among 8.92 million patients from 25 organizations participating in the American Medical Group Association (AMGA) national learning collaborative to calculate and compare predicted and observed adult hypertension prevalence.

HEALTH TECHNOLOGY CORNER

Tumbling Microbots For Future Health Treatments
Microbots are tiny automated machines programmed to perform specific tasks. They are so tiny—as small as a cell—that they can be injected into the body to do tasks, such as clearing out plaque from arteries, performing tissue biopsies, or delivering targeted treatment to tumors. Because of their size and precision, these microbots could provide less-invasive treatments than a typical surgery or deliver medication in a much more targeted way than a pill. According to an article in the July/August 2018 issue of the journal American Scientist, researchers have been working on developing these tiny robots for three decades, but recent advancements in engineering have led to a surge in research. Animal testing has shown positive results. Microbots have been propelled by hydrogen microbubbles in live mice to treat gastric bacterial infections. For application in humans, challenges involve enabling microbots to move through wet areas and traverse through air pockets in the stomach, intestines, and lungs. Early studies show potential for a tumbling motion to make it possible to navigate such difficult terrains.

Using Shark Skin Patterns To Halt The Spread Of Infections
Efforts to combat the spread of infections, especially in health care settings, mostly involve the use of antibacterial cleaning agents and antibiotic drugs. Another possible strategy is the use of coatings that are antibacterial (inactivating bacteria) or antifouling (preventing the build-up of bacteria) on surfaces such as doorknobs. As reported on May 23, 2018 in the journal ACS Applied Material Interfaces, such a coating was developed with a structure inspired by shark skin. Bacterial attachment is reduced by 70% on the micropatterned, photocatalytic coating, compared with smooth films of the same composition. Most of the bacteria that do settle on the coating are inactivated when the coating is exposed to ultraviolet light. Because the coatings are imprinted onto a flexible substrate, it should be possible to use them in practical applications.

return to trends july - august 2018

21ST CENTURY CURES ACT, CANCER MOONSHOT, AND PRECISION MEDICINE

John Colbert

August 27, 2018

Trends Archives

Francis S. Collins, Director of the National Institutes of Health, presented testimony on July 25, 2018 at a hearing of the House Energy and Commerce Committee, Health Subcommittee on implementation of the 21st Century Cures Act. Among specific areas of scientific opportunity supported by the Act, he high- lighted two components of its Innovation Fund: the Cancer Moonshot, and the bold new Precision Medicine Initiative, called All of Us. The Cancer Moonshot initiative aggressively is pursuing an ambitious goal to accelerate advances in cancer prevention, diagnosis, treatment, and care. Such advances include immunotherapy, in which a person's own immune system is taught to recognize and attack cancer cells. After years of research supported by NIH, immunotherapy is leading to dramatic cures of some cancers, such as leukemia, lymphoma, and melanoma. Moreover, each year as many as 135,000 American women who have undergone surgery for the most common form of early stage breast cancer face a difficult decision, whether or not also to undergo chemotherapy to improve their odds. TAILORx, a large NIH-funded clinical trial, shows that about 70% of such women actually do not benefit from chemotherapy and a genomic test of tumor tissue can identify them quite reliably, producing a significant cost savings perhaps up to $1 billion a year.

The centerpiece of the Precision Medicine Initiative, the All of Us Research Program, will enroll one million or more individuals. On May 6 of this year when enrollment was launched in seven sites across the nation, 10,000 participants were reached. As of the Congressional hearing on July 25, more than 86,000 volunteers had signed up to contribute their health data in many ways over several years. Some are enrolled through health provider organizations, of which 10 are part of the NIH enterprise, including community health centers and the Department of Veterans Affairs. Other participants enroll as direct volunteers, who sign up over the Internet. Almost half are from historically underrepresented racial and ethnic groups, which will enhance research into health disparities. With each new person enrolled, every biological sample preserved, every electronic health record collected, every survey filled out, these data will hold increased promise for advancing human health.

return to trends july - august 2018

DEVELOPMENTS IN HIGHER EDUCATION

John Colbert

August 27, 2018

The opportunity to obtain a quality college-level education is associated with many desirable aspects of life, such as being able to find suitable employment that accords with an individual’s capabilities and interests, and also with having an improved chance to achieve a satisfactory level of income derived from participation in the U.S. economy. Public policy as represented by what occurs in the legislative and regulatory spheres is aimed at increasing student access to higher education, making the pursuit of academic degrees and certificates affordable, and guaranteeing an appropriate level of educational quality. Democrats and Republicans often fail to agree on the most effective means of fulfilling these objectives. The Higher Education Act (HEA) represents an important vehicle for enhancing progress, but it is clear that meaningful action needs to occur more swiftly. The HEA has not been reauthorized since 2008 and the prospect of its being enacted in 2018 continues to appear quite dim.

Democrats Introduce Plan In Congress To Reauthorize The Higher Education Act (HEA)
House Democrats on July 26, 2018 introduced their own plan called the Aim Higher Act (H.R. 6543) to reauthorize the HEA. It makes higher education more accessible by creating targeted programs that allow traditionally underrepresented students to enroll in college, strengthening existing access programs, simplifying the financial aid application, and ensuring students have access to a quality program. The proposed legislation also makes college more affordable today and addresses the rising cost of college to reduce the burden on students in the future. Generally, the bill offers a set of counterpoints to the Republican version of this legislation, known as the Promoting Real Opportunity, Success and Prosperity Through Education Reform (PROSPER) Act (H.R. 4508). Democrats intend to offer legislative choices that are more generous than current programs for students and borrowers by increasing funding levels for Pell Grants, for example, and making loans more affordable. The bill also would revive the Perkins Loan Program, which expired last year, and restructure the Federal Work-Study and Supplemental Educational Opportunity Grant programs. Whereas the PROSPER Act would eliminate regulations on for-profit colleges, drop benefits for student borrowers, such as Public Service Loan Forgiveness, and streamline other student aid programs, the Democrats’ bill not only rejects many aspects of PROSPER, it would make current accountability rules tougher and direct new federal funds to student aid and programs for college readiness and completion.

U.S. Department Of Education Proposes New Set Of Higher Education Regulations
The Department of Education on July 25, 2018 proposed a new package of higher education regulations aimed at protecting student borrowers; holding higher education institutions accountable for misrepresentation and fraud; and providing financial protections to taxpayers by at-risk institutions. The Institutional Accountability regulations were published on the Department’s website after months of public hearings and negotiated rulemaking that engaged a wide variety of higher education interested parties. These proposed regulations that were open for public comment over the next 30-day period include:

Establish a borrower defense to repayment adjudication process that is clear, consistent, and fair to borrowers who were harmed by institutional misconduct.
Replace the current “state standard” for adjudicating claims with a Federal standard that clearly defines misrepresentation and enables more expeditious review of student claims.
Facilitate collection and review of evidence for deciding claims and ensure that the Secretary of Education can recoup from institutions the financial losses associated with successful borrower defense claims.
Encourage students to seek remedies directly from institutions that have committed acts of misrepresentation.
Expand from 120 days to 180 days the period of time during which students who left an institution prior to its closure are eligible for a closed school loan discharge while at the same time incentivize closing institutions to engage in orderly teach-outs, which enable more students to complete their program.

return to trends july - august 2018

GENDER BIAS IN HOW PROFESSIONALS ARE SPOKEN ABOUT

John Colbert

August 27, 2018

Trends Archives

A manuscript appearing in the July 10, 2018 issue of the journal Proceedings of the National Academy of Sciences of the USA (PNAS) reports evidence for a gender bias in how individuals speak about profession- als. When discussing professionals or their work, it is common to refer to them by surname alone (e.g., “Darwin developed the theory of evolution”). Evidence indicates that individuals are more likely to refer to male than female professionals in this way. This gender bias emerges in archival data across domains. For example, students reviewing professors online and pundits discussing politicians on the radio are more likely to use a surname when speaking about a man (vs. a woman).

Gender inequality persists in many professions, particularly in high-status fields, such as science, technol- ogy, engineering, and mathematics (STEM). Potentially contributing to this unequal state is gender bias in implicit and explicit forms. This particular PNAS article offers evidence of a form of gender bias that manifests in the way that individuals refer to professionals when speaking about them and identifies the consequences of this bias. Men and women were, on average across studies, more than twice as likely to describe a male (vs. female) professional by surname in domains, such as science, literature, and politics. This simple difference in reference affects judgments of eminence, with participants judging those professionals described by surname as more eminent and 14% more deserving of honors, such as a National Science Foundation Career Award. This gender bias may contribute to the gender gap in perceived eminence as well as in actual recognition and partially may explain the persistent state of women’s underrepresentation in high-status fields, including STEM.

return to trends july - august 2018

TECHNOLOGY’S IMPACT ON THE HEALTH WORKFORCE

John Colbert

August 27, 2018

Trends Archives

Developments in the health technology arena continue to unfold at a robust pace. An aspect that may not attract as much attention as it deserves is how the health workforce will be affected. An example stems from 2007 when direct-to-consumer (DTC) genotyping for genomic risk assessment of common, genetically complex conditions began to become available. According to an article published in the May 2018 issue of the journal Health Affairs, among the marketplace options that are accessible, the firm 23andMe makes it possible to buy a kit and use the plastic tube contained in it to deposit two ml. of saliva and mail it to the company where a search will be conducted of the DNA for specific genetic variants known as single nucleotide polymorphisms (SNPs) associated with particular health conditions.

The purchaser later will receive a report containing some findings that may engender considerable stress because the test reveals the presence of the APOE4 variant, which is associated with the onset of Alzheimer’s disease. Association is not causation, yet a result of that kind can be highly worrisome for the individual who produced the saliva. Once a sense of panic is triggered, an expected response would be to seek professional advice regarding what to do next.

Primary care physicians represent a logical source of assistance, but current shortages of them exist and future projections indicate that the situation offers no signs of improvement. Even when they are available, it is likely that some of them may feel unprepared to work with patients at high risk for genetic conditions and also lack confidence in interpreting test results. Another professional group that may be in a favorable position to offer sound advice consists of genetic counselors.

As of May 2017 there were only 4,242 certified genetic counselors in North America. Becoming one typically involves completing a master’s program, obtaining clinical experience, and passing an exam from the American Board of Genetic Counseling. According to a 2018 report by a genetic counselors working group, that number is not projected to expand sufficiently even to meet traditional needs, such as genetic screening for a person who has a family history of cancer or who wants to become pregnant. ASAHP member institutions may be in a position to create new programs to add to the current supply. If so, they would need to determine: how much it will cost to do so, if there are enough faculty, and if enough students eventually will apply for admission.

CRISPR (clustered, regulatory, interspaced, short, palindromic repeats) is a gene editing tool that is being investigated for use in genetic modification of living organisms. If it reaches a stage where parents would be able to use it to engineer their offspring to be more intelligent, athletic, or imbued with other desirable attributes, genetic experts will be needed to provide sound advice. A challenge involving heritable genome interventions is to ensure that only the precise genome locations are the intended targets. Inappropriate, permanent gene modifying efforts may produce harmful results not only for the immediate offspring of a pair of parents, but also can influence successive generations.

Return to TRENDS July - August 2018

More Articles from TRENDS October 2018