By Peggy Lowe
via npr.org

Recruiting doctors to live and work in rural America is a chronic problem. Most health centers try to attract workers with big salaries and expensive homes.

Shots previously reported that one center in Maine was trying to lure medical students to the countryside for their final two years with the hope that they stick around.

The Ashland Health Clinic, a tiny hospital in southwest Kansas, is trying a different tack — a reverse-recruitment model. It’s called mission-focused medicine, and it’s based on serving problems most commonly found in third-world countries.

Ashland, population 855, sits about a five-hour drive south of Kansas City. It’s one of the last outposts on the Kansas open range, where buffalo still really roam along the rolling, dusty plains. There’s no gas station, unless you count the pump at the farmer’s co-op that uses dial-up for credit card approval. The nearest Starbucks is 160 miles away.

The Ashland clinic has 24 beds. The next closest center is 50 miles north, in Dodge City. (Yeah, the same one from those old cowboy movies.)

So when Benjamin Anderson interviewed for the clinic’s CEO job in 2009, he says the board chairman was exceedingly blunt.

Anderson says the chairman told him, “Ben, our facilities are 55 years old. Our finances are challenged. Our morale is low. Turnover is up. We’ve been without an administrator for six months. We’ve been without a doctor for seven or eight months. We really need this facility in this community. And if we don’t have this facility, we’ll lose our school. And if we don’t have our hospital and our school, this will become a ghost town very quickly.”

That pitch clicked for Anderson. He gave up his physician recruiter job in Dallas and moved with his wife out here to become Ashland’s new CEO.

“I’ve always had to have a job that matters,” he says. “I have to have a position that I know it’s not just a paycheck.”

Anderson is now well known on Ashland’s Main Street. But he knew he needed doctors for the hospital to succeed, and he knew he had to offer something different than the thousands of small towns he was competing with.

So he came up with a novel plan. He offers potential candidates eight weeks off to do missionary work overseas. Because he’s found that a doctor who is willing to sleep on a cot in the Amazon or treat earthquake victims in Haiti is ready to serve in rural Kansas. He calls it mission-focused medicine.

“When you recruit a mission-focused provider, they want to see the ghettos,” he says. “They want to know that there’s no Spanish-speaking provider in more than a one-hour drive. They want to see houses that are falling down, widows that are uncared for. They want to know that there’s need and that by them coming there, they would fill a disparity that would otherwise not be filled. So we reversed it.”

It worked. Last July, Dr. Dan Shuman and his family moved here from the Austin, Texas, area. The difference between here and all the other needy areas was his ability to continue his missionary work in Haiti and Mexico during his eight weeks off. But Shuman says Ashland’s own challenges were equally attractive.

“When you’re primary focus is sort of a mission-based focus, when you get into things in order to try to relieve suffering or work toward eliminating disparities,” Shuman says, “then you want to know about those things. It’s appealing to see opportunities.”

Studies suggest that finding primary care providers in rural areas is at crisis levels. More medical students are specializing, so general practitioners are very hard to find. And those who can deal with the lower pay and isolation in rural areas? Even harder. So Anderson raised the bar by shooting for a higher cause. At every staff meeting, he’s part cheerleader, part chaplain.

Indeed, things are looking up for Ashland. In addition to Shuman, Anderson has recruited a nursing director. And that doc who slept on the cot in the Amazon was recently in Ashland for interviews.
Peggy Lowe is a reporter for Harvest Public Media.

via The Baltimore Sun


Baltimore Inner Harbor from Federal Hill – photo by ktylerconk on Flickr

Frustrated by Maryland’s high rate of health disparities, state leaders are proposing a new attack — one more commonly associated with economic development. Gov. Martin O’Malley’s 2012-2013 budget will include funding to create Health Enterprise Zones, where doctors and community groups in areas with large health disparities, such as Baltimore, could add medical and support services for minorities. Tax credits and other financial incentives would be available to spur interest.

The plan is designed to save lives and healthcare dollars, according to Lt. Gov. Anthony G. Brown, who last summer formed a work group on disparities led by Dr. E. Albert Reece, dean of the University of Maryland School of Medicine.

“Maryland has world-class hospitals, top medical schools and one of the highest rates of primary-care physicians per capita, and yet we continue to see disparities in health care and outcomes among Maryland’s racial and ethnic communities. It’s clear that a lack of access to primary care in many communities is a significant factor driving these disparities,” Brown said, adding that funding is in the governor’s budget proposal, which has yet to be released.

According to state and national data, the disparities are many: In Maryland, the infant mortality rate among blacks is almost three times that for whites, the incidence of new HIV infections among blacks is almost 12 times that of whites, and Hispanics are more than four times as likely not to have health insurance as whites. Moreover, nearly twice as many African-Americans suffer from diabetes as whites, and hospital admission rates were three times higher for blacks with asthma and 41/2 times as high for blacks with hypertension. Treating such illnesses is costly, according to the work group, which cited data showing nearly $230 billion in direct medical costs could have been saved from 2003 to 2006 if there were no racial and ethnic health disparities.

The proposed program would work something like economic enterprise zones, where businesses receive subsidies to create jobs and activity in certain areas. The health zones program would be a pilot, available in two or three geographic areas. New and existing primary-care practitioners could receive loan assistance repayment; income, property or hiring tax credits; and assistance in installing health information and other technology. Subsidies would be capped, likely in the tens of thousands of dollars. Local health departments might get involved in recruiting participants.

Brown said he would push to expand the program statewide if it proves successful in a couple of years — not a given, considering the logistical and cultural complexity of the problems. For example, residents of some neighborhoods don’t have easy access to grocery stores that sell fresh fruit and vegetables, or don’t visit the doctor until there is an emergency. Reece said many groups have tackled disparities, but the work group wanted to focus its attention on chronic diseases responsible for 80 percent of health costs. They drilled down to a few key maladies that often have “ripple” effects. They include diabetes, hypertension and asthma.

“We decided to identify … areas where we thought we could make an effective impact within a reasonable time frame,” he said. The health enterprise zones approach is unique, he believes. Work group members got the idea from a similar program built around children’s needs in the community of Harlem in New York City. Program applicants are likely to come predominantly from rural and urban area where disparities are most pronounced.

In Baltimore, studies show a 20-year gap in life expectancy between upper-income, predominantly white neighborhoods and poorer, predominantly minority neighborhoods. Recently, city health department officials began working with community leaders in 55 neighborhoods to identify the most pressing health needs and develop plans to tackle them. The state’s zones would complement these efforts, Reece said. His work group also proposed other elements to promote health and track outcomes.

The group suggested Health Innovation Prizes with small financial rewards and public recognition for individuals and groups that improve health and well-being in their community. The group also recommended tracking disparity data for programs that already exist for primary care physicians and hospitals. Incentives and penalties assessed through these programs could eventually be linked to disparities.

Reece said the prize and the enterprise zones are two things Maryland can do now to help reduce disparities in a few key geographic and health areas. If legislation to create the zones is passed during the current legislative session, the details will be worked out by the state Department of Health and Mental Hygiene.
Already, Dr. Joshua M. Sharfstein, department secretary, supports the move: “The creation of Health Enterprise Zones will help communities target resources to have the most powerful impact.”

meredith.cohn@baltsun.com

via American Human Development Project


Click here to explore a set of interactive maps with data from 2008-2011. In the map above, I selected “High School Freshmen not Graduating after 4 Years” from the “dashboard of risks” menu, for all states, all ethnic groups, and the most recent data set. You can also view data by top 10 metropolitan areas, congressional districts, and so on.

Whites in Washington, DC, live, on average, twelve years longer than African Americans in the same city.

In the 2007–9 Great Recession, college graduates faced an un- and underemployment rate of 1 in 10; the rate for high school dropouts was greater than 1 in 3.

In no U.S. states do African Americans, Latinos, or Native Americans earn more than Asian Americans or whites.

These startling facts are just some of the issues covered in The Measure of America 2010-2011. With a foreword by Jeffrey D. Sachs, the second volume in The Measure of America series is an easy-to-understand guide to where different groups stand today, and why. The book contains American Human Development Index ranking for all 50 states, 435 congressional districts, major metropolitan areas, racial and ethnic groups, as well as men and women. It concludes with a set of recommendations for priority actions required to improve scores on the Index across the board and to close the stark gaps that separate groups.

The Measure of America 2010-2011 also shines a spotlight on risks to progress and opportunity, and identifies tested approaches to fostering resilience among different groups: Who is most at risk for obesity? How can workers secure better footholds in the job market? How important is early childhood education? This report provides the tools necessary to build upon past policy successes, protect the progress made over the last half century from emerging risks, and develop an infrastructure of opportunity that can serve a new generation of Americans.

via NYTimes, By BARRY MEIER and JANET ROBERTS

One afternoon last spring, a little-known congressman from Minnesota made an impassioned plea before a House oversight committee.

Rein in the Food and Drug Administration’s uncertain approval process for new medical devices, urged the Minnesota congressman, Erik Paulsen, or Minnesota and other states stand to lose up to 400,000 jobs because of lost investment in the device industry.

Over the following month, Mr. Paulsen’s campaign committee took in $74,000 from people with a stake in device regulation, much of it from executives affiliated with venture capital funds and their spouses. Now Mr. Paulsen, a two-term Republican, is a sponsor of a bill that would make it easier to bring new medical products to market.

As Congress considers reauthorizing a law that sets the fees for medical device makers, venture capitalists are emerging as a rich and influential ally of device companies eager to remove what they say are regulatory roadblocks in the approval process. The push has alarmed patient advocates and some doctors, who have been calling on the F.D.A. to intensify its oversight of devices, particularly in light of some all-metal artificial hips that are failing prematurely at an unusually high rate.

“They have this unwritten assumption that every new device is innovative,” Dr. Rita Redberg, who is the editor of the Archives of Internal Medicine, said, referring to the venture capital funds. But some devices, she said, “are killing people or causing significant harm.”



People associated with funds that underwrite companies developing new devices and other health products have made more than $3.3 million in political donations to Republicans, Democrats and political action committees over the past five years, according to an analysis of federal contributions by The New York Times.

Though such people donate for many reasons, about 20 percent of the money from the 182 donors identified by The Times went directly to candidates and political action committees supporting a streamlining of F.D.A. policy or other issues of importance to medical products producers. The total contributions from such donors could be much higher; The Times limited its analysis to individuals affiliated with venture capital funds that have joined two lobbying associations.

Investment funds and business groups have also increased their lobbying in Washington and have generated a stream of reports arguing that regulations are crippling innovation and driving away investment.

Simply put, the industry’s champions argue that the F.D.A. suffers from high personnel turnover, an unwieldy bureaucracy and a regimen that forces start-up device companies to run new and costly tests constantly, often duplicating past efforts.

“This is about survival,” said Michael Carusi, a general manager at an investment fund in Palo Alto, Calif., Advanced Technology Ventures, who contributed $1,000 to Mr. Paulsen. “We are deeply concerned about the future.”

Medical devices encompass a wide array of products, such as heart defibrillators, artificial joints and diagnostic equipment.

Lobbying to smooth the approval process has intensified over the last year as Congress prepares to reauthorize the law that requires device producers to pay fees to the F.D.A., fees that are used to pay the agency’s operating costs. Lawmakers have an opportunity to alter the agency’s regulatory procedures for the first time since the law last came up for renewal in 2007.

An industry lobbying group, the National Venture Capital Association, has intensified its focus on device regulation. In 2010, the association, which lobbies on many issues, spent more than $2.5 million, according to data from the nonpartisan Center for Responsive Politics. About $350,000 of that was related to devices, drugs and health care, a figure that is expected to increase to $450,000 this year, said an association spokeswoman, Emily Mendell.

While it is not unusual for businesses to point to regulation as a barrier to economic and job growth, medical device investors have found a particularly receptive audience on Capitol Hill in recent months. In October alone, 10 bills have been introduced by Republicans in the House to speed up the F.D.A. device approval process; in the Senate, similar legislation has been introduced by Amy Klobuchar, a Democrat of Minnesota.

Since February, four House panels have held hearings on the impact of F.D.A. procedures on device approval. At those sessions, 19 of the 26 listed witnesses were investors, entrepreneurs, industry consultants, trade group officials or patients who said that agency delays in approving a device had harmed them or a loved one. The list included no patients injured by a flawed device; one hearing in the Senate had a more varied witness list. Two weeks ago, four Democratic congressmen wrote to their Republican counterparts about the imbalance in the House testimony and suggested the hearings had failed to address potential dangers “if medical devices are not appropriately regulated.”

The letter, signed by Henry A. Waxman of California, Diana DeGette of Colorado, John Dingell of Michigan and Frank Pallone of New Jersey, also urged that hearings be held on the metal hip problem and similar issues.

Venture fund executives like Mr. Carusi and lawmakers like Mr. Paulsen insist that they are equally concerned about safety. However, in their view, a big part of the problem at the F.D.A. is philosophical; top officials, these critics say, have overreacted to recent episodes involving flawed products and become risk-averse. As a result, devices are available first in Europe, they say.

“The key is to strike the right balance,” said Dr. Josh Makower, a device developer and a consultant to New Enterprise Associates, a venture fund in Palo Alto.

F.D.A. officials said they have recently tried to address investors’ concerns by announcing programs to encourage innovation and reduce regulatory burdens. Still, the head of the agency’s device division, Dr. Jeffrey E. Shuren, said that executives like Dr. Makower seemed more interested in politicizing the issue than resolving it through discussion.

“The dialogue has become more political and adversarial,” Dr. Shuren said.

Some medical experts have also questioned recent studies about the negative impact of regulations, calling the reviews flawed in methodology.

William Vodra, a lawyer in Washington who has worked closely with medical device producers, said that investors had legitimate concerns about regulatory speed. That is because the approval of a new device can begin a process in which a start-up company is acquired by a larger manufacturer and early investors profit by cashing out.

But such investors may be less interested in what happens to that device after it reaches the market because they have already moved on, said Mr. Vodra, who served on an Institute of Medicine panel that recently concluded the F.D.A. failed to properly assess the safety and effectiveness of many new devices.

Mr. Paulsen, the Minnesota congressman, did not respond to requests for an interview. But a spokesman, Tom Erickson, said that the lawmaker’s testimony this spring was unrelated to any campaign donations and reflected his long-held view that the F.D.A. was undermining an industry crucial to Minnesota.

“He gave his testimony because he feels these jobs are being threatened by an inconsistent and unpredictable F.D.A.,” Mr. Erickson said. Mr. Paulsen, along with Democrats and Republicans from states that are home to device makers, has also sought to repeal a tax on sales imposed on the industry under the health care overhaul law.

Dr. Makower, the venture fund consultant, has donated $5,000 to Mr. Paulsen, records show.

“I think that he understands this issue,” said Dr. Makower.

August 30, 2011 from WAMU

The Walter Reed Army Medical Center has a storied past. It has been the country’s leading Army hospital for more than 100 years, sitting on a complex that includes a Civil War battlefield. There was a time when 16,000 patients a year sought treatment for wounds of war or illness.

By the end of August, all of the patients and doctors will have left, moved to Bethesda and Fort Belvoir as the Army consolidates its bases. But as one era closes, another opens: Washington, D.C., may be left with nearly 70 acres of prime real estate.

Neighborhood Businesses Face Change
Just after the midday rush at Ledo’s Pizza on Georgia Avenue in Northwest D.C., Tim and Kelly Shuy sit down at a table.

“We get a lot of military families, people who are visiting, folks who are in the hospital. We get a lot of contractors,” Kelly says.

Their pizzeria is across the street from the sprawling Walter Reed campus. Lush with trees and a hilly landscape, the campus includes several iconic 100-year-old buildings with red tile roofs where patients, their families and staff were able to wander and just look out on the rest of the neighborhood from a distance.

Many in the neighborhood call the medical center a fortress. But for the Shuys, it was a mainstay. Doctors and patients alike have supported their business for years.

“Some of them come in uniforms. We have patients who come in who haven’t been out of Walter Reed,” Kelly says. “I’ve had dozens of people tell me this is their first meal out of the hospital.”

But those days are just about over.

“We’ve been saying goodbye to people for a long time. We say goodbye to people every day,” Kelly Shuy said. “But it’s horrible — we’ve had tears over saying goodbye to people who are regulars.”

Of course the Shuys are losing more than just familiar faces.

“As far as the business goes, obviously it’s a huge hit for us,” Kelly says. As Walter Reed closes down, it leaves behind questions. What is going to take its place? There is no shortage of opinion among interested residents:

“We are looking for quality space for our students,” says Christine Encinas.

“We’d like to use part of it to develop affordable family housing,” says Troy Swanda.

“We’d like to see a bit of parkland right along here,” says Ellen McBarnett. “Many of the neighbors have been talking about dog-walk parks or places for children to play.”

City Eyes Retail Development
And that’s just the beginning. The State Department will take a chunk of Walter Reed’s 113 acres, possibly for embassies. But that leaves almost 70 acres for D.C. In a city where a quarter of the land is owned by the federal government, demand for land is high.

“This is a uniquely vocal community, let me just put it that way,” says Victor Hoskins, deputy mayor of Planning and Economic Development. He co-chairs the committee that is going to figure out just what the District of Columbia is going to do with all of this land.

“Actually, the interest we’ve gotten from a number of retailers already has been, really, quite astounding. What’s going to happen is when that fence comes down [and] we develop the retail along there, it will become a place to go,” Hoskins says. “And there’s a chance now to revive a Main Street, which is Georgia Avenue, which has for years been suffering from decay.”

D.C.’s government has a major interest, as well. For 100 years, this property has been federal and untaxable. The city estimates it could get $20 million a year in tax revenue. And the people who worked at Walter Reed mostly drove in and drove out, not spending as much in the neighborhood as destination consumers might. Plus, if retail takes off, it might supply local jobs. Of course, that’s assuming the city gets it right.



This satellite image shows how the Walter Reed Campus will be divided between the District of Columbia (purple) and the State Department (yellow). The District’s 67-acre portion includes both the old and new hospital buildings.

Coming Up With A Plan
Faith Wheeler is a neighborhood representative who lives near Walter Reed. Standing about a mile away from the hospital, she points to a block where new development didn’t work out so well.

“Well, I don’t want to see all those for-lease signs; look at that,” she says. “If that happened on Georgia Avenue’s Walter Reed campus, it would be awful, horrible. According to textbook ideas, this is the place where retail ought to be booming. It’s not.”
This is what Wheeler does not want to see: a street that’s a commuter corridor, lined by sterile and vacant office buildings. One thing she does want is some sort of tribute to the place’s history. And that is likely; many of the historic building facades will be kept. But Wheeler’s voice is one of many.

Public Meetings, And Many Rules
“It’s kind of the new realities of urban planning in the 21st century,” says Lisa Benton-Short, a professor of geography at George Washington University who has written about previous base closings. She says the Walter Reed campus will take awhile to sort out.

“I think for much of the 20th century, planners were quite top-down in their planning,” she says. “They told us what we needed in our spaces. Sometimes they were right, and sometimes they weren’t. In the last 25 years or so, the planning profession has really changed. And one of the most important ways it’s changed is to bring in public participation and planning.”

That means public workshops, public forums and many public meetings. Benton-Short says it will be messy. And the military has its rules, as well.

There will have to be services for the homeless, there will have to be organizations that serve the community, such as schools. And there’s an entire bureaucratic process that will probably take two years before a deal is finalized, let alone anything getting built. The U.S. Department of Housing and Urban Development will have to approve the plan, and there will have to be an environmental impact assessment, as well.

“We’re talking 10 years, 15 years before these visions are actually transformed into reality,” Benton-Short says.

That only heightens the fear of area businesses who will have to wait that long. There’s also radioactive waste from X-ray machines and cancer treatments that needs cleaning up. And there’s asbestos to be removed. That’s all possible — but it will take time. It’s also one reason that the amount D.C. will have to pay the Army for the land hasn’t been nailed down yet. But when all is said and done, one thing everyone agrees on is that the site holds real potential.

A Positive Legacy
“This is something that I hope will be a positive,” says Ethelbert Dawson, 77, who attended Walter Reed’s official closing ceremony last month. He lives around the corner, and for 25 years, he worked at Walter Reed as a research chemist.

“When I was here, I never thought that this day would ever come. We used to call it Walter Wonderful, because that’s what it was.”

He says he can’t really predict what this new space will mean for Washington, D.C.

“But for Walter Reed and all of the positiveness that hospital has given this community,” Dawson says, “I don’t know if they can ever reduplicate that.”

All eyes are on this space, to see whether the disappearance of a 100-year-old place of healing will usher in an urban rebirth — or leave a scar.

We have presented the following chart to clients on multiple occasions to demonstrate the shifting prominence of different sectors in the US economy (in terms of employment) over time.

Key Takeaways:
From our perspective, one of the most significant trends visible here is the decline of manufacturing relative to other industries. Since 1970, total manufacturing employment has fallen from nearly 18 million to just over 11 million jobs. At the same time, health services, along with professional and business services, have emerged from relatively small employment sectors to major drivers.

While the chart does tell a story about the relative influence of each sector in terms of employment, the employment numbers are not contextualized in terms of total U.S. population. In particular, questions about the steady increase in government employment prompted us to revisit the visual in order to adjust for the growth of the size of the U.S. economy overall to create a more nuanced view of how each sector has been represented in the U.S. economy over time.


Key Takeaways:
The above chart provides greater context for the employment changes of these same industries by comparing their share of all jobs in the U.S. In this picture, the decline in manufacturing employment is even steeper, dropping from 26% of all jobs to just 9%. Moreover, the rise in government employment from the previous chart is seen more clearly as a function of the overall growth of the nation’s economy. In other words, government’s share of employment has remained relatively constant over the last 40 years.


Key Takeaways:
Like the first chart, the gradual yet steady decline of manufacturing since the 1970s is evident. Professional and business services and health services also show an upward trajectory, increasing their relative shares of the nation’s total gross domestic product (GDP).

The most striking difference in this data set from the previous employment charts is financial activities. If employment was the only indicator used to judge this sector’s importance, the viewer may determine that financial activities is not a major force in the overall economy. On the contrary, financial activities has dramatically increased its share of total GDP and now comprises the single largest share of economic activity in the U.S.