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Continuity of Care and the Cost of Treating Chronic Disease

July 21, 2014 Comments off

Continuity of Care and the Cost of Treating Chronic Disease
Source: RAND Corporation

Strengthening coordination of care in the U.S. health care system is a priority for policymakers and the medical community. Poor coordination of care can drive up costs and harm patient health, especially for patients with chronic illnesses who see many different providers across many different settings. Some new models of care, such as the patient-centered medical home, focus on improving coordination as a way to provide affordable, high-quality care. Are these new models having the desired effect?

To answer this question, RAND researchers studied one important aspect of care coordination: continuity of care — the extent to which a patient’s care visits occur with the same provider. Researchers reviewed insurance claims data to gauge the association between continuity of care, costs, and patient outcomes during episodes of care for Medicare patients with one or more of three chronic diseases: congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and type 2 diabetes mellitus (DM).

Researchers used a continuity of care (COC) index to measure the number of providers and/or practices involved in a patient’s care during a 365-day episode of care. The index ranges from 0 (each visit involved a unique provider) to 1 (all visits were billed by a single provider). An increase in the COC index reflects either fewer providers involved in a patient’s care or a concentration of visits among fewer providers.

Findings from this study show that modest improvements in continuity of care correlate with sizable reductions in service use, complications, and costs:

  • Higher levels of care continuity for CHF, COPD, and DM patients were consistently associated with lower rates of hospitalizations, emergency room visits, and complications.
  • An 0.1-unit increase in the COC index (which ranges from 0 to 1) was associated with episode-of-care costs for CHF, COPD, and DM patients that were on average 5 percent lower.
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Iran’s Influence in Afghanistan: Implications for the U.S. Drawdown

July 18, 2014 Comments off

Iran’s Influence in Afghanistan: Implications for the U.S. Drawdown
Source: RAND Corporation

This study explores Iranian influence in Afghanistan and the implications for the United States after the departure of most American forces from Afghanistan. Iran has substantial economic, political, cultural, and religious leverage in Afghanistan. Kabul faces an obdurate insurgency that is likely to exploit the U.S. and international drawdown. The Afghan government will also face many economic difficulties in future years, and Afghanistan is highly dependent on international economic aid. Additionally, the biggest problem facing Afghanistan may be political corruption. Iranian influence in Afghanistan following the drawdown of international forces need not necessarily be a cause of concern for the United States though. Although Tehran will use its cultural, political, and economic sway in an attempt to shape a post-2016 Afghanistan, Iran and the United States share core interests there: to prevent the country from again becoming dominated by the Taliban and a safe haven for al Qaeda.

This study examines Iran’s historic interests in Afghanistan and its current policies in that country, and explores the potential implications for U.S. policy. The research is based on field interviews in Afghanistan, the use of primary sources in Dari and Persian, and scholarly research in English.

The Future of Driving in Developing Countries

July 17, 2014 Comments off

The Future of Driving in Developing Countries
Source: RAND Corporation

The level of automobility, defined as travel in personal vehicles, is often seen as a function of income: The higher a country’s per capita income, the greater the amount of driving. However, levels of automobility vary quite substantially between countries even at similar levels of economic development. This suggests that countries follow different mobility paths. The research detailed in this report sought to answer three questions: What are the factors besides economic development that affect automobility? What is their influence on automobility? What will happen to automobility in developing countries if they progress along similar paths as developed countries? To answer these questions, the authors developed a methodology to identify these factors, model their impact on developed countries, and forecast automobility (as defined by per capita vehicle-kilometers traveled [VKT]) in four developing countries. This methodology draws on quantitative analysis of historical automobility development in four country case studies (the United States, Australia, Germany, and Japan) that represent very different levels of per capita automobility, in combination with data derived from an expert-based qualitative approach. The authors used the latter to assess how these experiences may affect the future of automobility in the BRIC countries: Brazil, Russia, India, and China. According to this analysis, automobility levels in the four BRIC countries will fall between those of the United States (which has the highest per capita VKT level of the four case studies) and Japan (which has the lowest). Brazil is forecasted to have the highest per capita VKT and India the lowest.

Why Is Veteran Unemployment So High?

July 17, 2014 Comments off

Why Is Veteran Unemployment So High?
Source: RAND Corporation

According to official statistics, the unemployment rate of young military veterans ages 18-24 reached 29 percent in 2011. This report seeks to put that statistic in perspective by examining the historical time-series of veteran unemployment, comparing the veteran unemployment rate to that of non-veterans, and examining how veteran unemployment varies with time since military separation. Between 2000 and 2011, younger veterans were, on average, 3.4 percentage points more likely to be unemployed than similarly situated younger non-veterans. However, this difference between veteran and non-veteran unemployment falls rapidly with age and time since military separation. The report concludes that the best available evidence supports the hypothesis that relatively high rates of veteran unemployment reflect the fact that veterans, especially younger veterans, are more likely to have recently separated from a job — namely, military service — and, consequently, are more likely to be engaged in job search, which takes time, especially during periods of slow economic growth. The available evidence lends little support to the hypothesis that veterans are inherently disadvantaged in the civilian labor market. Limiting unemployment benefits available to recently separated veterans would likely reduce the length of unemployment spells, but the net effect of such a policy action on the long-term federal budget is unclear. There is very limited evidence on the effectiveness of other federal policies aimed at facilitating the transition of veterans into the civilian labor market.

Effects of Heath Care Reform on Disability Insurance Claiming

July 15, 2014 Comments off

Effects of Heath Care Reform on Disability Insurance Claiming
Source: RAND Corporation

The Affordable Care Act (ACA) will fundamentally change the conditions that influence Americans to apply for federal disability insurance benefits. Because disability insurance confers health insurance in addition to cash benefits, it is an attractive option for many individuals with work-limiting disabilities. At the same time, leaving employment to apply for disability insurance benefits (a requirement for application) can be risky for those who obtain health insurance through their employers, making it a relatively unattractive option for others. By enabling access to affordable private health insurance and expanding access to subsidized public health insurance, the ACA alters the calculus of disability claiming decisions. Whether it will lead to more or fewer applications for disability benefits is not obvious. Research summarized here offers empirical evidence that, on net, disability applications are likely to decrease.

There is great interest in this issue because the numbers of disability beneficiaries have swelled in recent years relative to the number of workers paying into the system, leading the Board of Trustees of the Federal Disability Insurance Trust Fund to predict that the system will run out of funds by 2016.

It is too soon, of course, to know what the actual effects of national health reform will be on disability applications. But a recent RAND study has examined data from Massachusetts, which implemented reforms in 2006 that share the key features of the ACA, including creation of an insurance exchange as a source of lower-cost individual coverage and expansion of Medicaid (subsidized coverage for low-income individuals). Using administrative data from the Social Security Administration (SSA), the researchers analyzed changes in application rates for the two federal disability insurance programs — Supplemental Security Insurance (SSI) and Social Security Disability Insurance (SSDI) — in Massachusetts before and after the reform, statewide and by county, and compared changes to those in neighboring states and counties.

We summarize what the researchers expected to find in the data, what they actually found, and the implications of their results for national health reform.

The Future of the Army’s Civilian Workforce: Comparing Projected Inventory with Anticipated Requirements and Estimating Cost Under Different Personnel Policies

July 14, 2014 Comments off

The Future of the Army’s Civilian Workforce: Comparing Projected Inventory with Anticipated Requirements and Estimating Cost Under Different Personnel Policies
Source: RAND Corporation

In keeping with the coming drawdown in military end strength, the Department of Defense is planning to scale back its civilian workforce over the next several years. After reaching nearly 295,000 full-time employees in fiscal year (FY) 2010, the size of Army’s civilian workforce has started to fall. It is necessary to manage this drawdown so that sufficient people remain available in key positions. The authors projected the future supply of Army civilians under various scenarios and examined how the Army might manage supply to meet projected demand, by bringing together workforce supply and demand models. The RAND Inventory Model was used to project the supply of Army civilians, by command and occupation, based on historical patterns of internal transfers and separations, and various scenarios for future hiring. The supply projections were matched with demand projections from RAND’s Generating-Force-to-Operator model, which translates budgets for the Army’s operating force into projected changes in the institutional Army, to estimate the numbers of new hires or force reductions needed to meet the demand for civilians. The findings suggest that meeting future targets will require reducing hiring rates below historical levels but that substantial hiring will still be needed in most commands. If demand drops considerably below current projections, larger cuts would likely be required. Workforce cost is projected to change largely in line with the number of personnel. If requirements based on the FY 2014 President’s Budget are met by FY 2017, nominal costs are projected to remain approximately constant, with expected civilian pay raises offsetting workforce reductions.

Armed and Dangerous? UAVs and U.S. Security

July 9, 2014 Comments off

Armed and Dangerous? UAVs and U.S. Security
Source: RAND Corporation

Armed drones are making the headlines, especially in their role in targeted killings. In this report, RAND researchers stepped back and asked whether these weapons are transformative. The answer is no, though they offer significant capabilities to their users, especially in counterterrorism operations as has been the case for the United States. Will they proliferate? Yes, but upon a closer look at the types of systems, only a few rich countries will be in a position to develop the higher technology and longer range systems. U.S. adversaries and others will likely find weapons such as aircraft and air defenses more cost and militarily effective. Their proliferation will not create the kinds of global dangers that call for new arms control efforts, but the risks to regional stability cannot be dismissed entirely, as is the case of any conventional weapon. How the United States will use these weapons today and into the future will be important in shaping a broader set of international norms that discourage their misuse by others.

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