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Nearly everyone has heard from the political left and progressives for plans to create a single-payer healthcare system, Medicare for all, or Medicare-optional programs. However, even many well-informed people don’t know about Maryland’s strategy to fight out of control healthcare costs: the all-payer model. This model, in place for nearly forty years, exempts the state from the Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS) and allows Maryland to set rates for these services for Medicare, Medicaid, and Children's Health Insurance Program (CHIP) recipients. As part of an agreement with the national Center for Medicare & Medicaid Services (CMS), Maryland must limit inpatient and outpatient hospital per capita growth to 3.58 percent and save $330 million in Medicare costs over a five-year period. Additionally, they must meet several quality measures: matching national Medicare 30-day readmissions rates, reduce potentially preventable complications by 30 percent over five years, and submit annual reports on population health measures. [1]  This bold strategy seems to be working. From 2014 to 2016, Maryland saved $461 million in total care costs, resulting in growth at 2.1 percent below the national healthcare growth rate. They even saved $586 million in hospital costs, which was 5.5 percent lower than the national growth rate and far more than the required $330 million in five years. Goals for improving patient care and reducing complications were also met. [2] In fact, complications were reduced 26.3 percent, per capita costs were kept at 1.47 percent, and Medicare saved $116 million in 2014 alone. [3] As a result of their success, CMS approved an extension through 2023 along with an expansion that went into effect on January 1, 2019. This expansion will include some doctor visits, mental health support, and long-term care instead of just hospitals as was previously done. [4] Considering that much of America’s healthcare expenditures come from long-term care of the elderly and chronic diseases, this expansion could result in additional savings while increasing quality of care. Under the new agreement, Maryland must meet a goal of $1 billion in savings by 2023. Some experts argue that this model works because it consolidates the demand-side of healthcare to engage in collective bargaining to rein in expenditures. [5] The all-payer model has evaded attention for years, but that appears to be changing, even in a bipartisan fashion. While it was introduced under Governor O’Malley and the Obama Administration in 2013, it has continued and expanded under Governor Hogan and the Trump Administration in 2019. Furthermore, the Governor of Vermont, Peter Shumlin, has taken notice in his mission to move Vermont to a value-based care model in contrast to the fee-for-service model used for years. [5] Pennsylvania has also adopted global budgeting for their rural hospitals, while France, Germany, Japan, Switzerland, and the Netherlands use all-payer rate setting as the backbone of their universal coverage models. [6] With Congress divided and many states trying to solve their healthcare problems on their own, is the all-payer model the solution to their problems?
The views expressed above are solely the author's and are not endorsed by the Virginia Policy Review, The Frank Batten School of Leadership and Public Policy, or the University of Virginia. Although this organization has members who are University of Virginia students and may have University employees associated or engaged in its activities and affairs, the organization is not a part of or an agency of the University. It is a separate and independent organization which is responsible for and manages its own activities and affairs. The University does not direct, supervise or control the organization and is not responsible for the organization’s contracts, acts, or omissions. References [1] https://innovation.cms.gov/initiatives/Maryland-All-Payer-Model/
[2] https://www.healthcaredive.com/news/marylands-all-payer-model-saved-medicare-millions-in-first- 3-years/519458/ [3] https://www.advisory.com/-/media/Advisory-com/Health-Policy/2016/Maryland-All-Payer-Model- White-Paper.pdf [4] https://www.advisory.com/daily-briefing/2018/05/16/maryland-all-payer-model [5] http://www.ncsl.org/research/health/equalizing-health-provider-rates-all-payer-rate.aspx [6] https://theintercept.com/2017/07/24/single-payer-meet-all-payer-the-surprising-state-that-is- quietly-revolutionizing-healthcare/
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BackgroundFor Winston-Salem residents without the means or ability to drive, the bus system plays a critical role in determining their ability to reach jobs, education, medical care, child care, public benefits, and community activities. The Business 40 infrastructure improvement project presents an opportunity to consider the mobility of all Winston-Salem residents and to focus on how the bus system can be used to advance health equity in our community. The NC DOT has designated funds to expand bus service during the Business 40 closure.
The analysis in Table 1 reflects the current total amount of time it takes citizens from each ward (Map) to reach key healthcare access locations, prior to any increase in transit services.
These data are a baseline from which to measure how improvements in bus service impact the amount of time residents spend traveling to health services.  MethodOur analysis utilizes the Google Transit API (Application Programming Interface) to calculate optimum transit duration from multiple locations in each ward to the major health assets in the community.[1] (Note: Novant Medical Center and Wake Forest Baptist Medical Center are along the same bus routes and are separated by +/- 5 minutes on the bus.) The API allows for calculation of additional details about the trip, including:
 ConclusionsEconomic mobility in Winston-Salem is a pressing concern. For those without the means or ability to access private transportation, it takes a disproportionately greater amount of time to reach important health care assets. The Business 40 closure affords an opportunity to consider how the bus system influences residents’ ability to access to health services, and how improvements to bus services may enhance health care access and utilization. This brief analysis is limited to data regarding health care access, though Google API can be broadly used to document transportation equity within our community. Further critical thought about the impact of NC DOT Business 40 closure mitigation funds should be ongoing. We anticipate the expanded bus services will support a more equitable and just public transportation system. Recommendations
Notes[1] WSTA has provided Google bus schedule and route information for display on Google Maps. The Google Transit API makes this data available for querying based on specific start times, start locations, and destinations. The addresses utilized for this analysis are available here. AuthorsMichael DeWitt is a data scientist working for Wake Forest University in Winston-Salem, NC. He recently moved to higher education after working in the manufacturing sector for the last ten years. His interests are in statistical programming and analysis, Bayesian modeling, survey analysis, and improving social mobility. Phillip Summers works for the Wake Forest Baptist Medical Center in Winston-Salem, North Carolina. He was a Research Associate with the Department of Family and Community Medicine before joining the Program in Community Engagement as an Associate Director. He has used his background in Public Health leadership in a variety of non-profit organizations both locally and globally. His research and practice focus on health and justice for immigrants and reducing health disparities. Jeff Bloomfield, Keena Moore, and Megan Irby also contributed to this research and article. The views expressed above are solely the author's and are not endorsed by the Virginia Policy Review, The Frank Batten School of Leadership and Public Policy, or the University of Virginia. Although this organization has members who are University of Virginia students and may have University employees associated or engaged in its activities and affairs, the organization is not a part of or an agency of the University. It is a separate and independent organization which is responsible for and manages its own activities and affairs. The University does not direct, supervise or control the organization and is not responsible for the organization’s contracts, acts, or omissions.
Harm reduction models use a variety of strategies to eliminate the harmful consequences associated with substance abuse. These strategies seek to reduce morbidity and mortality associated with substance abuse for those who are not ready to quit all together. Such programs resemble a stepping stone process and allow persons who inject drugs to make gradual progress to overcome their addiction. According to the Rural Health Information Hub, “The goal of harm reduction models is to reduce at-risk, moderate and high-risk behaviors often associated with substance abuse.” One of the key principles of harm reduction practice from the Harm Reduction Coalition is, “Accepts, for better and or worse, that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them.” This principle highlights the knowledge and acceptance that the programs put into place are not direct solutions but help assist people in taking steps towards ending their addiction. Syringe exchange programs allow persons who inject drugs to exchange used needles for new, sterile needles and syringes to reduce the risk of spreading human immunodeficiency virus (HIV). These programs also provide counselling, HIV and hepatitis B and C testing, and referrals to treatment centers. The hope of these programs is to reduce to spread of HIV and hepatitis B and C while also providing education, counseling and testing to persons who inject drugs. Even though these programs are controversial, they have drastically reduced the rate of HIV transmission and risk of hepatitis infections among injection drug users without increasing the rate of the illegal drug use. According to the Centers for Disease Control and Prevention (CDC), the use of these programs has increased during the past decade. The service provided by these programs have been misinterpreted as enabling drug users by giving them easy access to clean needles. However, the goal of these programs is to reduce the transmission of HIV and hepatitis B and C.  There has been an increase in the last decade of drug injection in the United States. While the drug usage has not increased, people who started off with the oral analgesics have transitioned to injecting prescription opioids and heroin. “The big picture here is that we’ve had a lot of progress reducing HIV infections spread by needles and we’re at risk of stalling or reversing that progress,” said CDC Director Tom Frieden in an interview with The Washington Post. As a result of the opioid epidemic, he said, “more people appear to be injecting drugs, more people are sharing needles, and there are more places not covered by syringe service programs.” There is a need to increase the number of comprehensive harm reduction/syringe exchange programs in the rural areas of Virginia. According to the CDC, “Substantially fewer syringe service programs were located in rural and suburban than in urban areas, and harm reduction services were less available to persons who inject drugs outside urban settings.” According to the CDC, “Because increases in substance abuse treatment admissions for drug injection have been observed concurrently with increases in reported cases of acute Hepatitis C infection in rural and suburban areas, state and local jurisdictions could consider extending effective prevention programs, including syringe service programs, to populations of persons who inject drugs in rural and suburban areas.” A law passed by the General Assembly in 2017 allows 55 localities around the state to create comprehensive harm reduction programs. According to the Virginia Department of Health, the state has only approved two sites so far and only one is up and running. The first program in Virginia began in Wise County. The program has served dozens of people since opening in the summer of 2018 and has collected more needles than it distributed. The second location will be running out of the free clinic, Health Brigade, in Richmond. These programs are necessary to provide persons who inject drugs with clean needles in order to prevent the spread of HIV and hepatitis B and C. In addition, these programs provide these people with the education, counseling, and testing they need in order to quit their drug addiction. Megan SaetreMegan is a Communications Assistant at the Virginia Rural Health Association. The VRHA has offices in Blacksburg, Luray, and Big Stone Gap. Its mission is to improve the health of rural Virginians through education, advocacy, and fostering cooperative partnerships. The views expressed above are solely the author's and are not endorsed by the Virginia Policy Review, The Frank Batten School of Leadership and Public Policy, or the University of Virginia. Although this organization has members who are University of Virginia students and may have University employees associated or engaged in its activities and affairs, the organization is not a part of or an agency of the University. It is a separate and independent organization which is responsible for and manages its own activities and affairs. The University does not direct, supervise or control the organization and is not responsible for the organization’s contracts, acts, or omissions. Referenceshttps://www.cdc.gov/mmwr/preview/mmwrhtml/mm6448a3.htm
https://www.washingtonpost.com/news/to-your-health/wp/2016/11/29/white-rural-drug-users-lack-needle-exchange-programs-to-prevent-hiv-infections/?utm_term=.7947b55f8034 https://www.nejm.org/doi/full/10.1056/NEJMp1507252 https://www.ruralhealthinfo.org/toolkits/substance-abuse/2/harm-reduction/syringe-services http://www.wvtf.org/post/one-year-later-wise-county-needle-exchange-only-state#stream/0 https://harmreduction.org |
