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03.19 For Better Internet Discourse, "Respect" This

Wednesday, March 19th, 2014 | Allison Rizzolo

With the arrival of spring, we're trying a fresh approach to the way you can interact with our online content.

We believe that engaging with fair-minded perspectives that we may not agree with is good for democracy. This practice helps us break out of a simplistic "for or against" framework toward an issue and come to a rounder comprehension of the issue and approaches to resolving it.

Unfortunately, the civil exchange of opposing perspectives is hard to find on the Internet, where interaction feels like the Wild West. Inherent anonymity doesn't help, and neither does the click-bait game. Conflict, after all, is newsworthy. (This is something we certainly struggle with here!) All of this animosity on the Internet could actually be doing some real damage.

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03.18 What's Missing When We Talk About Regulating Higher Ed

Tuesday, March 18th, 2014 | Allison Rizzolo

Ask a college president or a higher ed policy wonk what they think about for-profit colleges, and they'll likely have a strong opinion. But ask the same of a student who's attending a for-profit college and you'll probably receive a blank stare.

For-profit colleges dominate headlines - not only in education media, but also in mainstream press. One of the reasons for-profits are so newsworthy is because they're controversial.

Not all for-profits are the same. Many innovate quickly, offer skills and training directly applicable to the workforce, and provide the flexibility modern students need. At the same time, many are unscrupulous, leaving students saddled with debt and without a legitimate credential.

The federal government is trying to crack down on these less-scrupulous institutions. Via what's known as the gainful-employment rule, the government will withhold federal financial aid from any career education program (for-profit or not-for-profit) that fails to meet certain criteria. For example, average loan payments should not eat up 8 percent or more of a typical graduate's total earnings.

The gainful-employment conversation is mainly relegated to experts, and is relatively meaningless to many students who remain ignorant about for-profit higher education. Forty-seven percent of current undergraduates at a for-profit college say "nothing comes to mind" when they hear the term "for-profit college." Students at community colleges are also unfamiliar with the term, as are adults without degrees who anticipate returning to college. Furthermore, 65 percent of students enrolled in a for-profit college are unsure if their school is for-profit or not.

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03.11 Do Americans Really Loathe The Federal Government?

Tuesday, March 11th, 2014 | JEAN JOHNSON

What does it mean when fewer than 1 in 5 Americans say they are satisfied with the federal government? Over the last few years, survey researchers have fielded dozens of questions that seem to show the public’s contempt for the federal government.

In a Pew poll last year, just 12 percent of Americans said they were “basically content” with the federal government, while 30 percent were angry about it, and 55 percent were frustrated. Just 19 percent of the public says it trusts the government in Washington to do what is right most of the time. It’s a stunning number. When Presidents Eisenhower and Kennedy were in office, that number was above 70 percent.

But if so many Americans are so dismissive of government, then why were so many of us appalled by the government shutdown last fall? Is this just further proof that Americans will happily indulge in anti-government rhetoric, but that they really like government and what it does for them? Or are there more complex and consequential questions lying beneath the surface—questions that deserve much more careful analysis and discussion?

Here is a quick tour of some of what lies beneath.

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03.07 Joint Ventures Between Communities and Schools

Friday, March 7th, 2014 | Public Agenda

The following is an interview with Carolyn Farrow-Garland, of the Kettering Foundation, about recent research from Public Agenda and Kettering. The research, "Joint Ventures," explores what could happen when communities and schools work together to tackle improving local education.

Carolyn, why did Kettering and Public Agenda take on this project?

For communities where education reform has gotten bogged down, we wanted to offer an idea for a process they could use to spark progress. This project also enables us to highlight how different actors in public education— administrators, teachers, and parents— feel about the accountability trends in education, so that everyone involved in the problem can see other actors' side of it. It’s an outgrowth of research we conducted over the past few years looking at how the public defines “accountability” compared to how experts and professionals generally think about it.

Accountability has been such a strong theme in education reform over the past decade, but we’ve seen key differences in the way leaders and members of the public talk about it. Leaders often focus on holding teachers, principals, and schools accountable for student learning and using test scores as a main way to judge that. Parents and the broader public often bring a broader set of issues to the table, including the idea of holding parents and communities more accountable for children’s learning. Parents interpret accountability as being relational rather than informational, so they want school officials to use communication strategies that help them understand why certain policy changes are implemented.

So our question for this project was: Can education leaders and professionals join with parents and community members to “co-frame” goals for their schools, and what happens when they do?

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02.28 Patients' Views On Reforming The Physician Fee-For-Service Payment System

Friday, February 28th, 2014 | DAVID SCHLEIFER, PH.D.

Reprinted from Health Affairs Blog (February 28th, 2014).

Virtually all serious proposals for health care cost containment include reforming the fee-for-service payment system. Last fall’s bipartisan proposal to fix Medicare’s sustainable growth rate included provisions to reward physicians for providing high-value rather than high-volume care. Ostensibly, realigning physicians’ financial incentives would lead to higher quality, better coordinated, and more appropriate care.

But would patients necessarily be aware that their physicians are being paid differently? And would they even care? A new research report from Public Agenda and the Kettering Foundation suggests that consumers could play a role in advancing payment reform. But in order to work through the trade-offs of changing the system, employers and payers must help members of the public understand that most reimbursement is currently fee-for-service.

Public Agenda asked a total of 44 insured and uninsured Americans, 40 to 64 years old, to deliberate together in focus groups over the pros and cons of several approaches to cost containment. Participants had some recent contact with the health care system as patients but none were seriously ill. They considered payment reform, price transparency, increased consumer cost-sharing, government price-setting, and expanded access to Medicare, among other approaches.

We held the deliberative focus groups in February and March 2013 in Secaucus, New Jersey; Montgomery, Alabama; and Cincinnati, Ohio, as well as a pilot in Stamford, Connecticut. After the groups, we followed up with participants for in-depth interviews. These focus groups do not provide information about how other types of consumers, particularly young people, view different approaches to addressing health care costs.

As we prepared for this research, we spoke with several health system executives, physicians, foundation leaders, and policy researchers who predicted that insured people would be uninterested in cost-containment because their insurance shields them from the true costs of their care. But contrary to their expectations – and consistent with recent findings from the Commonwealth Fund – we found that both insured and uninsured focus group participants were upset about high out-of-pocket costs and angry about administrative complexity. Moreover, participants routinely described physicians as greedy pushers of too many tests and procedures. A New Jersey woman joked that she would “have no blood left” if she submitted to every procedure her physician recommended.

But focus group participants did not know that the current reimbursement system is largely fee-for-service. When we explained this defining feature of the American health care system to them in basic terms, participants said that this helped them understand why they had so often been subject to care that they described as overly aggressive. They also were eager to grapple with how payment reform and other approaches to cost-containment would affect their own care.

Focus group participants saw pros and cons to paying physicians fixed amounts per patient or per episode of care. They thought it would help them better predict their own out-of-pocket expenses and help doctors focus more on patients than on paperwork. They also figured that it would prevent some of the excessive, inappropriate care that so many of them reported experiencing.

But participants also expressed some reservations about payment reform. Many were concerned that physicians would retaliate by skimping on care. As a man in New Jersey said, “I bet you the doctors won’t like it.” An Ohio woman asked, “Are you really giving me the full scope of everything you would if you were charging for every little thing?” Several participants assumed that if reimbursement were based on health outcomes, physicians would discharge people from hospitals prematurely or refuse to treat sicker patients.

Payment reform is not a magic bullet. But in the midst of economists‘ and policymakers‘ debates over projected health care spending growth, the success of payment reform could play a significant role in determining whether or not the current slowdown in growth proves durable. Given the difficulty of dispelling the myth of government death panels, it is reasonable to ask whether it is advisable to engage Americans on cost-containment measures such as payment reform. But in our experience, lack of meaningful citizen engagement on tough policy choices can lead to pushback. As Paul Ginsburg wrote recently, “failing to engage beneficiaries…exposes payment reforms to the risk of political backlash.”

In summary, qualitative focus group research does not provide generalizable data, but this research does provide a detailed picture of how this group of consumers thinks through different options for controlling costs, including payment reform. Our focus group participants were eager to discuss payment reform. They did so with an impressive degree of interest, thoughtfulness and, despite some differences of opinion, civility. Their suspicion that some physicians are motivated by profits indicates that some consumers may be eager to choose providers and insurance plans that embrace value over volume. Helping consumers understand that most physician reimbursement is fee-for-service and making use of their concerns about out-of-pocket spending may help to move payment reform forward.


02.05 Facing the Facts on Health Care

Wednesday, February 5th, 2014 | Stephen C. Schoenbaum, MD, MPH

Stephen Schoenbaum is a physician, former executive director of the Commonwealth Fund Commission on a High Performance Health System, and a special advisor to the president of the Josiah Macy Jr. Foundation.

Passage and implementation of the Affordable Care Act raises questions about how to achieve cost control, including how best to replace the current fee-for-service payment system and how to rethink what exactly our health insurance plans cover.

But beyond these important policy questions, this research raises concerns about some Americans’ values related to health care. Persons in most developed countries are used to the idea that every member of society should have coverage and is entitled to access to health care. They do not understand, and frankly neither do I, why in the United States a sizeable minority of the population feels that health care is a privilege.

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01.29 In Health Care, Is Complexity More Problematic Than Cost?

Wednesday, January 29th, 2014 | Nancy Metcalf

This commentary offers reflection on the findings and implications from "Curbing Health Care Costs: Are Citizens Ready to Wrestle with Tough Choices?" Nancy Metcalf is a senior editor at Consumer Reports magazine who reports on health. She has answered thousands of consumers’ questions about health care and insurance in her “Ask Nancy” column.

Here is what consumers in other advanced industrial democracies need to understand about their health care systems: practically nothing. From cradle to grave, their health care needs are met nearly automatically by mechanisms that operate behind the scenes. No one has to worry about picking the “wrong” health insurance plan, or not being able to afford the cost of a serious illness or injury. There are no serious public debates about whether doctors make too much money, whether governments are in the pocket of the drug companies, or whether some people are “free riders.” It just never comes up, because these countries long ago reached a political consensus that health care is a human right, and that “social solidarity,” a term that most Americans have never heard, dictates that it be available on an equal basis to all.

The citizen groups convened by Public Agenda illuminate how Americans interpret their experience with an impossibly complex system that offers far less and demands far more of them as consumers than any other country’s.

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01.23 To Curb Costs, We Must Engage the Public on Health Care

Thursday, January 23rd, 2014 | DANIEL YANKELOVICH

This commentary offers reflection on the findings and implications from "Curbing Health Care Costs: Are Citizens Ready to Wrestle with Tough Choices?" Daniel Yankelovich is a public opinion pioneer and cofounder of Public Agenda.

Though the recent Public Agenda study on health care costs is small in scale, it leads to several far-reaching conclusions. I want to use my nickel to comment on one of them.

The study presented three strategies for health care cost containment to average, older adult Americans (ages 40 to 64): make the public pay more for services; hold doctors and administrators responsible for reforms in efficiency; and/or, have the government control prices. Frankly, I am surprised by how clear-cut the implications of these discussions were. For a variety of reasons, the first and third strategies seem hopelessly impractical, leaving only the second for consideration. I have spelled out below the reasoning behind this conclusion.

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01.16 Tough Choices on Health Care - Ready or Not, Here They Come

Thursday, January 16th, 2014 | JEAN JOHNSON

How many experts view rising health care costs.
(Via IMDB, Copyright 1981 - Lucasfilm, Ltd.)

Remember Harrison Ford as Indiana Jones, running away from an enormous boulder, glancing over his shoulder, racing to avoid being crushed? For the Congressional Budget Office (CBO), health care is the boulder that could devastate the federal budget if we can’t figure out better ways to contain rising costs. Many experts see this issue as one of, if not the, most urgent budgetary threats we face.

The federal government spent roughly a trillion dollars on health care in 2013, including Medicare, Medicaid, and the Children’s Health Insurance Program. With an aging population, more of us will be on Medicare. Due to The Affordable Care Act (ACA), more people are being covered by Medicaid and receiving government subsidies to buy their own insurance. According to the CBO, rising health care costs will "pose a challenge not only for the federal government’s two major health insurance programs, Medicare and Medicaid, but also for state and local governments, businesses, and households."

There has been some good news lately -- health care costs haven’t been rising as quickly as in the past, and there’s vigorous debate among policy wonks over why this is happening and whether costs could start rising more quickly again. The White House Council of Economic Advisors, for one, believes that some reforms in the ACA are helping slow the growth in costs.

But health care costs are still rising -- by 3.7 percent in 2012.

Polls repeatedly show broad support for "reducing health care costs," and on the face of it, people do seem to grasp that the U.S. spends an awful lot of money on health care.

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01.15 On Health Care, We Need More and Better Information and Deliberation

Wednesday, January 15th, 2014 | Thomas Workman, Ph.D.

This commentary offers reflection on the findings and implications from "Curbing Health Care Costs: Are Citizens Ready to Wrestle with Tough Choices?" Thomas Workman is the Principal Communication Researcher and Evaluator in the Health Program at the American Institutes for Research, where he leads its Center for Patient and Consumer Engagement.

As is evident in "Curbing Health Care Costs: Are Citizens Ready to Wrestle with Tough Choices?", there are disconcerting contradictions and inconsistencies in Americans’ views on health care that indicate the need for continued public information and deliberation. Several of these contradictions are worth noting, as they may hold a key for developing successful approaches to engaging the public in policies and practices that enable quality care and controlled cost.

Disconcerting contradictions and inconsistencies in Americans’ views on health care indicate the need for continued public information and deliberation.

As the report notes in its introduction, the current cost crisis is certainly not new, yet public consciousness and a sense of urgency have begun emerging only in the past five years. The reasons are many: unlike all other consumer services, the majority of health-care costs are indirect, handled through a third-party payer. Out-of-pocket costs were historically an issue only for the poor, uninsured and underinsured. The rest of the nation remained fairly protected and blissfully unaware. But those days have passed.

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