The who, what, and why of risk adjustment: a technology on the cusp of adoption

Risk adjustment (RA) consists of a series of techniques that account for the health status of patients when predicting or explaining costs of health care for defined populations or for evaluating retrospectively the performance of providers who care for them. Although the federal government seems to have settled on an approach to RA for Medicare Advantage programs, adoption and implementation of RA techniques elsewhere have proceeded much more slowly than was anticipated. This article examines factors affecting the adoption and use of RA outside the Medicare program using case studies in six U.S. health care markets (Baltimore, Seattle, Denver, Cleveland, Phoenix, and Atlanta) as of 2001. We found that for purchasing decisions, RA was used exclusively by public agencies. In the private sector, use of risk adjustment was uncommon and scattered and assumed informal and unexpected forms. The most common private sector use of RA was by health plans, which occasionally employed RA in negotiations with purchasers or to allocate resources internally among providers. The article uses classic technology diffusion theory to explain the adoption and use of RA in these six markets and derives lessons for health policy generally and for the future of RA in particular. For health policy generally, the differing experiences of public and private actors with RA serve as markers of the divergent paths that public and private health care sectors are pursuing with respect to managed care and risk sharing. For the future of RA in particular, its history suggests the need for health service researchers to consider barriers to use adoption and new analytic technologies as they develop them.     

Obesity, courts, and the new politics of public health

Health care politics are changing. They increasingly focus not on avowedly public projects (such as building the health care infrastructure) but on regulating private behavior. Examples include tobacco, obesity, abortion, drug abuse, the right to die, and even a patient's relationship with his or her managed care organization. Regulating private behavior introduces a distinctive policy process; it alters the way we introduce (or frame) political issues and shifts many important decisions from the legislatures to the courts. In this article, we illustrate the politics of private regulation by following a dramatic case, obesity, through the political process. We describe how obesity evolved from a private matter to a political issue. We then assess how different political institutions have responded and conclude that courts will continue to take the leading role.     

The changing process and politics of health policy in Korea

Korea recently introduced three major health care reforms: in financing (1999), pharmaceuticals (2000), and provider payment (2001). In these three reforms, new government policies merged more than 350 health insurance societies into a single payer, separated drug prescribing by physicians from dispensing by pharmacists, and attempted to introduce a new prospective payment system. This essay compares the three reforms in Korea and draws important lessons about the country's changing process and politics of health care policy. The change of government, the president's keen interest in health policy, and democratization in the public policy process toward a more pluralist context opened a policy window for reform. Civic groups played an active role in the policy process by shaping the proposals for reform-a major change from the previous policy process that was dominated by government bureaucrats. The three reforms also showed important differences in the role of interest groups. Strong support by the rural population and labor unions contributed to the financing reform. In the pharmaceutical reform, which was a big threat to physician income, the president and civic groups succeeded in quickly setting the reform agenda; the medical profession was unable to block the adoption of the reform but their strikes influenced the content of the reform during implementation. Physician strikes also helped block the implementation of the payment reform. Future reform efforts in Korea will need to consider the political management of vested interest groups and the design of strategies for both scope and sequencing of policy reforms.     

PENDULUM--a guideline-based approach to the interpretation of STR mixtures

Several years ago, a theory to interpret mixed DNA profiles was proposed that included a consideration of peak area using the method of least squares. This method of mixture interpretation has not been widely adopted because of the complexity of the associated calculations. Most reporting officers (RO) employ an experience and judgement based approach to the interpretation of mixed DNA profiles. Here we present an approach that has formalised the thinking behind this experience and judgement. This has been written into a computer program package called PENDULUM. The program uses a least squares method to estimate the pre-amplification mixture proportion for two potential contributors. It then calculates the heterozygous balance for all of the potential sets of genotypes. A list of "possible" genotypes is generated using a set of heuristic rules. External to the programme the candidate genotypes may then be used to formulate likelihood ratios (LR) that are based on alternative casework propositions. The system does not represent a black box approach; rather it has been integrated into the method currently used by the reporting officers at the Forensic Science Service (FSS). The time saved in automating routine calculations associated with mixtures analysis is significant. In addition, the computer program assists in unifying reporting processes, thereby improving the consistency of reporting.     

Driving under the influence of drugs -- evaluation of analytical data of drugs in oral fluid, serum and urine, and correlation with impairment symptoms

A study was performed to acquire urine, serum and oral fluid samples in cases of suspected driving under the influence of drugs of abuse. Oral fluid was collected using a novel sampling/testing device (Dr?ger DrugTest System). The aim of the study was to evaluate oral fluid and urine as a predictor of blood samples positive for drugs and impairment symptoms. Analysis for cannabinoids, amphetamine and its derivatives, opiates and cocaine was performed in urine using the Mahsan Kombi/DOA4-test, in serum using immunoassay and gas chromatography-mass spectrometry (GC-MS) confirmation and in oral fluid by GC-MS. Police and medical officer observations of impairment symptoms were rated and evaluated using a threshold value for the classification of driving inability. Accuracy in correlating drug detection in oral fluid and serum were >90% for all substances and also >90% in urine and serum except for THC (71.0%). Of the cases with oral fluid positive for any drug 97.1% of corresponding serum samples were also positive for at least one drug; of drug-positive urine samples this were only 82.4%. In 119 of 146 cases, impairment symptoms above threshold were observed (81.5%). Of the cases with drugs detected in serum, 19.1% appeared not impaired which were the same with drug-positive oral fluid while more persons with drug-positive urine samples appeared uninfluenced (32.7%). The data demonstrate that oral fluid is superior to urine in correlating with serum analytical data and impairment symptoms of drivers under the influence of drugs of abuse.     

Social isolation and delayed discovery of bodies in houses: the value of forensic pathology, anthropology, odontology and entomology in the medico-legal investigation

The bodies of socially isolated people may remain undiscovered in their own houses for prolonged periods. Occasionally the body is in situ for sufficient time to become skeletonised, or partially so. Medico-legal investigation of these cases is complicated by degradation and contamination of evidence. Thus, a multidisciplinary forensic investigation is recommended. The potential contributions of forensic pathology, anthropology, odontology and entomology are outlined here with reference to two cases that occurred in Victoria, Australia, in 2003. Forensic pathologists are often unable to determine the cause of death in skeletonised bodies, however, they may find evidence to support either a natural or unnatural mode of death, and they may describe skeletal pathology or trauma, and identify skeletal features to support radiological identification of the deceased. Anthropologists can provide supplementary evidence of skeletal trauma. Additionally, they can assess age, sex, stature and racial affiliation from skeletal remains. Odontologists can identify individuals through comparison with ante-mortem dental records; however, potential difficulties exist in identifying the treating dentist of a socially isolated person. Odontologists may also examine the teeth and oro-facial skeleton for trauma. Entomologists may estimate minimum death time and/or season of death. Entomological examination of insect remains may also confirm that a body has lain in situ for a considerable period.     

Mitochondrial DNA error prophylaxis: assessing the causes of errors in the GEP'02-03 proficiency testing trial

A qualitative and quantitative analytical method was developed and validated for the determination of 49 licit and illicit drugs in oral fluid. Small oral fluid samples, volume 1mL, were collected from volunteers using a modified Omni-Sal device and the analytes were extracted from an oral fluid/buffer mixture using a single Bond Elut Certify solid phase extraction cartridge. Liquid chromatography-tandem mass spectrometry (LC-MS-MS) and gas chromatography-repetitive full scan mass spectrometry (GC-MS) were used in parallel to analyze the extracts for the targeted drugs. Extracts were analyzed by GC-MS in their underivatized form and as their pentafluoropropionyl derivatives. Deuterated internal standards were used for quantification of drugs of abuse by LC-MS-MS to minimize matrix effects. Methadone-d(9) and tumoxetine were used as the internal standards for quantification of non-derivatized and derivatized analytes respectively by GC-MS. Linearity was demonstrated over the range 5-200 ng/mL and limits of detection were less than 4 ng/mL for each drug analyzed. The method demonstrated acceptable recoveries for most of the analytes and good intra- and inter-day precision. Acquisition of data by repetitive full scan GC-MS allows the addition of further analytes to the target menu.     

Mobile phase influence on electrospray ionization for the analysis of smokeless powders by gradient reversed phase high-performance liquid chromatography-ESIMS

The solution parameters associated with gradient elution reversed phase high-performance liquid chromatography (HPLC) were characterized by evaluating the electrospray ionization mass spectrometry (ESIMS) response of selected smokeless powder additives. Using direct liquid infusion, the positive ion ESIMS responses were determined for three general classes of powder constituents: dialkylphthalate acid esters, N,N'-dialkyl-N,N'-diphenyl urea based stabilizers and nitroso-, nitro-, and dinitro- derivatives of diphenylamine. The relative ESIMS intensities of the powder components were investigated as a function of three solution parameters: ammonium acetate concentration, pH, and percent methanol. The effect of the ammonium acetate concentration demonstrates that the electrolyte is required for efficient ionization and the ESIMS intensity was optimal at a concentration of 2mM for the selected compounds, except 2,4'-dinitrodiphenylamine. The aqueous solution pH, corresponding to the available protons in solution, did not have a significant effect on the ESIMS intensity of the analytes. The percent methanol was evaluated with both decreasing and constant electrolyte concentrations to demonstrate the effects of droplet stability and ion transfer into the gas phase. These findings were applied to the analysis of the selected smokeless powder additives using HPLC-ESIMS to illustrate increased sensitivity for the protonated molecules.