Zane Gates, MD, is a Robert Wood Johnson Foundation (RWJF) Community Health Leader and medical director of Altoona Regional Partnering for Health Services in Altoona, Pennsylvania. Gates and Patrick Reilly, president of Impact Health Solutions, founded the Empower3 Center for Health program, which is the model for a new health care law in Pennsylvania.

The Commonwealth of Pennsylvania has recently adopted a law to fund community-based clinics that can demonstrate real impact to the community with regard to increased access, reduced costs, lower emergency room (ER) visits, and improved behavioral health outcomes for the low-income working uninsured.  It is modeled on community-based clinics featuring a unique structure that I created along with Patrick Reilly, an insurance consultant from western New York:— Empower3 Center for Health program.

The model we created features an “insurance-less” office concept that allows patients to come in as frequently as needed without worrying about being billed or having any balances to pay. The program has no co-pays, deductibles or balance billing when the patients use the participating community hospital that partners with the program.  Since there is no billing at the point of service, there is more face time with the medical professionals to spend creating a true relationship that focuses on care and provides dignity to the patients seeking quality medical care. The office is open five days a week to provide access to patients as needed. 

David S. Jones, MD, PhD, is the A. Bernard Ackerman Professor of the Culture of Medicine at Harvard Medical School's Department of Global Health & Social Medicine. He is a 2007 recipient of a Robert Wood Johnson Foundation (RWJF) Investigator Award in Health Policy Research, and the author of Broken Hearts: The Tangled History of Cardiac Care.

Every day, all over America, people visit their doctors with chest pain and other symptoms of coronary artery disease. Each year, more than a million of them choose to undergo bypass surgery or angioplasty. Are these decisions good ones? Even though modern medicine has committed itself to an ideal of evidence-based medicine, with its clinical trials, meta-analyses, and practice guidelines, the answer is not always clear. By looking closely at the history of these procedures, it is possible to understand some of the reasons why this is the case. With support from a RWJF Investigator Award in Health Policy Research, I looked at three specific questions: the role of evidence and intuition in medical decisions, the reasons why it can be so difficult to determine the risks of medical interventions, and the problem of “unwarranted variation” in medical practice.

Pamela A. Kulbok, DNSc, RN, PHCNS-BC, FAAN, is a Robert Wood Johnson Foundation Executive Nurse Fellow. She is the Theresa A. Thomas Professor of Nursing and a professor of public health sciences at the University of Virginia, chair of the Department of Family, Community, and Mental Health Systems, and coordinator of the public health nursing leadership track of the master’s in nursing program.

With the recent release of second edition of the Public Health Nursing: Scope and Standards of Practice (American Nurses Association, 2013), now is a perfect time to reflect on the past and look toward the future of public health nursing (PHN). Public health nurses have always focused on improving the health of populations through health promotion and disease prevention. Since the establishment of visiting nursing in Boston and the Henry Street Settlement in New York City in the late 1800s, public health nurses have worked with families and communities in schools and homes, with immigrant populations in industrialized cities, and with rural communities to address challenging social conditions and to promote the health of the public.

It was evident with the founding of the National Organization of Public Health Nurses in 1912 that “something must be done” to prepare nurses with a broader education and emphasis on social conditions and prevention. Today, more than ever before, when health care in the United States is shifting its emphasis from an illness care system to one focused on health promotion and prevention, we need public health nurse generalists and advance practice public health nurses prepared to lead health care reform. 

Richard Rieselbach, MD, is an alumnus of the Robert Wood Johnson Foundation Health Policy Fellows program and a professor emeritus and health policy consultant for the University of Wisconsin Medical Foundation.

In the last decade, the nation’s community health centers (CHCs) have doubled their capacity. They now provide care for more than 22 million underserved children and adults in every state. But they’re going to need to do it again. By 2019, some 40 million patients will be in need of care.

The United States does not have enough primary care providers to serve these new patients, and our public investment in health professions education—graduate medical education (GME)—is failing to produce the pipeline we need. Medical students are choosing specialties over primary care at an alarming rate, and a policy vacuum keeps the GME program from being held accountable.

An initiative was launched in 2011 that I think holds great promise: the Teaching Health Center Graduate Medical Education initiative. This five-year, $230 million program was funded by the Affordable Care Act and created to increase the number of primary care graduates trained in community settings.

My colleagues and I have proposed a modified and expanded version of this initiative, called “CHAMP” Teaching Health Centers (CHAMP THCs). Our teaching model would pair CHCs with academic medical centers to develop a THC track that would encourage students to graduate in primary care and practice in urban and rural underserved areas.

Mark I. Neuman, MD, MPH, is director of fellowship research and research education for the division of emergency medicine at Boston Children’s Hospital, and an assistant professor of pediatrics at Harvard Medical School. The following blog, adapted from a commentary he co-authored in Pediatrics, originally appeared on Vector, the science and innovation blog of Boston Children's Hospital.

It’s no secret that the U.S. health care system is in the midst of a financial crisis. As a nation, we spend nearly 18 percent of our Gross Domestic Product on health care, and health care costs remain the largest contributor to the national debt. In 2011 alone, the cost of maintaining the nation’s 5,700 hospitals exceeded $770 billion.

If ever there was a time for a societal mandate to reduce health care costs, that time is now.

It’s widely accepted that one of the first steps to reining in runaway health care costs is reducing variability in the manner in which care is delivered. Well-defined and well-disseminated best practice guidelines can improve the reproducibility and standardization of care. In time, these guidelines may reduce costly and unnecessary tests and hospitalizations, while providing a platform on which to measure and enhance quality. More consistency may also allow providers to be more efficient with their time, space and personnel.

If it’s so costly, why is health care variability so abundant?

Robin Whittemore, PhD, APRN, FAAN, is an associate professor at Yale School of Nursing. Whittemore has received national and international recognition for her work in behavioral interventions for type 1 and type 2 diabetes. One focus of her work has been to examine ways to improve access to health programs for vulnerable high-risk populations. She is the primary investigator on a study funded by the RWJF Interdisciplinary Nursing Quality Research Initiative to prevent diabetes among at-risk adults in public housing. This post originally appeared on the U.S. Department of Health and Human Services’ National Partnership for Action blog.

Minority adults are at a disproportionate risk for developing type 2 diabetes, a challenging illness to manage that is a leading cause of morbidity and mortality in the U.S. Evidence indicates that lifestyle change programs, which incorporate healthy eating, physical activity and modest weight loss, can prevent or delay the development of type 2 diabetes. Yet, access to diabetes prevention programs is limited, particularly among minority and low-income adults.

To help address the issues with access to diabetes prevention programs, we designed a study to link existing community resources—public housing communities and a homecare agency— to minority and low-income adults at-risk for type 2 diabetes. Public housing communities provide housing at reduced rental costs for families of low socioeconomic status. We chose this setting because these communities often have the space and personnel to support a community-based program. The homecare agency consists of nurses who monitor and implement healthcare in a home environment, and are trusted health professionals in public housing communities.

Jason Karlawish, MD, is a professor of medicine, medical ethics and health policy at the University of Pennsylvania and the director of Penn’s Neurodegenerative Disease Ethics and Policy Program. He is the recipient of a Robert Wood Johnson Foundation Investigator Award in Health Policy Research.

“Prescribe the right drug to the right patient at the right time” is not a new medical practice, but when a biomarker—that is, a measure of disease pathophysiology—or a gene makes this decision, that is a radically new medical practice. The promise of personalized medicine is that biomarker and gene driven algorithms will do much of the work of medicine. By predicting patients’ future health and the outcomes of an intervention, they will guide what doctors recommend to their patients. Like the theory of evidence-based medicine, personalized medicine promises a more objective, efficient and precise medical practice.

To date, personalized medicine has largely flourished “below the neck,” that is, in the care of patients with common medical diseases, particularly cancer and cardiovascular disease. In the last two decades though, the National Institutes of Health, the pharmaceutical industry, and researchers have invested substantial time and money in research such as the Alzheimer’s Disease Neuroimaging Initiative (called “ADNI”) dedicated to discovering and validating the biomarkers and genes that predict whether a brain will fail. This research is beginning to reshape how we talk about the diagnosis and treatment of the aging brain, an organ that is more and more, like hearts and bones, regarded as an organ “at risk.” As a result, clinicians, ethicists, and health care policy-makers are beginning to ask how we should practice personalized medicine for the seemingly healthy brain that is at risk for neurodegenerative dementias such as Alzheimer’s, Parkinson’s, Lewy Body Disease and frontotemporal lobar degeneration.

The Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, recommended that nurses be empowered and prepared to take leadership roles, becoming full partners in hospitals and other health care settings to redesign health care in the United States.

In this video, produced by the New Jersey Action Coalition, Dave Knowlton, president and CEO of the New Jersey Health Care Quality Institute, and Robert Wise, president and CEO of the Hunterdon Healthcare System, talk about the importance of having nurses in leadership positions on hospital boards.

Last spring, Time Magazine published a much-discussed article that looked at how hospitals set prices for the services they provide, and the wide variations in pricing from one hospital to another. But hardly anyone actually pays those seemingly outrageous prices, Robert Wood Johnson Foundation (RWJF) Interdisciplinary Nursing Quality Research Initiative co-director Mark V. Pauly, PhD, says, because public and private insurance companies negotiate them down for their customers.

In the third video in a series of RWJF Clinical Scholars Health Policy Podcasts, Clinical Scholar Chileshe Nkonde-Price, MD, interviews Pauly, an economist, about the price of hospital care and the difference between posted prices and what consumers pay.

The video is republished with permission from the Leonard Davis Institute.

Sarah M. Miller is a Robert Wood Johnson Foundation (RWJF) Scholar in Health Policy Research (cohort 19). She has a PhD in economics from the University of Illinois at Urbana-Champaign. Her dissertation examines the effect of the 2006 Massachusetts health care reform on emergency room (ER) use. Miller will soon become an assistant professor of economics at the University of Notre Dame. Read all the blog posts in this series.

The Emergency Medical Treatment and Active Labor Act (EMTALA) guaranteed all patients the right to receive urgent care in an emergency department regardless of their ability to pay. While the intent of the EMTALA was to ensure no patient was refused emergency care simply because they did not have health insurance, by covering only emergency department care, and not primary or preventive care, the EMTALA created incentives for patients to use the health care system inefficiently. These incentives may be especially salient for low-income or uninsured patients who have limited access to health services outside of emergency departments and community health centers.

The law established that patients could always receive care in the emergency department even if they didn’t have the cash to pay upfront, or an insurance company picking up the tab, but the mandate did not extend to private physicians’ offices. Some state laws go so far as to dictate that uninsured patients can receive free care in the ER if they have sufficiently low incomes.