Understanding VA's Use of and Relationships With Community Care Providers Under the MISSION Act

BACKGROUND

Congress has enacted 2 major pieces of legislation to improve access to care for Veterans within the Department of Veterans Affairs (VA). As a result, the VA has undergone a major transformation in the way that care is delivered to Veterans with an increased reliance on community-based provider networks. No studies have examined the relationship between VA and contracted community providers. This study examines VA facility directors' perspectives on their successes and challenges building relationships with community providers within the VA Community Care Network (CCN).

OBJECTIVES

To understand who VA facilities partner with for community care, highlight areas of greatest need for partnerships in various regions, and identify challenges of working with community providers in the new CCN contract.

RESEARCH DESIGN

We conducted a national survey with VA facility directors to explore needs, challenges, and expectations with the CCN.

RESULTS

The most common care referred to community providers included physical therapy, chiropractic, orthopedic, ophthalmology, and acupuncture. Open-ended responses focused on 3 topics: (1) Challenges in working with community providers, (2) Strategies to maintain strong relationships with community providers, and (3) Re-engagement with community providers who no longer provide care for Veterans.

CONCLUSIONS

VA faces challenges engaging with community providers given problems with timely reimbursement of community providers, low (Medicare) reimbursement rates, and confusing VA rules related to prior authorizations and bundled services. It will be critical to identify strategies to successfully initiate and sustain relationships with community providers.

ISPOR, the FDA, and the Evolving Regulatory Science of Medical Device Products

The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) is a key venue for members from private industry, government, and academia to collaborate and share advances in regulatory, clinical, and reimbursement science for drugs, devices, and diagnostics. In parallel, the US Food and Drug Administration (FDA) "is responsible for advancing the public health by helping to speed innovations that make medical products more effective, safer, and more affordable." In 2012, the Medical Device Innovation Consortium (MDIC) was formed as a public-private partnership bringing together government, industry, and nonprofit organizations to advance approaches that promote patient access to safe, innovative medical technologies. With a focus on regulatory science, the MDIC has been assessing how to apply real-world evidence (RWE) regulatory science to medical devices. A key goal of this project is to review the history of RWE regulatory science, define terms, and explain why and how RWE is being considered across the total product life cycle, including regulatory assessment. Unique considerations of real-world data for in vitro diagnostics are also taken into account. We envision that these activities will help ensure a high level of rigor and integrity of RWE necessary for regulatory use cases and demonstrate where RWE can be successfully used for regulatory decision making. The ISPOR, FDA, and MDIC are providing the needed leadership in ensuring that diverse stakeholders share a meaningful voice in determining RWE use and, by so doing, are improving the quality and efficiency of care, enhancing health outcomes, and addressing broader societal concerns of reducing health disparities and costs.

Strange Bedfellows: Native American Tribes, Big Pharma, and the Legitimacy of Their Alliance

Lost in the cacophony surrounding the debate about high drug prices is the fundamental principle that pharmaceutical innovation will not occur without the prospect of outsized returns enabled through market exclusivity. Biopharmaceutical patents are currently under siege, subject to challenge both in inter partes review ("IPR") proceedings and in Hatch-Waxman actions. These twin assaults threaten to eliminate the incentives necessary for biotechnological innovation--particularly for discoveries made upstream in the innovation pipeline--thus imperiling the development of new drug therapies. But a fascinating solution has emerged: invoking tribal immunity to shield pharmaceutical patents from IPR before the Patent Trial and Appeal Board ("PTAB"). This serves two critically important objectives: promoting tribal self-sufficiency, and encouraging investment in life-saving and life-improving new drugs. Contractual partnerships between Native American tribes and pharmaceutical companies not only provide the tribes with a steady stream of royalty revenue, but also insulate biopharmaceutical patents from challenge in IPR proceedings through the invocation of long-established principles of tribal sovereign immunity. This Note is the first piece of scholarship to comprehensively analyze, and advocate for, the right to invoke tribal sovereign immunity in IPR proceedings.

The National Trust: A viable model of care for adults with intellectual disabilities in India

The longevity of people with intellectual disabilities is increasing in developing nations. However, developing nations lack a proper system of care for aging persons with intellectual disabilities. Until now the care has been provided by parents and relatives in the home environment in developing countries, but this scenario is also changing; therefore, there is a strong need to explore a plan of care for this population which is also feasible and replicable. The National Trust is an autonomous body of the Government of India which has developed a comprehensive plan of care for adults with intellectual disabilities. In this article, the National Trust is discussed using a socioecological model. The replicability and suitability of this model for other developing countries are discussed.

Medical Director Responsibilities to the ESRD Network

The 18 regional ESRD Networks are established in legislation and contract with the Centers for Medicare and Medicaid Services to improve the quality and safety of dialysis, maximize patient rehabilitation, encourage collaboration among and between providers toward common quality goals, and improve the reliability and the use of data in pursuit of quality improvement. The Networks are funded by a $0.50 per treatment fee deducted from the reimbursement to dialysis providers, and their deliverables are determined by a statement of work, which is updated in a new contract every 3 years. The Conditions for Coverage require dialysis providers to participate in Network activities, and failure to do so can be the basis for sanctions against the provider. However, the Networks attempt to foster a collegial relationship with dialysis facilities by offering tools, educational activities, and other resources to assist the facilities in meeting the evolving requirements by the Centers for Medicare and Medicaid Services on the basis of national aims and domains for quality improvement in health care that transcend the ESRD program. Because of his/her responsibility for implementing the quality assessment and performance improvement activities in the facility, the medical director has much to gain by actively participating in Network activities, especially those focused on quality, safety, patient grievance, patient engagement, and coordination of care. Membership on Network committees can also foster the professional growth of the medical director through participation in quality improvement activity development and implementation, authorship of articles in peer-reviewed journals, creation of educational tools and presentations, and application of Network-sponsored materials to improve patient outcomes, engagement, and satisfaction in the medical director's facility. The improvement of care of patients on dialysis will be beneficial to the facility in achieving its goals of quality, safety, and financial viability.

The modernization of American public law: health care reform and popular constitutionalism

The Patient Protection and Affordable Care Act (ACA) transformed U.S. public law in crucial ways extending far beyond health care. As important as were the doctrinal shifts wrought by National Federation of Independent Business v. Sebelius, the ACA's structural changes to public law likely will prove far more important should they become entrenched. The struggle over the ACA has triggered the kind of "constitutional moment" that has largely replaced Article V's formal amendment procedure since the Prohibition fiasco. The Court participates in this process, but the definitive and enduring character of these constitutional moments' outcomes springs from broad popular engagement. Despite the Court's ruling and the outcome of the 2012 elections, the battle over whether to implement or shelve the ACA will continue unabated, both federally and in the states, until We the People render a clear decision. Whether the ACA survives or fails will determine the basic principles that guide the development of federalism, social insurance, tax policy, and privatization for decades to come. In each of these areas, the New Deal bequeathed us a delicate accommodation between traditionalist social values and modernizing norms of economic efficiency and interest group liberalism. This balance has come under increasing stress, with individual laws rejecting tradition far more emphatically than the New Deal did. But absent broad popular engagement, no definitive new principles could be established. The ACA's entrenchment would elevate technocratic norms across public law, the first change of our fundamental law since the civil rights revolution. The ACA's failure would rejuvenate individualistic, moralistic, pre-New Deal norms and allow opponents to attempt a counterrevolution against technocracy.

The future of conflicts of interest: a call for professional standards

Stricter policies regarding conflicts of interest policies will increase transparency but have limitations and unintended adverse consequences. Physicians and the medical profession should take the lead in developing policies, rather than responding to external regulations. The goal is to reduce significant risks of undue influence, while keeping the burdens and opportunity costs of policies acceptable.

The future of urban water services in Latin America

In recent decades, problems with the provision of drinking water and sanitation services around the world have increasingly been addressed by attempts at privatisation, recasting clean water as an essentially economic, rather than public, good. This approach gained particular acceptance in Latin America, but with limited success. In order to address the full range of social, economic and environmental values necessary to sustain water resources over time, public and governmental involvement in establishing integrated water management, pursuing ‘soft path’ approaches, assuring stakeholder input and setting policy will be essential to the process.

Public–private partnerships in solid waste management: sustainable development strategies for Brazil

An often overlooked issue in the discussion of sustainable development is that of municipal solid waste management. Yet solid waste management is pervasive in all sustainable development objectives: its management, or lack thereof, can have major implications for the health of the environment, economy and society. This article argues the need for a governance dimension in the sustainability model, taking into account implementation strategies, monitoring and institutional controls. This focus heavily relies on integrated public–private partnerships and deliberative democracy approaches in order to achieve sustainability within the solid waste management sector. In this article, national and local policies in Brazil are analysed, primarily focusing on the inclusion of informal waste collection into municipal solid waste management schemes. The city of Curitiba, in the state of Paraná, which is world-renowned for its innovative sustainable development policies, is used to frame and illustrate the case.

Re-engineering drug discovery and development

The rate of new drug approvals in the US has remained essentially constant since 1950, while the costs of drug development have soared. Many commentators question the sustainability of the current model of drug development, in which large pharmaceutical companies incur markedly escalating costs to deliver the same number of products to market. This Issue Brief summarizes the problem, describes ongoing governmental efforts to influence the process, and suggests changes in regulatory science and translational medicine that may promote more successful development of safe and effective therapeutics

Public–nonprofit partnership performance in a disaster context: the case of Haiti

During disasters, partnerships between public and nonprofit organizations are vital to provide fast relief to affected communities. In this article, we develop a process model to support a performance evaluation of such intersectoral partnerships. The model includes input factors, organizational structures, outputs and the long-term outcomes of public–nonprofit partnerships. These factors derive from theory and a systematic literature review of emergency, public, nonprofit, and network research. To adapt the model to a disaster context, we conducted a case study that examines public and nonprofit organizations that partnered during the 2010 Haiti earthquake. The case study results show that communication, trust, and experience are the most important partnership inputs; the most prevalent governance structure of public–nonprofit partnerships is a lead organization network. Time and quality measures should be considered to assess partnership outputs, and community, network, and organizational actor perspectives must be taken into account when evaluating partnership outcomes.

Policy entrepreneurship in the development of public sector strategy: the case of London health reform

The development of health policy is recognized as complex; however, there has been little development of the role of agency in this process. Kingdon developed the concept of policy entrepreneur (PE) within his ‘windows’ model. He argued inter-related ‘policy streams' must coincide for important issues to become addressed. The conjoining of these streams may be aided by a policy entrepreneur. We contribute by clarifying the role of the policy entrepreneur and highlighting the translational processes of key actors in creating and aligning policy windows. We analyse the work in London of Professor Sir Ara Darzi as a policy entrepreneur. An important aspect of Darzi's approach was to align a number of important institutional networks to conjoin related problems. Our findings highlight how a policy entrepreneur not only opens policy windows but also yokes together a network to make policy agendas happen. Our contribution reveals the role of clinical leadership in health reform.

The political economy of maize production and poverty reduction in Zambia: analysis of the last 50 years

Poverty and food security are endemic issues in much of sub-Saharan Africa. To eradicate extreme poverty and hunger in the region remains a key Millennium Development Goal. Many African governments have pursued economic reforms and agricultural policy interventions in order to accelerate economic growth that reduces poverty faster. Agricultural policy regimes in Zambia in the last 50 years (1964–2008) are examined here to better understand their likely impact on food security and poverty, with an emphasis on the political economy of maize subsidy policies. The empirical work draws on secondary sources and an evaluation of farm household data from three villages in the Kasama District of Zambia from 1986/87 and 1992/93 to estimate a two-period econometric model to examine the impact on household welfare in a pre- and post-reform period. The analysis shows that past interventions had mixed effects on enhancing the production of food crops such as maize. While such reforms were politically popular, it did not necessarily translate into household-level productivity or welfare gains in the short term. The political economy of reforms needs to respond to the inherent diversity among the poor rural and urban households. The potential of agriculture to generate a more pro-poor growth process depends on the creation of new market opportunities that most benefit the rural poor. The state should encourage private sector investments for addressing infrastructure constraints to improve market access and accelerate more pro-poor growth through renewed investments in agriculture, rural infrastructure, gender inclusion, smarter subsidies and regional food trade. However, the financing of such investments poses significant challenges. There is a need to address impediments to the effective participation of public private investors to generate more effective poverty reduction and hunger eradication programmes. This article also explores the opportunities for new public–private investments through South–South cooperation and Asia-driven growth for reducing poverty in Zambia.

What more can plant scientists do to help save the green stuff?

The Global Strategy for Plant Conservation (GSPC) was the first such effort under the Convention on Biological Diversity (CBD), and had gone through a 3-year process to reach the level of maturity that enabled it to be approved by consensus by all Governments present at the key session in The Hague in April 2002. It provided a model for subsequent CBD workplans, with targets, and undoubtedly contributed to the 2010 target of reducing the rate of biodiversity loss. In the event, few of the targets were achieved, because of numerous constraints at both policy and implementation levels. Even so, the GSPC stands as an important milestone in the global effort to conserve biodiversity. However, few plant scientists can be satisfied that the essential steps are being taken to ensure the conservation of plants, although, of course, plant scientists are only one part of the complex effort that will be required. This paper offers some suggestions that might be worth consideration, building on the basic principle in politics that a strong constituency is necessary to victory. In other words, although plant scientists play a crucial role, plant conservation is too important to leave in their hands alone; far broader support is required, including from the private sector, agriculture, forestry, trade, economics, tourism and even the military. Although botanical science provides a solid foundation, other branches of science are also important, ranging from anthropology to zoology. The legal profession also has important contributions to make (as well as the ability to hamper progress – for example through using issues such as access and benefit sharing to limit the exchange of genetic materials for even noncommercial use). 2010 was the United Nations Year of Biodiversity, and the GSPC targets reached their due date. It therefore seems timely to add some additional perspectives to the effort to update the GSPC. This paper suggests ways to reach a far broader constituency, provides tools to those who are expected to achieve the targets, and suggests ways to build a strong international constituency to conserve the world's botanical wealth.

Parent child coalitions: innovative public-sector management and early childhood development in Manitoba

This article considers a coalition model of governance as an innovative approach to public management. In general, the coalition governance model adopts key principles of new public management and inherits criticisms similar to those levelled against the new managerialism. Looking at a case study of parent child coalitions in Manitoba, this article explores some benefits and consequences of implementing and utilizing coalition governance as a model for social policy. It finds that the attempt to increase child-centred programming across the province required innovative adjustments to the management of this social policy issue, as well as a restructuring of the overarching policy structure. Innovative public management and the implementation of a coalition governance approach helped transform early childhood development in Manitoba from a private and personal family concern to a public policy issue. It has increased citizen engagement and has also increased government access to a previously inaccessible segment of society. Although these innovations resolved some key concerns, additional criticisms remain as yet unaddressed.

Diaspora, faith, and science: building a Mouride hospital in Senegal

This article examines a development initiative spearheaded by the members of a transnational diaspora – the creation of a medical hospital in the holy city of Touba in central Senegal. Although the construction of the hospital is decidedly a philanthropic project, Hôpital Matlaboul Fawzaini is better understood as part of the larger place-making project of the Muridiyya and the pursuit of symbolic capital by a particular Mouride "dahira". The "dahira's" project illuminates important processes of forging global connections and transnational localities, and underscores the importance of understanding the complex motivations behind diaspora development. The hospital's history reveals the delicate negotiations between state actors and diaspora organizations, and the complexities of public–private partnerships for development. In a reversal of state withdrawal in the neo-liberal era, a diaspora association was able to wrest new financial commitments from the state by completing a large infrastructure project. Despite this success, we argue that these kinds of projects, which are by nature uneven and sporadic, reflect particular historical conjunctures and do not offer a panacea for the failure of state-led development.

Deinstitutionalization and vocational rehabilitation for mental health consumers in Nova Scotia since the 1950s

In this paper we explore the broader policy determinants of the de-hospitalization of mental patients in Nova Scotia between the 1950s and 1980s and trace the background to the development of occupational rehabilitation programs in the community. For employment programs, the government chose to rely on non-profit NGOs as the suppliers of services. As a case study of such an organization, we examine the evolution of LakeCity Employment Services Association as a resource for people living with mental disabilities.

From closed ranks to open doors: Elaine and John Cummings' mental health education experiment in 1950s Saskatchewan

During late 1951 and early 1952, married couple, social biologist Elaine Cumming and psychiatrist John Cumming, led a mental health education experiment in Indian Head, Saskatchewan. The study, which was intended to inform strategies toward deinstitutionalization, sought to determine if attitudes regarding mental illness could be changed through commonly used educational practices. It was shaped by the shared interests of powerful philanthropic, charitable, psychiatric, academic and governmental bodies to create healthier citizens and a stronger democratic nation through expert knowledge. However, in addition to the disappointing findings indicating that attitudes remained unchanged, the town appeared to close ranks against the research team. Nonetheless, the Cummings' later association with sociologists at Harvard University enabled them to interpret the results in a way that lent the study credibility and themselves legitimacy, thus opening the door to their careers as very successful researchers and policy-makers.

The role of the public sector in the provision of housing supply in Turkey, 1950–2009

This study examines the changing role of the public sector in Turkey with regard to housing provision since 1950, and particularly since 2000, and seeks to clarify how public intervention has affected housing provision and urban development dynamics in major cities. Three periods may be identified, with central government acting as a regulator in a first period characterized by a ‘housing boom’. During the second period, from 1980 to 2000, a new mass housing law spurred construction activity, although the main beneficiaries of the housing fund tended to be the middle classes. After 2000, contrary to emerging trends in both Northern and Southern European countries, the public sector in Turkey became actively involved in housing provision. During this process, new housing estates were created on greenfield sites on the outskirts of cities, instead of efforts being made to rehabilitate, restore or renew existing housing stock in the cities. Meanwhile, the concept of ‘urban regeneration’ has been opportunistically incorporated into the planning agenda of the public sector, and — under the pretext of regenerating squatter housing areas — existing residents have been moved out, while channels for community participation have been bypassed.

The politics of partnerships: a study of police and housing collaboration to tackle anti-social behaviour on Australian public housing estates

This paper draws on the findings from a research project on partnership arrangements between the police and housing departments on three Australian public housing estates to tackle problems associated with illicit drug activity and anti-social behaviour (ASB). The analysis focused on the setting up of the partnerships and the interactions that followed from these institutional arrangements. The assumption that informs the paper is that when studying partnerships there is a need for a more critically framed analysis. The temptation to posit "a successful model" of what partnership entails and then to judge practices in relation to this model is considerable, but it inevitably falls into the trap of constructing a narrative of partnership success or failure in terms of individual agency (that is, the degree of commitment from individuals). The analysis undertaken in this paper has therefore sought to fathom a more complex set of organizational processes. Rather than confine the discussion to issues of success and failure, the study foregrounds the subjective accounts of individuals who work within partnership and the constraints they encounter. The paper therefore makes explicit the cultural tensions within and across agencies, contestation as to the extent of the policy "problem," and the divergent perspectives on the appropriate modes of intervention.

Supplier behaviour and public contracting in the English agency nursing market

The worldwide expansion in the use of private firms to deliver public services and infrastructure has promoted a substantial literature on public sector contract and relationship management. This literature is currently dominated by the notion that supplier relationships should be based upon trust. Less prominent are more sceptical approaches that emphasize the need to assiduously manage potential supplier exploitation and opportunism. This article addresses this imbalance by focusing upon the recent experience of the English National Health Service (NHS) in its dealings with its nursing agencies. Between 1997 and 2001, the NHS was subjected to considerable exploitation and opportunism. This forced managers to adopt a supply strategy based upon an assiduous use of e-auctions, framework agreements and quality audits. The article assesses the effectiveness of this strategy and reflects upon whether a more defensive approach to contract and relationship management offers a viable alternative to one based upon trust.

Similar problems, different solutions: comparing refuse collection in the Netherlands and Spain

Because of differences in institutional arrangements, public service markets, and national traditions regarding government intervention, local public service provision can vary greatly. In this paper we compare the procedures adopted by the local governments of The Netherlands and Spain in arranging for the provision of solid waste collection. We find that Spain faces a problem of consolidation, opting more frequently to implement policies of privatization and cooperation, at the expense of competition. By contrast, The Netherlands, which has larger municipalities on average, resorts somewhat less to privatization and cooperation, and more to competition. Both options-cooperation and competition-have their merits when striving to strike a balance between transaction costs and scale economies. The choices made in organizational reform seem to be related to several factors, among which the nature of the political system and the size of municipalities appear to be relevant.

Planning responds to gender violence: evidence from Spain, Mexico and the United States

Urban planning has been largely ineffective in addressing urban violence and particularly slow in responding to gender violence. This paper explores the public and private divide, structural inequalities, and issues of ethnicity and citizenship, in terms of their planning implications for gender violence. Drawing on evidence from Spain, Mexico and the United States, it examines how economic and social planning and gender violence intertwine. The three case studies demonstrate that the challenge is not only to break constructed structural inequalities and divisions between public and private spheres, but also to promote changes in the working models of institutions and organisations.

"Velddrift": the making of a South African company town

Recent reviews of South African urban history have highlighted its neglect of rural urbanization and the role of the state and capital in urban development. Natural resource frontiers offer a uniquely unobstructed view of rural urbanization under the aegis of capital and the state. The process has been well documented for South Africa's mineral revolution, but other resource frontiers have been completely ignored. The latter developed in the long shadow cast by mining and the urban metropoles, with their centripetal pull on labour and the state, making the company town an archetypal urban form on the rural periphery.

Seeds of hope, seeds of despair: towards a political economy of the seed industry in southern Africa

The seed industry in Southern Africa has been radically transformed by a policy of liberalisation and privatisation started under structural adjustment. Traditionally under the domain of parastatals, seed research, production and distribution has been criticised for failing to provide modern variety seed to smallholder farmers. However, the private companies which have stepped in to replace seed parastatals in southern Africa have proven no more effective in meeting the demands of smallholders. The Trade Related Intellectual Property Rights (TRIPs) Agreement, concluded in 1994 as part of the Uruguay Rounds of GATT negotiations, as well as certain biotechnological innovations such as Terminator or Traitor technologies, threaten to further undermine local seed production and consumption by destroying the informal seed sector so central to agricultural production in the region. What alternatives exist? The success of Zimbabwe's maize seed network offers some insight. Resting on a unique relationship between government and nationally based producer co-operatives, Zimbabwe's maize programme was able to provide nearly every farmer in the country with hybrid maize suited for local growing conditions.

Colonial modernism and the flawed paradigms of urban renewal: uneven development in Bombay, 1900-25

This article explores the failure of urban renewal in Bombay city during the first quarter of the twentieth century. It shows how colonial rule structured a class-driven process of uneven urban ‘improvements’ that actually exacerbated the problems of congestion, bad housing and environmental blight. In this process, the new forces of modernity were selectively appropriated to accentuate the differentiation in built forms and urban spaces. Finally, through implicit comparisons with contemporary developments in Europe, it reveals the limitations of urban regeneration in a laissez-faire colonial capitalist environment where the search for quick returns by competing economic actors precluded the adoption of long-term policies and interventionist strategies necessary to create the good city life.