News Article | May 23, 2017
Striking a better balance between programs to prevent child maltreatment and services for those who have already suffered from abuse could improve long-term outcomes for children and reduce child welfare system costs in the United States by $12 billion, according to a new RAND Corporation report. RAND researchers developed a quantitative model that simulates how 24 million children interact with the country's child welfare system. They considered options that increased both the quantity and effectiveness of services delivered to families. The model marks the first-ever attempt to integrate risk of maltreatment, detection, paths through the system and consequences to predict the impact of policy changes. Researchers analyzed the effects of three common strategies for improving the child welfare system: preventing maltreatment of children so that they don't need to enter the child welfare system, supporting family preservation efforts that keep children in the system with their parents, and encouraging care by relatives (kinship care) when out-of-home care is necessary. "Our findings suggest that better outcomes can be achieved through a combination of prevention and treatment services, and that these changes will essentially pay for themselves," said Jeanne Ringel, lead author of the report and a senior economist at RAND, a nonprofit research organization. "When a balance is struck between prevention and treatment, children will be less likely to experience poor outcomes - including substance abuse, homelessness, criminal conviction, and underemployment - as young adults." Every year, about 3 million children face either abuse or neglect, according to the Fourth National Incidence Study of Child Maltreatment. The child welfare system aims to help those who encounter such harm. Services are provided at the community level and include investigating reports of neglect or abuse, providing family preservation services, and placing kids in foster care or care by relatives. RAND's model estimates that a set of policies aimed at increasing both the number and the effectiveness of prevention and kinship care services would yield $12.3 billion in cost savings for those 24 million children. Under this scenario, spending would increase by $4.3 billion, but these additional costs would be offset by a subsequent reduction of $16.6 billion in system spending. Total caseload would also fall. When the quality and quantity of both prevention and kinship care increase, the RAND model indicates that cases of maltreatment would decline by about 10 percent. As a result, child welfare referrals would decrease by 3 percent. Importantly, the likelihood of negative long-term outcomes -- homelessness, underemployment, criminal conviction and substance abuse - would decrease by about 7 percent. "Our analysis makes it clear that pursuing both prevention and treatment measures will improve the lives of children and their families," Ringel said. The report, "Improving Child Welfare Outcomes: Balancing Investments in Prevention and Treatment," was funded by the Pritzker Foster Care Initiative and conducted under the auspices of four units at RAND: Health; Labor and Population; Education; and Justice, Infrastructure and Energy. Other authors are Dana Schultz, Joshua Mendelsohn, Stephanie Brooks Holliday, Katharine Sieck, Ifeanyi Edochie and Lauren Davis.
News Article | May 3, 2017
What's come to be known as the "drone war" is almost always portrayed as soulless, clinical remote killing carried out by machines operating thousands of miles away. But drone warfare isn't just about machines. There are real humans piloting the drones, just as there are real victims. Hollywood has tried to shine a light on the psychological pressures these drone pilots face; sitting in air-conditioned, lifeless shipping containers in Creech Air Force Base, Nevada. But nothing can compete with real life testimonials. A study into the stress and dissatisfaction of the US Air Force's remotely piloted aircraft community, conducted by RAND, offers a chilling and humanising glimpse into the world of US Air Force drone pilots. The report concludes that there are indeed several psychological stressors placed upon drone pilots, ranging from the long hours to the general morale of the teams, but it's the anonymous comments from USAF drone pilots that stand out the most. We fly all the friggin time, constantly, never stops. I'm stressed. I'm the only instructor. I was training a student for eight hours. Then in the last two hours, I was asked more questions than all day. I was so all over the place, my brain was overworked. I was trying not to get too short-tempered with him. [The worst part is] the drive, the drive, the drive. A lot has to do with local community and will not support a growing Air Force base, not willing to accept any sort of drinking. I can't feel my toes, even though I wear warmers [in the Remotely Piloted Aircraft Operations Center]. It blows my mind that we have eight squadrons that are 24- hours operations, but there is not a single 24-hour service on this base. • They won't let us PT [physical training] test at Nellis, just because we're from Creech. The Air Force public affairs office never lets anyone know the value of what we do. They want an RPA everywhere, so combatant command [COCOM] wants a drone on something, but doesn't realize the strain. "How is our mission helping end the war(s)? With every IED [improvised explosive device] emplace we kill, are we any closer to ending the overall conflict? . . . Is there any end in sight?" I get burned out mentally from eight consecutive instruction days. "Seven out of the ten airmen I've had here are trying or are going to get out or have expressed extreme depression or talked of suicide." Can be hard to "off someone" and then go back home and hug the kids. The transition is hard. Everything is classified, everything that we do you can't talk to your friends, coworkers, and family outside of work. I know a lot of people that need to talk to someone but won't do it on their own, because they don't want to hurt the rest and people shut down. That's just a sampling. The RAND study conducted 28 hour-and-a-half focus group sessions with some 180 USAF airmen, assigned to pilot, sensor operator, and intelligence positions. Several previous studies have already exposed the high rate of 'burnout' and unique stressors drone pilots experience, but these sorts of raw testimonials are still rare in the relatively new era of drones. For remote pilots, they are indicative of a psychologically traumatic style of future warfare. To learn more about America's drone pilots, watch Motherboard's sit-down with Brandon Bryant, a former drone pilot and sensor operator for the of the US Air Force.
News Article | April 27, 2017
A new RAND report identifies the likely concerns of North Korean elites about their possible fates under various unification scenarios and recommends actions that the Republic of Korea (ROK), also known as South Korea, could take now to help North Korean elites feel more positive about, or at least less resistant to, unification. While Korean unification is a major issue in South Korea, North Korean propaganda suggests that an ROK-led unification would be a disaster for North Korean elites, using this fear to bind elites closer to the regime and make them more hostile and resistant to ideas of unification. Without changing those views of North Korean elites it is difficult to imagine how peaceful unification could be achieved, the report finds. "There are five conditions that would likely help North Korean elites feel that unification could be good for them," said Bruce Bennett, author of the report and a senior international defense researcher at the RAND Corporation, a nonprofit, nonpartisan research organization. "These include ensuring their individual safety and security, maintaining their positions, maintaining their wealth, ensuring their family's safety and privileges, and being able to do something meaningful for their country." The report does not predict unification but notes that conditions for unification could develop at any time, warranting preparation. It proposes unification policies in each of these areas that the South Korean government should consider with urgency. It would take time (perhaps years) for the North Korean elites to believe the sincerity of these policies. If the South Korean government were to wait until just before or after unification to announce such policies, many North Korean elites would not believe them. The report notes that South Korea could address the unification issue by planning to continue the role of many elites in the combined Korean government and/or the combined Korean economy. Given the limitations of the South Korean legal system (only 50,000 prison spaces and a judiciary sized for the expected number of convicted South Korean criminals), South Korea would potentially need to consider extending amnesty to perhaps millions of North Koreans who have engaged in giving or taking bribes and other lesser crimes defined by South Korean law. "South Korea could also be assembling funds to support the costs of unification to clarify to North Koreans the reality of South Korean planning, consistent with the vision for unification put forward by South Korean President Lee Myung-bak," Bennett said. "South Korea would need to communicate these efforts to North Korea." It is impossible to determine how Korean unification might actually occur. While peaceful transition would clearly be the most desired option, unification could also occur as the result of conflict or a North Korean government collapse. Across these scenarios, a favorable outcome to unification would depend on convincing Northern elites that unification would be something they could live with, and not something unacceptably bad, the report concluded. The report, "Preparing North Korean Elites for Unification," was sponsored by the Korea Foundation and conducted within the International Security and Defense Policy Center of the RAND National Security Research Division (NSRD). NSRD conducts research and analysis on defense and national security topics for the U.S. and allied defense, foreign policy, homeland security, and intelligence communities and foundations and other non-governmental organizations that support defense and national security analysis.
News Article | June 20, 2017
'Principal Pipelines' to Develop School Leaders May Be Affordable Way to Improve Schools, RAND Corporation Finds Improving school leadership by better selecting, training and evaluating principals can be an affordable option for school districts that aim to reduce turnover and improve schools, according to a new report by the nonprofit, nonpartisan RAND Corporation. The first-of-its kind study examined how six large urban school districts are investing in their leaders through a concept called "principal pipelines." The idea is to help school districts develop a better preparation, hiring, evaluation and support system for principals to ensure they are effective. The Wallace Foundation funded the initiative. While states and school districts are grappling with a shortage of highly effective principals for all schools, there has been little information about what level of resources would be required to do so. RAND's report fills this gap. Researchers found that developing a pipeline to improve school leadership has been affordable for the six districts, which spent 0.4 percent of their annual budgets to better the quality of school leaders. "Districts can likely prioritize developing better principals with the resources they have now," said Susan Gates, one of the lead researchers on the report. "Our research found the main expense of this effort was the salaries of district staff members who helped screen, support and evaluate principals -- activities that most districts are already doing, just not in a strategic way." The study found that the districts spent about $5.6 million annually (about $31,000 per principal) on the leadership initiative during the four years examined. Nearly half (44 percent) of that consisted of district staff salaries for the staff's time on the effort. To put these estimates in context, the RAND study found the per-pupil costs work out to $42, compared with $608 that U.S. school districts spend on school administration, $477 on transportation and $447 on food services. Other expenses of the new program included preparing new principals, then coaching and evaluating them and providing professional development. Most of this funding was not new grant funds provided by Wallace but drawn from existing school district funds that were reallocated from other uses. "Our research found that principal pipelines are not a big-ticket item for these school districts," said Julia Kaufman, the other lead researcher. "School districts can look at our research and consider the likely costs for various activities intended to improve leadership." Researchers found that districts spent relatively little to develop and revise job standards for principals, and then hire them -- $292 per principal and $2,894 per principal, respectively. The Wallace Foundation launched the Principal Pipeline Initiative in 2011 to determine if large urban school districts could build pipelines and whether stronger pipelines would improve schools and raise student achievement districtwide. It initially awarded grant funding of $7.5 million to $12.5 million to each district to cover part of the costs of setting up the pipelines. Districts were given additional funding of $430,000 to $1 million each to strengthen the skills of principals and supervisors. Those districts were Charlotte-Mecklenburg Schools in North Carolina, Denver Public Schools in Colorado, Gwinnett County Public Schools in Georgia, Hillsborough County Public Schools in Florida, the New York City Department of Education and Prince George's County Public Schools in Maryland. Other authors of the report, "What it Takes to Operate and Maintain Principal Pipelines: Costs and Other Resources," are Melody Harvey, Yan Wang and Mark Barrett. This report breaks down the various costs of better selecting, training and evaluating principals and provides average estimates based on costs from all six districts. It does not address the impact on student learning and other outcomes. RAND expects to publish a second research report in December 2018 examining those issues. "This study is significant because it provides district leaders with clear and useful information that they haven't had before on the costs of building a principal pipeline," said Elizabeth Ty Wilde, senior research and evaluation officer at Wallace. "Its findings show that districts can make progress on key aspects of building principal pipelines aimed at developing effective leaders, and can cover a large percentage of those costs with existing funds." "The RAND study and other recent studies contain important lessons for all districts that want effective principals leading their schools," added Jody Spiro, director of education leadership at Wallace. "Previous studies show that building principal pipelines have the potential to reduce unwanted turnover for both teachers and principals. The RAND study now shows that pipelines are affordable as well." The mission of RAND Education, a division of the RAND Corporation, is to bring accurate data and careful, objective analysis to the national debate on education policy.
News Article | June 23, 2017
Most of the federally qualified health centers that participated in a program to help them adopt a "medical home" model of advanced primary care were successful in doing so according to a new RAND Corporation study. These changes improved access to primary care, but did not decrease the use of specialty care, acute care services or Medicare expenditures. Researchers say the results underscore the challenges safety net clinics face in changing their practice models. In particular, strengthening primary care systems for vulnerable or under-served populations may be far more challenging because of patients' long-standing disease burdens, substantial social service needs, and limited English proficiency or health literacy. Once medical services become more accessible, these populations may receive more needed medical care, which is one goal of a medical home model, according to the study. The findings are published online by the New England Journal of Medicine and will be published in the July 20 print edition. "Primary care medical practices are rapidly adopting the patient-centered medical home model of care and one result may be that under-served patients use more services once it becomes easier to access care," said Justin Timbie, lead author of the study and a senior health policy researcher at RAND, a nonprofit research organization. "There also is evidence that improvements in primary care may lead to reductions in specialty care and cost over a longer period than we examined in this study." Patient-centered medical homes are primary care practices that provide comprehensive, personalized, team-based care using patient registries, electronic health records and other advanced capabilities. Comprehensive primary care can improve outcomes for chronic conditions like diabetes and asthma, while lowering costs by reducing patients' needs for care from hospitals and emergency departments. From 2011 to 2014, the federal Centers for Medicare & Medicaid Services, in partnership with the Health Resources and Services Administration, provided additional payments and technical assistance to approximately 500 federally qualified health centers to enhance their services in accordance with the medical home model and seek formal recognition from the National Committee for Quality Assurance (NCQA). Such a designation requires the adoption of processes to improve access, continuity and coordination of care to patients. Federally qualified health centers are community-based organizations that provide comprehensive primary care and other health services to people of all ages, regardless of their ability to pay or whether they have health insurance. RAND researchers evaluated the medical home program by examining billing data of Medicare beneficiaries treated at the clinics and surveying the Medicare beneficiaries about their care. They compared the clinics in the federal demonstration to other federally qualified health centers that were not receiving support from the medical home project. While 70 percent of the clinics in the demonstration project received the highest level of medical home recognition, it took most of them the full three years to achieve the goal. By contrast, about 11 percent of the comparison clinics achieved NCQA's highest level of medical home recognition, although an additional 26 percent of comparison clinics obtained lower levels of NCQA recognition or recognition from other organizations. While patient visits declined at both sets of clinics, the drop was smaller in the demonstration sites. Researchers say this likely reflects patients having better access to care than at the comparison sites. Patients who used the demonstration clinics reported better access to care and some measures of quality of care for diabetes were better at the demonstration sites. The demonstration sites also had relatively larger increases in visits to hospital emergency departments, inpatient admissions and spending on physician services. "We found that many of the health centers in our comparison group also made changes to adopt a medical home model, which may have limited the differences we saw among those who participated in the federal demonstration project," said the study's senior author Dr. Katherine Kahn, a professor at the David Geffen School of Medicine at UCLA and Distinguished Chair in Health Care Delivery Measurement and Evaluation at RAND. Researchers noted that the management fees paid to demonstration sites -- $6 per month for each Medicare enrollee -- were perceived by clinic directors as helpful but inadequate to support the added staff and other investments needed to support practice change. Larger payments or support from additional payers may be needed to trigger the type of advanced practice changes that may reduce Medicare spending. "Future tests of medical home interventions in federally qualified health centers should consider alternative approaches that consider the magnitude of financial assistance and the evaluation's duration to better understand how to help federallly qualified health centers implement practice change and how these changes can lead to improvements in health outcomes for vulnerable Medicare beneficiaries," Kahn said. Support for the research was provided by the federal Centers for Medicare & Medicaid Services. Other authors of the study are Claude M. Setodji, Amii Kress, Peter J. Mendel, Emily K. Chen, Beverly A. Weidmer, Christine Buttorff, Rosalie Malsberger, Mallika Kommareddi, Afshin Rastegar, Aaron Kofner, Lisa Hiatt and Ammarah Mahmud, all of RAND; Dr. Mark W. Friedberg of RAND, Brigham and Women's Hospital and Harvard Medical School; Tara A. Lavelle of Tufts Medical Center; and Katherine Giuriceo of the Centers for Medicare & Medicaid Services. RAND Health is the nation's largest independent health policy research program, with a broad research portfolio that focuses on health care costs, quality and public health preparedness, among other topics.
News Article | June 15, 2017
While a California ballot initiative reducing penalties for some criminal offenses promised to save local governments money, quantifying such savings will require significant changes in the way local agencies track workloads, according to a new RAND Corporation report. Establishing better performance metrics to follow both the workload created by new policies and the consequences of such changes would allow policymakers to examine whether reforms such as those imposed by Proposition 47 are saving money, according to the report. The recommendations come from an examination of eight Los Angeles County departments that was intended to quantify the cost savings promised by 2014's Proposition 47, which reduced criminal penalties for many nonviolent property and drug crimes. RAND researchers concluded there was too little information available to create credible estimates of cost savings, despite there being evidence that many of the departments saw a drop in workloads. The county departments lack the infrastructure needed to readily monitor workload changes and translate those changes into a fiscal impact, according to the study. "Some departments had too few resources prior to the passage of Proposition 47, so any savings that occurred led to improvements in workloads, but did not necessarily created cost savings," said Sarah Hunter, the study's lead author and a senior behavioral scientist at RAND, a nonprofit research organization. "Moreover, we found there was too little information tracked about specific workload changes to translate into reliable fiscal estimates." RAND researchers estimated changes in workloads since the approval of Proposition 47 for eight county departments: the District Attorney's Office, the Public Defender's Office, the Alternative Public Defender's Office, the Sheriff's Department, the Probation Department, the Department of Health Services, the Department of Mental Health Services and the Department of Public Health. Researchers found that while Proposition 47 triggered a reduction in felony cases for the legal and policing agencies, it also increased the number of misdemeanor cases the departments faced. In addition, the three legal agencies realized additional work involving past offenders who filed for relief under the law, which allows people who were convicted of certain felonies in the past to petition to have their convictions downgraded. While the Sheriff's Department saw a drop in arrests for narcotics violations, arrests for larceny increased. Researchers found that the overall custody population in the county jails dropped, but the Sheriff's Department noted there was an increase in workload triggered by more inmates with mental health problems. "Proposition 47 was different from other criminal justice reforms in that it created new types of criminal violations, which makes it more difficult to identify impact by examining how individuals and their cases were handled before and after the reforms," Hunter said. While counties across California are interested in understanding the impact of Proposition 47 on workloads, RAND researchers were unable to identify any comprehensive efforts to tie workload changes to costs or that any entity had created a set of metrics to be used across jurisdictions. RAND researchers recommend Los Angeles County managers consider several options for better understanding the impact that Proposition 47 is having on the use of services and criminal justice outcomes. One approach would be to follow for several years a group of people who benefit from the Proposition 47 changes to assess their need for services and see whether they ultimately commit further criminal offenses. In order to pursue such a project, the county would need to create a database that can to link individuals and their data over time across different county departments, while also protecting individual privacy rights. The county also needs to consider improving the metrics collected by the eight agencies studied and the ability to link those measures to individual initiatives such as the Proposition 47 reforms. For example, metrics could include collecting the number of people affected by Proposition 47 that received mental health and drug treatment. The project was supported by the Los Angeles County Chief Executive's Office. The study, "Impact of Proposition 47 on Los Angeles County Operations and Budget," is available at http://www. . Other authors of the study are Lois M. Davis, Rosanna Smart and Susan Turner. The project was conducted within the RAND Justice Policy Program, which conducts research across the criminal and civil justice system on issues such as public safety, effective policing, drug policy and enforcement, corrections policy, court reform and insurance regulation.
Jena A.B.,Harvard University |
Seabury S.,RAND |
Lakdawalla D.,University of Southern California |
Chandra A.,Harvard University
New England Journal of Medicine | Year: 2011
BACKGROUND: Data are lacking on the proportion of physicians who face malpractice claims in a year, the size of those claims, and the cumulative career malpractice risk according to specialty. METHODS: We analyzed malpractice data from 1991 through 2005 for all physicians who were covered by a large professional liability insurer with a nationwide client base (40,916 physicians and 233,738 physician-years of coverage). For 25 specialties, we reported the proportion of physicians who had malpractice claims in a year, the proportion of claims leading to an indemnity payment (compensation paid to a plaintiff), and the size of indemnity payments. We estimated the cumulative risk of ever being sued among physicians in high- and low-risk specialties. RESULTS: Each year during the study period, 7.4% of all physicians had a malpractice claim, with 1.6% having a claim leading to a payment (i.e., 78% of all claims did not result in payments to claimants). The proportion of physicians facing a claim each year ranged from 19.1% in neurosurgery, 18.9% in thoracic-cardiovascular surgery, and 15.3% in general surgery to 5.2% in family medicine, 3.1% in pediatrics, and 2.6% in psychiatry. The mean indemnity payment was $274,887, and the median was $111,749. Mean payments ranged from $117,832 for dermatology to $520,923 for pediatrics. It was estimated that by the age of 65 years, 75% of physicians in lowrisk specialties had faced a malpractice claim, as compared with 99% of physicians in high-risk specialties. CONCLUSIONS: There is substantial variation in the likelihood of malpractice suits and the size of indemnity payments across specialties. The cumulative risk of facing a malpractice claim is high in all specialties, although most claims do not lead to payments to plaintiffs. (Funded by the RAND Institute for Civil Justice and the National Institute on Aging.) Copyright © 2011 Massachusetts Medical Society. All rights reserved.
Hussey P.S.,South Hayes Street W7W |
Wertheimer S.,Harvard University |
Annals of Internal Medicine | Year: 2013
Background: Although there is broad policy consensus that both cost containment and quality improvement are critical, the association between costs and quality is poorly understood. Purpose: To systematically review evidence of the association between health care quality and cost. Data Sources: Electronic literature search of PubMed, EconLit, and EMBASE databases for U.S.-based studies published between 1990 and 2012. Study Selection: Title, abstract, and full-text review to identify relevant studies. Data Extraction: Two reviewers independently abstracted data with differences reconciled by consensus. Studies were categorized by level of analysis, type of quality measure, type of cost measure, and method of addressing confounders. Data Synthesis: Of 61 included studies, 21 (34%) reported a positive or mixed-positive association (higher cost associated with higher quality); 18 (30%) reported a negative or mixed-negative association; and 22 (36%) reported no difference, an imprecise orindeterminate association, or a mixed association. The associations were of low to moderate clinical significance in many studies. Of 9 studies using instrumental variables analysis to address confounding by unobserved patient health status, 7 (78%) reported a positive association, but other characteristics of these studies may have affected their findings. Limitations: Studies used widely heterogeneous methods and measures. The review is limited by the quality of underlying studies. Conclusion: Evidence of the direction of association between health care cost and quality is inconsistent. Most studies have found that the association between cost and quality is small to moderate, regardless of whether the direction is positive or negative. Future studies should focus on what types of spending are most effective in improving quality and what types of spending represent waste. Primary Funding Source: Robert Wood Johnson Foundation. © 2013 American College of Physicians.
Climatic Change | Year: 2013
Scenarios exist so that decision makers and those who provide them with information can make statements about the future that claim less confidence than do predictions, projections, and forecasts. Despite their prevalence, fundamental questions remain about how scenarios should best be developed and used. This paper proposes a particular conceptualization of scenarios that aims to address many of the challenges faced when using scenarios to inform contentious policy debates. The concept envisions scenarios as illuminating the vulnerabilities of proposed policies, that is, as concise summaries of the future states of the world in which a proposed policy would fail to meet its goals. Such scenarios emerge from a decision support process that begins with a proposed policy, seeks to understand the conditions under which it would fail, and then uses this information to identify and evaluate potential alternative policies that are robust over a wide range of future conditions. Statistical cluster analyses applied to databases of simulation model results can help identify scenarios as part of this process. Drawing on themes from the decision support literature, this paper first reviews difficulties faced when using scenarios to inform climate-related decisions, describes the proposed approach to address these challenges, illustrates the approach with applications for three different types of users, and concludes with some thoughts on implications for the provision of climate information and for future scenario processes. © 2012 RAND Corporation.
Auerbach D.I.,RAND |
Kellermann A.L.,RAND Health
Health Affairs | Year: 2011
Although a median-income US family of four with employerbased health insurance saw its gross annual income increase from $76,000 in 1999 to $99,000 in 2009 (in current dollars), this gain was largely offset by increased spending to pay for health care. Monthly spending increases occurred in the family's health insurance premiums (from $490 to $1,115), out-of-pocket health spending (from $135 to $235), and taxes devoted to health care (from $345 to $440). After accounting for price increases in other goods and services, the family had $95 more in monthly income to devote to nonhealth spending in 2009 than in 1999. By contrast, had the rate of health care cost growth not exceeded general inflation, the family would have had $545 more per month instead of $95-a difference of nearly $5,400 per year. Even the $95 gain was artificial, because tax collections in 2009 were insufficient to cover actual increases in federal health spending. As a result, we argue, the burdens imposed on all payers by steadily rising health care spending can no longer be ignored. © 2011 Project HOPE- The People-to-People Health Foundation, Inc.