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Genetic disorders are a leading contributor to mortality in neonatal and pediatric intensive care units (ICUs). Rapid whole-genome sequencing (rWGS)-based rapid precision medicine (RPM) is an intervention that has demonstrated improved clinical outcomes and reduced costs of care. However, the feasibility of broad clinical deployment has not been established. The objective of this study was to implement RPM based on rWGS and evaluate the clinical and economic impact of this implementation as a first line diagnostic test in the California Medicaid (Medi-Cal) program. Project Baby Bear was a payor funded, prospective, real-world quality improvement project in the regional ICUs of five tertiary care children's hospitals. Participation was limited to acutely ill Medi-Cal beneficiaries who were admitted November 2018 to May 2020, were

California has long sought to achieve universal health insurance coverage for its residents. The state's uninsured population was dramatically reduced as a result of the Affordable Care Act (ACA). However, faced with federal threats to the ACA, California is exploring how it might take greater control over the financing of health care. In 2017 the state Senate passed the Healthy California Act, SB-562, calling for California to adopt a single-payer health care system. The state Assembly did not vote on the bill but held hearings on a range of options to expand coverage. These hearings highlighted the many benefits of unified public financing, whether a single- or multipayer system (which would retain health plans as intermediaries). The hearings also identified significant challenges to pooling financial resources, including the need for federal cooperation and for new state taxes to replace employer and employee payments. For now, California's single-payer legislation is stalled, but the state will establish a task force to pursue unified public financing to achieve universal health insurance. California's 2018 gubernatorial and legislative elections will provide a forum for further health policy debate and, depending on election outcomes, may establish momentum for more sweeping change.

This comprehensive, biennial report provides an overview of insurance trends throughout the state and looks specifically at coverage of California's working adults, elderly as well as children's coverage. It also examines the consequences of lacking insurance and provides policy recommendations. Based on data from the California Health Interview Survey (CHIS) that was collected during a period of economic growth — 2007 — the report provides a clear picture of the adequacy of health insurance arrangements at a time of seemingly high capacity. The authors found that health insurance coverage system stagnated even as the economy expanded. Using the data from several CHIS survey cycles, the report shows little change in employment-based coverage and a drop in employment-based coverage for children between 2001 and 2007. The report also found that nearly one in 13 Californians had some kind of medical debt and that those with debt were twice as likely as those without debt to report delays in getting needed medical care.

Physician turnover is an important source of expense, burnout, and poor quality of care. Using a novel method with Centers for Medicare & Medicaid Services data, this study examined turnover rates by physician, practice, and patient characteristics. The findings shed new light on turnover trends over time and differences across specialty and gender and, collectively, have important policy and clinical implications. Visual Abstract. Physician Turnover in the United States: Physician turnover is an important source of expense, burnout, and poor quality of care. In this study, Bond and colleagues used a novel method with Centers for Medicare & Medicaid Services data to examine turnover rates by physician, practice, and patient characteristics. Their findings shed new light on turnover trends over time and differences across specialty and gender and, collectively, have important policy and clinical implications. Background: Medical groups, health systems, and professional associations are concerned about potential increases in physician turnover, which may affect patient access and quality of care. Objective: To examine whether turnover has changed over time and whether it is higher for certain types of physicians or practice settings. Design: The authors developed a novel method using 100% of traditional Medicare billing to create national estimates of turnover. Standardized turnover rates were compared by physician, practice, and patient characteristics. Setting: Traditional Medicare, 2010 to 2020. Participants: Physicians billing traditional Medicare. Measurements: Indicators of physician turnover—physicians who stopped practicing and those who moved from one practice to another—and their sum. Results: The annual rate of turnover increased from 5.3% to 7.2% between 2010 and 2014, was stable through 2017, and increased modestly in 2018 to 7.6%. Most of the increase from 2010 to 2014 came from physicians who stopped practicing increasing from 1.6% to 3.1%; physicians moving increased modestly from 3.7% to 4.2%. Modest but statistically significant (P  < 0.001) differences existed across rurality, physician sex, specialty, and patient characteristics. In the second and third quarters of 2020, quarterly turnover was slightly lower than in the corresponding quarters of 2019. Limitation: Measurement was based on traditional Medicare claims. Conclusion: Over the past decade, physician turnover rates have had periods of increase and stability. These early data, covering the first 3 quarters of 2020, give no indication yet of the COVID-19 pandemic increasing turnover, although continued tracking of turnover is warranted. This novel method will enable future monitoring and further investigations into turnover. Primary Funding Source: The Physicians Foundation Center for the Study of Physician Practice and Leadership. [ABSTRACT FROM AUTHOR]

The tendency by many health plans to select risks can be discouraged and considerably reduced by implementing an effective risk adjustment system. This system will provide high-risk individuals with access to high-quality care by accurately predicting their future health care needs using easily-accessible information. It will also promote effective management of basic health services.

Less than half of the US population lives in areas that could support a type of health care reform called managed competition. The theory behind managed competition, a proposal supported by President Clinton and members of Congress, is that individual provider groups such as health maintenance organizations (HMO) compete for health consumers. A study on the minimal population needed to sustain managed competition based estimates on the existing physician-enrollee ratio of successful HMOs and on the assumption that at least three health plans are needed for competition. A community of at least 1.2 million people could support three fully independent HMOs. A community of 360,000 could support three HMOs, but there would have to be some sharing of facilities and specialized services. A community of 180,000 could support three plans but would have to share cardiology and urology services. For the 37% of the population that does not live in areas with health markets greater than 360,000, alternative approaches to health care reform will be needed.

The primary justification for private insurance is the hypothesis that competition among private insurers will lead to an environment in which physicians and hospitals will continually strive to improve the quality and economy of the care they provide, and to be responsive to the preferences of the consumers they serve. However, to date, competition among private insurers has failed miserably in achieving this goal. In order to achieve this goal, competition among insurers must be regulated in an entirely different manner than it is currently. This article describes the ways in which health insurance is currently regulated, and argues that passive regulation directed at assuring financial solvency of insurers should be transformed into an active purchasing authority. This purchasing authority would empower the demand side, creating an environment of managed competition that rewarded those provider groups able to offer high quality, economical care.

Using data from the Current Population Survey, this article shows that low-income workers were much less likely to have employer-sponsored insurance in 1989 than they were in 1979. For example, workers earning $6.00 per hour in 1989 were over 10 percentage points less likely to have employer sponsored health insurance than were workers earning $3.51 per hour in 1979 (the constant dollar equivalent of $6.00 per hour in 1989). The decline in employer sponsored coverage was confined to low income workers; coverage levels did not decline for workers earning $30,000 per year and more. The paper explores two types of explanations for the decline in coverage among low-income workers. First, the decline might have resulted from increases in the price of medical care, the cost of administering health insurance, and from a breakdown in the small group insurance market. Second, the decline might have resulted from changes in the structure of the economy that changed the types of jobs available to low-income workers. Since coverage declines among the self-employed parallel coverage declines among the employed, it seems likely that increases in the price of health insurance are a larger part of the cause for coverage declines than are changes in the structure of the economy, but further research on this question is needed.

The American system of health care financing and delivery is deteriorating. The causes of the problem are complex, and reform must emphasize the most important and correctable aspects. Among the major reasons for rising health care costs is that the system provides more incentives to spend than to avoid spending. The fee- for-service (FFS) system pays more for doing more, with no budget for how much a job should cost, and there is no price competition. Health maintenance organizations (HMOs) are cheaper, but often employers do not offer this alternative or pay more for FFS. A second problem is that the present system encourages specialists to exercise their specialties, not to produce acceptable outcomes at a reasonable cost. A better system would gather data on outcomes, treatments and resource use upon which to base clinical decisions. The current system pays more to poor physicians who have high rates of complications (and therefore more procedures and tests), while high-quality physicians are unrecognized and unrewarded. There are too many hospital beds, and too many specialists compared with primary care physicians. Third, insurance companies profit by excluding those who need them most. Finally, public funds are not distributed equitably or effectively. To ensure health care access for all, comprehensive reform of economic incentives and managed competition are proposed, including the Public Sponsor (a quasi-public agency) to equalize health access, mandated employer-provided health insurance, contributions from employers and employees, a limit on tax-free employer contributions, no increase in government spending, managed competition in the insurance industry, and quality control linking outcomes and effectiveness. This type of comprehensive reform is preferable to the imposition of direct government controls. (Consumer Summary produced by Reliance Medical Information, Inc.)

This article describes the challenges of a shared-savings model for high-need, high-risk Medicare beneficiaries, exemplified by the Independence at Home (IAH) demonstration. It suggests ways that the Centers for Medicare & Medicaid Services (CMS) could improve its risk-adjustment methodology for the IAH model. IAH's success, with CMS reporting more than $100 million in savings during its first five years, seven of fourteen practices receiving shared savings, and thirteen of fourteen practices meeting cost benchmarks, shows that such a model for small practices is useful for policy makers. [ABSTRACT FROM AUTHOR]