Since their release earlier this week, there has been extensive controversy over the new US Preventive Services Task Force (USPSTF) recommendations against routine mammograms for women under 50. These new recommendations have raised the ire of women across the US and have been disputed by the American Cancer Society, the Susan G. Komen Foundation and other cancer information and services organizations. USPSTF also questioned the value of breast self examination (BSE), saying it was not recommended because it has led to a high number of false positive results. That recommendation has also been called into question from a wide range of women’s organizations and individuals who have found breast lumps as a result of a BSE.

This latter recommendation hits home for me as my wife was recently diagnosed with Breast Cancer and is being treated here at the Jefferson Breast Center. The cancer was not caught from a routine mammogram but rather through her own monthly breast self exam. As a result of that exam, she visited our family doctor immediately. After an ultrasound and additional tests confirmed her breast cancer, she started treatment.

Without her monthly breast self exam, who knows when she would have seen her doctor, received her diagnosis, and begun treatment? BSE is an important, individual personal health screening that can and should be done routinely. My wife is Hispanic. A study from the University of Arizona’s Zuckerman College of Public Health earlier this year reported that two-thirds of Hispanic women diagnosed with breast cancer discovered it through BSE and not from diagnostic services provided within the healthcare environment. The USPSTF recommendation against BSE, if applied nationwide, could adversely impact early detection of breast cancer, especially among diverse populations, many of whom do not routinely use our healthcare system.

Rob Simmons, DrPH, MPH, CHES, CPH
Director, MPH Program
Jefferson School of Population Health

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Healthcare reform needs patient adherence -
http://ping.fm/Vi0Du

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While the debate rages on regarding Healthcare Insurance Reform, several key issues are either severely diminished or completely eliminated from the conversation. Many of the huge costs to the system are associated with the management of chronic illnesses, such as diabetes, asthma and heart disease. Patient compliance or adherence is one of the most critical elements of achieving improved outcomes for patients with chronic illnesses, helping to prevent costly complications and hospitalizations.

Unfortunately, the evidence regarding patient education, behavioral models, care coordinating infrastructure, and perhaps financial incentives to support patients with chronic illnesses lags behind treatment recommendations. While most health professionals are armed with myriad evidence-based clinical guidelines, little is understood or proven on how to engage patients to accept personal responsibility and become active participants in their health care.

Even a coordinated care model runs the risk of failing to achieve improved outcomes if patients do not adhere to recommendations. It is not enough for health professionals to counsel patients to stop smoking, eat a well balanced diet, get screened for markers of cancer and chronic illnesses, take their vaccines, statins, ACE inhibitors, check their blood sugar, etc. Unless there is a funding mechanism to provide the needed resources to support patients in their efforts to comply, we will continue to fail them and add to our ever-increasing cost burden to the system.

Until the system is geared up to support patients and caregivers with the best tools to accept more personal health responsibility and adhere to proper proven recommendations, we will continue to have sub-optimal outcomes no matter what we spend or recommend for healthcare reform changes.

Mike Toscani, PharmD
Project Director
Jefferson School of Population Health

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Like most of you, I have followed our country’s health care reform debate closely. Unfortunately, the conversation is confusing because the subject is complex and generally not presented in a logical and orderly fashion. The current approach to reform involves tweaking the current “system” rather than starting from scratch to design a rational one. Since the current system evolved in a haphazard fashion, attempts at reforming it will doubtless result in something equally complex.

Because the discussion involves strongly held beliefs about intensely personal and important issues, the discussions around health care reform have become quite heated. Emotions come into play, often vigorously, and can get to a point where objective discussion is no longer possible.

The word that seems to have triggered the most emotional response is socialism (the “S” word). It is used in almost a pejorative fashion, as if it is the worst thing that could possibly happen in America. Students of economics embrace capitalism strongly (others have different reasons) because it has proven unparalleled in raising standards of living for vast numbers of people and for providing innovation in our society.

The “S” word is commonly invoked when the discussion turns to a government-provided public insurance option. Simple definitions can help here. In capitalism, individuals own the means of production for goods and services. In socialism, the government owns them. Curiously, socialism is rarely used to describe Medicare, Medicaid, and the various other government-sponsored plans that account for roughly half of the health care dollars spent in this country, and are bona fide examples of “socialist” services.

My reaction to the use of this word has evolved from frustration to bemusement. First, most people cannot possibly have the facts concerning existing government-funded insurance plans in mind when they drop the “S” word in the context of health care reform. Second, for anyone looking at the matter objectively, it is clear that the United States is not a purely capitalistic country. We have many government-run services such as the military, highways, education, the postal service, social security, Medicare, etc. Thus, the United States contains elements of both capitalism and socialism, a so-called mixed economy.

As has become abundantly clear through our recent financial crisis and the government-sponsored rescue of our financial system, government spending when the private sector couldn’t (or wouldn’t) shortened what otherwise would have been an extended economic downturn. Having a little government (read socialism) mixed in with our capitalism can be a good thing. The flaw in the premise of most peoples’ assumption about capitalism is that free markets are inherently self-correcting. They are not. Simply having a capitalistic system does not guarantee a good outcome.

Similar reasoning can be applied to health care. Let’s examine the facts. The United States occupies 37th place in the World Health Organization’s ranking of healthcare quality in industrialized nations, despite the fact that we pay almost twice as much for health care. Perhaps our “capitalistic” healthcare system could use some “socialist” guidance, since it did not find an optimum outcome on its own. If not the government, who will provide guidance toward better outcomes in health care? As has occurred many other times in health care, the government (in the form of CMS) is leading the way to cost and quality reform through various demonstration projects and programs. Private insurance companies are following the government’s lead.

If we take the possibility of a government provided public insurance option to its extreme, is it so crazy to consider a government run health insurance system?
Let’s examine the premise of how insurance works. With a large number of people in a risk pool, the cost for any one individual is reduced. The larger the pool, the broader the risk is spread, the lower the cost.

How could we spread the risk as broadly as possible? A federal government provided public insurance option covering all Americans would do the trick. In point of fact, many Medicare services are administered by the Blues and other private insurance companies. Combining a single large insurance pool with private administration is a nice mixed economic insurance solution. Certainly not as crazy a scheme as what we endure now as a nation with regard to cost and quality…


Richard Jacoby, MD
Associate Professor
Jefferson School of Population Health

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October of 2009 has been an exciting month for health policy wonks. For those of us who enjoy the study of health policy, it doesn’t get much better than this. In this post we briefly describe some of the key health policy ideas still surviving the legislative process. This is not intended to be a thorough review of each measure. As always with complex legislation, the devil is in the details.

The “Mandate”: All the key bills making their way through the House and Senate include a mandate that everyone be required to have health insurance. A health insurance mandate is going to happen, one way or another. Now, for those of us without health insurance, there are provisions (tax credits or “subsidies”) to make insurance affordable. How much those tax credits will offset the cost of buying insurance for each income bracket is still being debated. Likewise, the size of the penalty for not buying insurance is also still being debated.

The “Public Option”: For all the attention this idea is getting from both inside and outside of the Washington beltway, it’s really less interesting to this student of health policy because it’s not as creative or innovative like the other tools being discussed e.g., health insurance exchanges, state-based high risk pools, payment reform, value-based purchasing initiatives… the list goes on. Yet, because the “public option” strikes at a historical, deep-rooted political ideal (the role of government in the private market), it has received the vast majority of attention from the media and the lay public. The audience should know that the “public option” is so fluid in meaning at this point that no one really knows what the “public option” will mean for healthcare. It could be national or state-based; states may be given the option to choose to participate; it might be tied to Medicare, it might negotiate with providers on its own. The point of having a public option is to make premiums affordable by keeping the insurance industry honest and competitive. Recent attention has been given to a maneuver that would create a pathway for the public option in the future only to be implemented (or “triggered”) if insurance companies fail to cover the desired percentage of the population. Votes are needed either way - look for compromises on this issue, not one extreme or the other.

Health Insurance Exchange(s): This is perhaps the most exciting part of health reform, yet few fully understand how important exchanges will be for this health system. For a whole lot of reasons, individuals purchasing insurance on their own have been at a massive disadvantage to those who receive insurance through their employer. An insurance exchange would create a clearinghouse of insurance plans for individuals and families to choose from. For the insurance industry, it also creates a massive pool of potential customers who otherwise might not seek insurance. Like the public option, the exact structure and functioning of the exchange or exchanges is not yet known, i.e., there could be one big national exchange or many “state-based” exchanges. Regardless of approach, there are a few things likely to be included in an individual market exchange. First, the government (either federal or state) will likely set the rules. For insurance companies to participate, the plans they offer would have to meet specific criteria for quality, cost, and access. Furthermore, the ratios by which they can increase or decrease premiums based on age, smoking status, and family size, will likely be fixed.

Subsidies: Finally, the most expensive piece of reform: premium subsidies. Every proposal creates subsidies to buy insurance – so regardless of plan, we will see subsidies. This is where the biggest chunk of the 800 billion to 1 trillion dollars will be spent. The core goal of every reform proposal is to get everyone insured, and health insurance is expensive. Therefore, based on percent of federal poverty level, individuals and families will receive some form of financial support from the federal government to offset the cost of purchasing insurance. The manner in which this financial support is distributed and the size of the subsidies based on income is still being debated.

The mandate, public option, insurance exchanges, and subsidies are 4 key ideas being debated this fall in Congress. There are many more ideas and changes to the system included within each proposal, however. Needless to say, it’s the golden years for health policy wonks – the months of November and December should be very exciting. Stay tuned.

Rich Toner, MS

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I am struck that most of the national conversation about "health reform" has really been all about "insurance reform". Missing from the national conversation are the crucial issues that face our dysfunctional system----unexplained clinical variation, waste, the epidemic of medical errors, solving the tort crisis and much more. NONE of the proposals coming from the Senate or the House even begins to get at these critical issues. We need leaders in Washgington and elsewhere to confront what is really broken and begin the difficult process of self evaluation to fix these core issues. We spend the most and get the least. Sure, on a particular case by case basis we might be fortunate enough to have insurance and to get great medical care---this is not the issue. The issue remains as to how to create value, how to reorganize the system to promote coordination of care, how to realign the financial incentives and finally, how to make the whole thing patient centered. I don't know about you, but my patience is almost running out. I hope we can get the conversation back on track to address these issues that truly matter, and that can help us deliver real reform. DAVID NASH

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As the United States population continues to age and the incidence of Alzheimer’s Disease and related disorders (ADRDs) increases, it is crucial that we examine end-of-life care in this patient population.

The prevalence of dementia in older adults is currently at 50% of the population over age 85. By 2030, approximately 8 million individuals will suffer from dementia. Unfortunately, end-of-life care for this population is less than adequate, and hospice care is too often underutilized. To explore this issue further, the Pennsylvania Hospice Network (PHN) developed a Task Force to survey Pennsylvania Hospice providers about barriers to and facilitators of hospice access for patients with dementia. PHN partnered with the Jefferson School of Population Health and the Delaware Valley Chapter of the Alzheimer’s Association to develop and refine the Survey instrument. The Survey link will be sent to hospice agencies via email this week with a request for response no later than October 31st.

In addition to hospice demographic data, the survey will illuminate providers’ access and quality concerns, such as the number of hospice enrollees with dementia and length of hospice stay in 2006-2008, trends in hospice admission for patients with dementia, perceived regulatory and other barriers to hospice care for this population, hospice capabilities in providing care to persons with dementia, and community outreach activities.

The Survey is a first step toward quantifying hospice access for persons with dementia. We expect that the findings will provide direction for further research and enhanced advocacy efforts, and data to inform policy direction. We will update you with more information in the near future.

If you have questions, please contact JoAnne Reifsnyder, PhD (joanne.reifsnyder@jefefrson.edu) or Laura Kimberly, MSW, MBE (laura.kimberly@jefferson.edu).

JoAnne Reifsnyder, PhD
Assistant Professor
Program Director, Chronic Care Management
Jefferson School of Population Health

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The term “population health” is often misunderstood. So, what does it really mean? Is it public health? How does the population differ from the public? David Kindig, a Senior Advisor at the Population Health Institute at the University of Wisconsin has been working on improving population health in his quest to make Wisconsin the healthiest state and is regarded as an authority on the topic. Kindig defines population health as the distribution of health outcomes within a population, the health determinants that influence distribution and the policies and interventions that impact the determinants. Mention of health determinants and policy clearly indicate that public health is a large component of population health, but that is not where it ends. The key difference between public and population health is the focus on health outcomes, which entails a clinical component as Dr. Abatemarco indicated in the last blog post. While population health is NOT public health the two are intertwined.

Population health is holistic. It seeks to reveal patterns and connections within and between multiple systems that can be analyzed in order to respond to the needs of the population. It must be interdisciplinary, collaborative and transparent. We have set out to create a learning environment for students here at Jefferson to learn these key concepts and develop population health leaders of the future. Many of our students have diverse backgrounds and that is the greatest asset, in my opinion, to the learning community. While the need for population health management is evident in every newspaper you pick up, news story you hear or journal article you read, our role is providing students with practical knowledge to be real change agents. With all of this in mind, we have been working to create a text describing these key concepts, which will serve as a resource for both students and professionals. Population Health: Innovation, Strategy and Practice will be published by Jones and Bartlett, Sudbury, Massachusetts in August 2010. Dr. David Nash, Dr. JoAnne Reifsnyder and I are collaborating from JSPH with Dr. Ray Fabius to edit this multi-authored text. We have engaged 32 authors from various backgrounds; medicine, public health, policy disease management, education, and industry. Our goal is to create a text that describes innovative approaches to address population health needs, provides strategies to work toward those goals and advises readers on how to integrate these concepts into practice or their daily work. I hope that you will share your comments and thoughts about the often misunderstood “population health” concept and look for our new book in late summer 2010!

Valerie Pracilio
Project Manger for Quality Improvement
Jefferson School of Population Health

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My name is Dr. Diane J. Abatemarco and I am energized by being here at the beginning of an exciting process – the creation of a school of population health that is cutting-edge in its science and its vision. I’d like to tell you a bit about my research. My primary areas of expertise include evaluation research methods, behavioral epidemiology and intervention science.

My primary research is focused on maternal and child health. I am the Co-Principal Investigator of Practicing Safety, a study to evaluate a pediatric-based practice change intervention to prevent child maltreatment of children age 0 to 3 years of age. The work is highlighted as an AHRQ Innovation http://www.innovations.ahrq.gov/content.aspx?id=1806, and can also be found on the American Academy of Pediatrics website http://www.aap.org/practicingsafety. The project is funded by the Doris Duke Charitable Foundation through the American Academy of Pediatrics. This work is important because a healthier start to life is necessary for a healthy life not only through childhood but into adulthood as well.

I’ve had several global health experiences; one is a US/Croatian Healthy Cities Partnership to delay the onset of alcohol use among adolescents in Split, Croatia. We implemented Project Northland, a U.S. intervention developed by Perry and Williams. My work in Croatia included the use of experimental design, qualitative and quantitative methods in implementation and evaluation. Working with the country of Croatia for more than four years was an incredible experience. Croatia has wonderful citizens who showed me how a country recently war torn could remain hopeful about life and their country.

The work I have done in social epidemiology has been to conduct a study of HIV infected pregnant women to determine their rates of treatment and to identify factors associated with receipt of treatment. I also conducted numerous survey research projects to determine tobacco prevalence among pregnant women, college students, and adults and surveyed prenatal providers about tobacco dependence treatment practices. Current and ongoing research includes the measurement of stress, anxiety, and socioeconomic factors as determinants of maternal health and birth outcomes, and an exploration of biomarkers that may inform us as to how anxiety affects gestation. We experience a great amount of stress in our lives and understanding how stress affects us biologically may lead to interventions that enhance the quality of our lives, thereby reducing stress, anxiety and depression.

Additionally, I am currently evaluating an obesity prevention program developed by a professor at Carnegie Mellon University. The project is called Fitwits - www.Fitwits.org. This exciting multidimensional intervention has received national attention from the Clinton Foundation. Watching the children interact with the Fitwits characters and seeing them digest (no pun intended) the nutritional knowledge shows that even our youth can make better eating choices with the right support.

All of my work is predicated on improving population health through the integration of public health and clinical care. As a key dimension of population health, each project promotes empowerment over one’s own health behavior. Join me in learning more about our new school as I begin to work with the faculty to develop doctoral programs in Population Health Sciences.


Diane J. Abatemarco, PhD, MSW Associate Professor, Director of Doctoral Programs
Jefferson School of Population Health

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Speaker of the House Nancy Pelosi was on the Jefferson campus last week with a local Congressional delegation. She emphasized the need for reform of our broken system and campaigned for the house bill. She is committed to a public option and to universal coverage. Her comments were compelling and they attracted a good deal of local press attention too. Dr. Nash was fortunate enough to be interviewed by Jefferson’s local ABC affiliate in a story that aired just after the Speaker’s visit!

Last week the Jefferson School of Population Health (JSPH) also hosted a symposium on The Future of Health Care in Pennsylvania: Developing Leaders in Health Care Quality and Safety. Thomas Jefferson University (TJU)’s president, Dr. Bob Barchi, kicked off the event by speaking about the need to improve quality, outcomes and access to health insurance. He also highlighted TJU’s commitment to improving the health care crisis by founding JSPH. The event included two panel discussions, and Kim Taylor, President of Centocor Ortho Biotech Inc., announced the recipients of full scholarships for two JSPH Health Policy students.

Rosemarie Greco, Senior Advisor to the Governor’s Office of Health Care Reform, served as the featured speaker and talked about the need for cultural transformation within health care. According to Greco, everyone must be involved in this transformation, and everyone must ask and understand the “why” behind need for health care reform. Unless there is a common understanding of the “why,” meaningful reform cannot take place.

The first panel discussion, moderated by Josh Goldstein of the Philadelphia Inquirer, focused on the stimulus plan and its national impact on health care. Much of the conversation centered on stimulus dollars for Health Information Technology (HIT) and the use of HIT to improve outcomes. Panelists also called for research to build the evidence base for higher quality bedside care and better outcomes.

The second panel, moderated by Chris Satullo of WHYY, explored health care reform in Pennsylvania and how we can leverage our state resources. Significant takeaways from the panel included innovation and its role in health care reform, opportunities and obstacles in the greater Philadelphia region to encouraging and embracing innovation, and the lack of a regional start-up culture. The panel also touched on public medical education in Pennsylvania and the importance subsidizing the cost of medical education in this region in order to bring young, talented people into a setting where medical innovation thrives. Dr. Nash concluded the afternoon by announcing that he hopes everyone will continue to participate in local and regional dialogue about these key issues.

David B. Nash, MD, MBA
Dean, Jefferson School of Population Health

Laura Kimberly, MSW, MBE
Director of Special Projects, Jefferson School of Population Health

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Last week was quite a week at the Jefferson School of Population Health. On Tuesday we hosted our first Orientation to welcome our incoming students, and Wednesday – 09/09/09 – was the first day of classes for the new school. Appropriately enough, President Obama brought his case for health care reform before a joint session of Congress that very same evening.

It’s likely that the students we greeted last week – the inaugural class of the Jefferson School of Population Health – will have witnessed historic changes to the way we organize and deliver health care in the United States – all by the time they complete their first year as a JSPH student. I continue to be amazed at the synchronous path we at JSPH continue to follow with our nation’s top domestic agenda in passing meaningful health care reform. I know that our students are tuned into our national dialogue on health care reform and how it meshes with our mission of preparing leaders with global vision to develop, implement and evaluate health policies and systems that improve the health of populations, and thereby enhance the quality of life.

The healthcare industry plays an increasingly vital role in our national economy, as employer and generator of almost 20 percent of our Gross Domestic Product (GDP). The intensifying complexity of this industry in an era of heightened expectations and scrutiny means that there is both need and demand for professionals and researchers who are well versed and prepared to assume leadership roles in public health, health policy and healthcare quality and safety.

To the members of our inaugural class, we look forward to serving you, and wish you success in the 2009-2010 academic year as we work together to fulfill our mission. The future of the United States as a vibrant nation depends on the nation’s leaders bringing affordable, quality health care to all Americans, and we will play a significant role in training and equipping these leaders for the job.

- Caroline Golab, PhD

Associate Dean, Academic and Student Affairs

Jefferson School of Population Health

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