No abstract

Objectives:To inform how the VA should develop and implement network adequacy standards, we convened an expert panel to discuss Community Care Network (CCN) adequacy and how VA might implement network adequacy standards for community care.Data Sources/Study setting: Data were generated from expert panel ratings and from an audio-recorded expert panel meeting conducted in Arlington, Virginia, in October 2017. Study Design:We used a modified Delphi panel process involving one round of expert panel ratings provided by nine experts in network adequacy standards. Expert panel members received a list of network adequacy standard measures used in commercial and government market and were provided a rating form listing a total of 11 measures and characteristics to rate.Data Collection Methods: Items on the rating form were individually discussed during an expert panel meeting between the nine expert panel members and VA Office of Community Care leaders. Attendees addressed discordant views and generated revised or new standards accordingly. Recorded audio data were transcribed to facilitate thematic analysis regarding opportunities and challenges with implementing network adequacy standards in VA Community Care.

Some state governments are considering cuts to the non-emergency medical transportation (NEMT) benefit for Medicaid enrollees, and some Federal officials have proposed making this easier. Yet, there is clear demand. In 2015 alone, low-income patients used 59 million rides for medical appointments. NEMT’s future is under threat because evidence that NEMT improves health care access and downstream outcomes is incomplete. Second, it remains largely unknown whether scarce public resources for transportation are being driven to those who benefit from its availability. This knowledge gap is answerable but unknown because of variations in how states administer NEMT. As a result, tracking who uses the services is inconsistent, and states are unable to link NEMT data with health care outcomes. Instead of cutting NEMT benefits, we believe an alternative path involves improved tracking and evaluations of the benefit first. Better informed policy decisions are needed. Otherwise, if policymakers implement blanket reductions in NEMT spending, they run the risk of causing more harm than good.

Several recent locality-focused studies suggest that the American Revolution was not particularly 'revolutionary'. These studies note continuity of pre and post-independence institutions and local leadership. But the American Revolution was experienced differently in different communities, and the American Revolution was likely more 'revolutionary' along the military frontiers—the subset of localities that experienced prolonged civil warfare—than in more peaceful locales. This study examines one wartorn locality, Monmouth County, New Jersey, to substantiate this hypothesis. The American Revolution split the pre-war leadership in Monmouth County into Whig and Loyalist blocs, and about half of the county's pre-war leaders dropped out of leadership as the war began. The gaps created by Loyalists dropping out of leadership plus the approximate doubling of local offices created a permeable and democratic, new leadership. Men of modest means came into leadership positions; men disaffected from the cause of independence continued being elected into local offices. Local leaders split into antagonistic factions that faced off at the polls, in the courts, and through a series of rival associations. Local political institutions, such as courts and elections, were scandal-plagued and dysfunctional for long stretches. The State legislature was compelled to censure county leaders for provocative and illegal conduct; twice, it voided the results of the county elections. The crucible of civil warfare created extraordinary stresses in Monmouth County, and by war's end, its leadership and governing institutions were substantially transformed. The pre-war elite were marginalized, new families achieved parity with established families in the leadership ranks, local institutions were re-made, and, despite the tribulations, competent local governance eventually emerged.

No abstract