Background The built environment can constrain or facilitate physical activity. Most studies of the health consequences of the built environment suffer from problems of selection bias associated with confounding effects of residential choice and transportation decisions. Purpose To examine the cross-sectional associations between objective and perceived measures of the built environment, BMI, obesity (BMI>30 kg/m2), and meeting weekly recommended physical activity (RPA) levels through walking and vigorous exercise. To assess effect of using light rail transit system (LRT) on changes in BMI, obesity, and meeting weekly RPA levels. Methods Data were collected on individuals before (July 2006–February of 2007) and after (March 2008–July 2008) completion of a light rail system in Charlotte, NC. BMI, obesity, and physical activity levels were calculated for a comparison of these factors pre- and post-LRT construction. A propensity score weighting approach adjusted for differences in baseline characteristics among LRT and non-LRT users. Data were analyzed in 2009. Results More positive perceptions of one’s neighborhood at baseline were associated with a −0.36 (p<.05) lower BMI, 15% lower odds (95% CI=0.77, 0.94) of obesity, 9% higher odds (95% CI = 0.99, 1.20) of meeting weekly RPA through walking, and 11% higher odds (95% CI= 1.01, 1.22) of meeting RPA levels of vigorous exercise. The use of light rail transit to commute to work was associated with an average −1.18 reduction in BMI (p<0.05) and an 81% reduced odds (95% CI= 0.04, 0.92) of becoming obese over time. Conclusions The results of this study suggest that improving neighborhood environments and increasing the public’s use of LRT systems could provide improvements in health outcomes for millions of individuals.

BACKGROUND: Historically, there has been a shortage of child psychiatrists in the United States, undermining access to care. This study updated trends in the growth and distribution of child psychiatrists over the past decade. METHODS: Data from the Area Health Resource Files were used to compare the number of child psychiatrists per 100 000 children ages 0 to 19 between 2007 and 2016 by state and county. We also examined sociodemographic characteristics associated with the density of child psychiatrists at the county level over this period using negative binomial multivariable models. RESULTS: From 2007 to 2016, the number of child psychiatrists in the United States increased from 6590 to 7991, a 21.3% gain. The number of child psychiatrists per 100 000 children also grew from 8.01 to 9.75, connoting a 21.7% increase. County-and state-level growth varied widely, with 6 states observing a decline in the ratio of child psychiatrists (ID, IN, KS, ND, SC, and SD) and 6 states increasing by .50% (AK, AR, NH, NV, OK, and RI). Seventy percent of counties had no child psychiatrists in both 2007 and 2016. Child psychiatrists were significantly more likely to practice in high-income counties (P , .001), counties with higher levels of postsecondary education (P , .001), and metropolitan counties compared with those adjacent to metropolitan regions (P , .05). CONCLUSIONS: Despite the increased ratio of child psychiatrists per 100 000 children in the United States over the past decade, there remains a dearth of child psychiatrists, particularly in parts of the United States with lower levels of income and education.

The largest source of health insurance coverage in the United States is through an employer or union. Despite the size and importance of this market, prices are opaque. In this study, we use 2016 to 2018 data from all but one state in the United States, covering $33.8 billion in hospital spending from three sources-self-insured employers, state-based all-payer claims databases, and health plans-to document variation in facility and professional prices for the commercially insured population. We also examine trends and potential reasons that may explain the observed variation in prices. In this study, prices reflect the negotiated allowed amount paid per service, including amounts from both the health plan and the patient, with adjustments for the intensity of services provided. We report differences in standardized negotiated prices and prices relative to Medicare reimbursement rates for the same procedures and facilities.This report is designed to provide price transparency to a large and important market. Price transparency has not been traditionally available in a manner that allows for an easy comparison of prices between hospitals and other providers. The price information in this report can help employers and other purchasers of health care assess the prices that they pay for health care services. This report can also help contribute to policy discussions on price transparency and how to lower health care prices for privately insured Americans.The findings of this study are reported at a high level in this report, and a supplemental Microsoft Excel spreadsheet and an interactive map both provide additional detail (www.rand.org/t/RR4394). This report follows two previous studies on hospital prices (White 2017; White and Whaley, 2019). The current report extends these prior studies by examining additional data sources and documenting prices for additional providers and for specific service categories. Unlike many other examinations of hospital prices, our studies identify hospitals and groups of hospitals under joint ownership ("hospital systems") by name.This research was funded by the Robert Wood Johnson Foundation and participating selfinsured employers and was carried out within the Payment, Cost, and Coverage Program in RAND Health Care in collaboration with the Employers' Forum of Indiana.RAND Health Care, a division of the RAND Corporation, promotes healthier societies by improving health care systems in the United States and other countries. We do this by providing health care decisionmakers, practitioners, and consumers with actionable, rigorous, objective evidence to support their most complex decisions. For more information, see www.rand.org/health-care, or contact

Better working conditions for clinicians and staff could help primary care practices implement delivery system innovations and help sustain the US primary care workforce. Using longitudinal surveys, we assessed the experience of clinicians and staff in 296 clinical sites that participated in the Centers for Medicare and Medicaid Services (CMS) Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration. Participating FQHCs were expected to achieve, within three years, patient-centered medical home recognition at level 3-the highest level possible. During 2013-14, clinicians and staff in these FQHCs reported statistically significant declines in multiple measures of professional satisfaction, work environment, and practice culture. There were no significant improvements on any surveyed measure. These findings suggest that working conditions in FQHCs have deteriorated recently. Whether findings would be similar in other primary care practices is unknown. Although we did not identify the causes of these declines, possible stressors include the adoption of health information technology, practice transformation, and increased demand for services.

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