From The Staff

Health Affairs Web First: Vietnam’s Health Care System, Explained By Its Minister Of Health


October 30th, 2014

In August, Vietnam’s Minister of Health, Nguyen Thi Kim Tien, was interviewed for Health Affairs by Tsung-Mei Cheng, recently released as a Health Affairs Web First.

Among the topics discussed was an overview of the unique characteristics of Vietnam’s health system; its strengths and weaknesses; health financing reform aimed at reaching the goal of universal health coverage; the prevention and control of infectious diseases; and how Vietnam has performed in achieving the Millennium Development Goals.

Cheng is a health policy research analyst at the Woodrow Wilson School of Public and International Affairs, Princeton University, in New Jersey. Health Affairs has previously published Cheng’s interviews with other world health ministers, including Thomas Zeltner of Switzerland (2010) and Chen Zhu of China (2012). Read the rest of this entry »

Health Affairs Briefing: Collaborating For Community Health


October 29th, 2014

Policymakers are paying increasing attention to the relationship between the characteristics of communities and the health of the people living in them. The November 2014 issue of Health Affairs, “Collaborating For Community Health,” examines new possibilities created by alignment of the fields of health and community development.

These possibilities come from both sides, including recent changes in the community development field that have set the stage for the new focus on improving health, as well as new approaches to health care financing that create incentives for improving health outcomes.

You are invited to join us on Wednesday, November 5, at a forum featuring authors from the new issue at the National Press Club in Washington, DC.

WHEN:
Wednesday, November 5, 2014
9:00 a.m. – 12:00 p.m.

WHERE:
National Press Club
529 14th Street NW
Washington, DC, 13th Floor

REGISTER NOW!

Follow live Tweets from the briefing @Health_Affairs, and join in the conversation with #HA_CommunityHealth. Read the rest of this entry »

The Latest Health Wonk Review


October 24th, 2014

Louise Norris at Colorado Health Insurance Insider provides this week’s “falling leaves” edition of the Health Wonk Review. Jennifer’s insightful read includes a Health Affairs Blog post from J. Stephen Morrison on the U.S. Ebola response and the role of CDC head Thomas Friedan. Read the rest of this entry »

Narrative Matters: Sensitizing Doctors To Patients With Disabilities


October 23rd, 2014

In the October Health Affairs Narrative Matters essay, a doctor who stutters confronts the stigma against patients—and providers—with disabilities. Leana Wen’s article is freely available to all readers, or you can listen to the podcast. Read the rest of this entry »

Health Affairs Web First: Noneconomic Damage Caps Reduced Medical Malpractice Payments, With Varied Effects


October 22nd, 2014

With the 2014 election weeks away, a provision of California’s Proposition 46, raising the cap on medical malpractice payments for noneconomic damages, has been in the news. This provision would increase the payment cap from $250,000 to $1.1 million. A new study, being released today by Health Affairs as a Web First, sheds light on the potential effect of this proposition.

Study authors Seth A. Seabury, Eric Helland, and Anupam B. Jena looked at the impact of medical malpractice reforms on the average size of malpractice payments in several physician specialties and compared how the effects differed according to the size of the cap. It found that caps reduced the average payments by 15 percent compared to no cap—and a $250,000 cap reduced average payments by 20 percent.

On the other hand, a less restrictive $500,000 cap had no significant effect. The authors also found specialty variations, with the largest impact involving pediatricians and the smallest for claims of surgical subspecialties and ophthalmologists. Read the rest of this entry »

Resources Don’t Solve Design Flaws


October 21st, 2014

The first three sessions of a conference I recently attended tackled some complex and important questions: How do we extend health insurance to people such as migrant and informal workers who don’t fit neatly into mainstream coverage programs? As we increase our investment in primary care, how do we assure that the performance of the primary care system is at the highest possible level? What types of evidence should we use as we make decisions in a dynamic health care system with limited opportunities for “gold standard” randomized controlled trials?

These are excellent questions, and they were perfect topics for a cutting-edge conference discussing the challenges facing the U.S. health care system.

But this conference was not about the U.S. health care system. These were opening “satellite” sessions at the Third Global Symposium on Health Systems Research held in Cape Town, South Africa. Read the rest of this entry »

Health Policy Brief: The Ninety-Day Grace Period


October 17th, 2014

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) examines the ninety-day grace period, a provision of the Affordable Care Act (ACA). Of the eight million people who enrolled in the insurance Marketplaces between October 2013 and March 2014, 85 percent received an advance premium tax credit. This provision allows a three-month grace period for nonpayment of insurance premiums for this group of consumers–and this group only–if they have previously paid at least one month’s full premium in that benefit year.

This grace period allows these new enrollees continuity of care, preventing them from shifting or “churning” in and out of coverage for nonpayment. Health care providers, however, have expressed concerns that this provision and the way the Centers for Medicare and Medicaid Services (CMS) has implemented it could expose them to considerable financial risk. This Health Policy Brief focuses on how this provision is being implemented and the concerns from the provider community. Read the rest of this entry »

Gordon And Betty Moore Foundation Names Harvey V. Fineberg Its New President


October 13th, 2014

Health Affairs was delighted to read today’s announcement that Dr. Harvey V. Fineberg will become the next president of The Gordon and Betty Moore Foundation, effective January 1, 2015. Until recently, Dr. Fineberg was president of the Institute of Medicine (IOM), serving two consecutive terms from 2002-2014. From 1997 to 2001, he served as Provost of Harvard University, and prior to that for 13 years as Dean of the Harvard School of Public Health.

Health Affairs has strong ties to both Fineberg and The Gordon and Betty Moore Foundation. This summer, I interviewed Fineberg about his tenure at the IOM; the audio recording of that wide-ranging conversation is available as a Health Affairs podcast.   Read the rest of this entry »

Posts On ACA Tax Forms, Replacement Plan Lead September Health Affairs Blog Top-Ten List


October 10th, 2014

Tim Jost’s post on complicated Affordable Care Act (ACA) tax forms and his review of Avik Roy’s ACA replacement plan were the most-read Health Affairs Blog posts for September. These were followed by a CVS Health post from Troyen Brennan and coauthors on rethinking the sale of tobacco products in pharmacies and a post on bundled payments and innovation from Rebecca Paradis of the Network for Excellence in Health Innovation.

The full list is below. Read the rest of this entry »

The Latest Health Wonk Review


October 10th, 2014

At Managed Care Matters, Joe Paduda provides this week’s edition of the Health Wonk Review. Joe’s post is an interesting read and includes a Health Affairs Blog post on from Suzanne Delbanco on results from the National Scorecard on Payment Reform. Read the rest of this entry »

Contributing Voices

Learning From Missed Opportunities To Diagnose US Ebola Patient Zero


October 30th, 2014

Over a century ago American physician Richard Cabot wrote about misdiagnoses, recognizing: “A goodly number of ‘classic’ time-honored mistakes in diagnosis are familiar to all experienced physicians because we make them again and again. Some of these we can avoid; others are almost inevitable, but all should be borne in mind and marked on medical maps by a danger-signal of some kind: ‘In this vicinity look out for hidden rocks,’ or ‘Dangerous turn here, run slow.’”

Ironically, despite the dramatic changes in the nature of medical practice over the last 100 years, Cabot’s words ring more true than ever today. This has become especially clear in the last few weeks since Ebola first touched US shores, uncovering one of the biggest ongoing vulnerabilities of outpatient medicine – misdiagnosis. Read the rest of this entry »

North Carolina Dental Board v. FTC: A Bright Line On Whiter Teeth?


October 30th, 2014

On October 14, 2014, the United States Supreme Court heard oral arguments in North Carolina Board of Dental Examiners vs. Federal Trade Commission.  The case does not involve the Affordable Care Act, but it goes to the heart of the professional self-regulatory paradigm that has governed the U.S. health care system for more than a century.  The specific legal question under review is the standard for determining when a state professional licensing board’s activities are subject to scrutiny for anticompetitive effect under the federal antitrust laws.

Antitrust law applies to private anticompetitive conduct.  Congress did not intend to interfere with state regulation that limits or even eliminates competitions.  As long as states do so using public agencies and officials, they are on safe ground.  If a state empowers private parties to administer such regulation, however, it not only must “clearly articulate” its intent to diminish competition, but also must “actively supervise” the conduct of the private parties.  In previous cases, the Supreme Court developed and elaborated this two-part test, which is called the “state action doctrine.” Read the rest of this entry »

Poverty’s Association With Poor Health Outcomes and Health Disparities


October 30th, 2014

A recent ecological study by Carl Stevens, David Schriger, Brian Raffetto, Anna Davis, David Zingmond, and Dylan H. Roby, published in the August issue of Health Affairs, showed significant associations between neighborhood poverty and diabetes-related lower extremity amputations (LEA) in the state of California, which adds to the growing evidence that where you live (not just how you live) may directly impact your health.

The authors linked data from multiple sources (i.e. California Health Information Survey, Census Bureau’s American Community Survey, health facility discharge data) and used geographic information system (GIS) analyses and regression analyses to identify amputation “hot spots” and uncovered a 10-fold variation in LEA rates between low-income and high-income neighborhoods. Read the rest of this entry »

Grand-Aides And Health Policy: Reducing Readmissions Cost-Effectively


October 29th, 2014

Hospital readmissions for the same condition within 30 days likely should not occur, and most often indicate system failure. Readmitted patients are either discharged too early, should be placed into palliative care or hospice, or most often are victims of a failure in transition of care from hospital to home. Most hospitals and physicians would like to eliminate such readmissions, particularly now that payers like Medicare are penalizing hospitals for high rates of readmission. Numerous approaches have been tried to reduce readmissions, with recent published improvements between a 2 percent and 26 percent reduction.

The Grand-Aides® program features rigorous training of nurse aides or community health workers to work as nurse extenders, 5 Grand-Aides to one RN or nurse practitioner (NP) supervisor, with approximately 50 patients per Grand-Aide per year. The Grand-Aides visit at home daily for the first 5 days post-discharge and then as ordered by the supervisor (e.g. 3 days the next week) for at least 30 days, extending as long as desired.

The post-discharge protocol for Grand-Aides includes the following: Read the rest of this entry »

Ebola And EHRs: An Unfortunate And Critical Reminder


October 28th, 2014

The Dallas hospital communication lapse that led to the discharge of a Liberian man with Ebola symptoms is an example of the failure of the American health care system to effectively share health information, even within single institutions. It is not possible to know whether a faster response would have saved Thomas Eric Duncan’s life or reduced risk to the community and health workers.

What is clear is that rapid sharing of information is one of the elements critical to halting the spread of Ebola. Had all members of the initial care team known of the patient’s recent arrival from an Ebola-stricken country and acted appropriately to quarantine Mr. Duncan, this would have limited the chance of exposing the public and enabled faster preventive protocols for treating personnel. Read the rest of this entry »

Lessons from Ebola: The Infectious Disease Era, And The Need To Prepare, Will Never Be Over


October 28th, 2014

With the wall-to-wall news coverage of Ebola recently, it’s hard for many to distinguish fact from fiction and to really understand the risk the disease poses and how prepared we are to fight it.

Fighting infectious diseases requires constant vigilance. Along with Ebola, health officials around the globe are closely watching other emerging threats: MERS-CoV, pandemic flu strains, Marburg, Chikungunya and Enterovirus D68. The best defense to all of these threats is a good offense — detecting, treating and containing as quickly and effectively as possible.

And yet, we have consistently degraded our ability to respond to these new, emerging and re-emerging threats by underfunding and undercutting existing capabilities and expecting the country to ramp up overnight when new threats emerge. Read the rest of this entry »

Adult Conversation On High-Priced Drugs? Don’t Hold Your Breath (But Hang In There) …


October 27th, 2014

The benevolent identity of the health care enterprise tends to moderate disagreements and keep them under a big tent of shared goals. In the case of very high prices for powerful new drugs, however, the commons gets stretched painfully thin. Drug companies which see themselves as pioneers are accused of being merely greedy. Cost-conscious payers and regulators are impugned for depriving patients of life-conserving treatment breakthroughs. A divisive political undercurrent often threatens to obtrude. Altogether, a tough environment for rational policy assessment.

Credit is due, accordingly, to the Brookings Institution, for putting a wide array of views on display at its October 1 forum on “the cost and value of biomedical innovation,” which was jointly sponsored by the Schaeffer Center at the University of Southern California. With the head of Gilead Sciences at one pole of the discussion and a leading generics industry attorney at the other, the discussion didn’t lack for strongly-held views, strongly stated.

But the tone was civil, a lot of useful information was exchanged, and the audience went away carrying a meta-message about the importance of maintaining an “adult conversation” on a subject of such obvious importance and difficulty. Read the rest of this entry »

Study Draws Misleading Conclusions Regarding 340B Program


October 23rd, 2014

After reading Rena Conti and Peter Bach’s recent study on hospitals’ purported misuse of the 340B Drug Discount Program, published in the October issue of Health Affairs, I had two questions: first, how are the authors substantiating their conclusions? Second, what kind of sensational sound bites are going to come from this?

These are the questions that responsible researchers must ask themselves so there is not a false representation of what they did, what they found, and how the actual findings compare to their research intentions. Researchers have to be equally precise in both their statistical analysis AND in the discussion of the results.

I was tempted to run through several counterpoints that my 15 years of 340B policy and research experience yields, but was tempered by both the word count limitations on a blog post and the straightforwardness of my main objection. Simply put, the authors’ conclusions are not substantiated by the data collected. Conti and Bach say that they “found” that hospitals “served communities that were wealthier and had higher rates of insurance” and “generated profits.” They did not find this. Read the rest of this entry »

Tax-Exempt Status For Nonprofit Hospitals Under The ACA: Where Are The Final Treasury/IRS Rules?


October 23rd, 2014

Months have now stretched into years, and there still remains no sign of final Treasury/IRS regulations interpreting the Affordable Care Act (ACA)’s provisions covering the expanded obligations of nonprofit hospitals that seek tax-exempt status under §501(c)(3) of the Internal Revenue Code.

The ACA amendments do not depend on formal agency policy to take effect. Nonetheless, Congress directed the Treasury Secretary to issue regulations and guidance necessary to carry out the reforms (26 U.S.C. §501(r)(7)). To this end, two important sets of proposed rules were issued: the first in June, 2012; and the second, in April 2013. While an informative IRS website lists various proposed rules and guidelines important to nonprofit hospitals, final rules seem to have performed a disappearing act.

Apparently recognizing the problems created by its delays, the agency has gone so far as to issue a special Notice letting nonprofit hospitals (and presumably the public) know that they can rely on its proposed rules. But this assurance overlooks the fact that the proposed rules themselves contained crucial areas in which final agency policy has not yet been adopted. Read the rest of this entry »

Implementing Health Reform: The Qualified Health Plan Federal Exchange Participation Agreement And More


October 21st, 2014

October 30 update: On October 24, 2014, CMS released a Guidance for Issuers on the Termination of a Consumer’s Enrollment in the Federally-facilitated Marketplace due to death.  When a individual enrolled in a qualified health plan through the FFM dies, coverage terminates effective on the date of death.  The FFM and insurer must learn of the death, however, to terminate coverage.

A death can be reported by the individual who filed the application for marketplace coverage covering the deceased or any member of the deceased’s coverage household who is at least 18 years of age.  The death can be reported through Healthcare.gov or through the call center, but if it is reported online, it should also be reported through the call center to establish the date of death and terminate coverage retroactively to the date of death.  Alternatively, someone who was not a member of the coverage household or the application filer can report the death, but then it must be documented with, for example, a death certificate, obituary, power of attorney, proof of executor, or proof of estate. The documentation must be mailed to the FFM’s London, Kentucky center

If the death is reported to the insurer rather than the FFM, the insurer should direct the person who reports the death to the FFM.  The remaining qualified individuals or enrollees may need to update their information with the FFM.  The FFM will then conduct a redetermination of eligibility of the remaining members of the household.  These changes may qualify the remaining enrollees for an special enrollment period if they result in loss of minimum essential coverage.

When coverage is terminated due to death, the FFM will instruct the insurer to terminate coverage prospectively through an 834 transaction.  The call center will then open a case through the Health Insurance Casework System to terminate coverage retroactively to the date of death.  It will also re-enroll qualified individuals in the household in coverage where appropriate.  Insurers should process premium refunds or adjustments in accordance with state law and industry practice.

CMS also announced on October 27, 2014 that it is making access to the FF-SHOP exchange early in Delaware, Illinois, Missouri, New Jersey and Ohio.  Small businesses in those states can establish a Marketplace SHOP account, assign a SHOP agent/broker to their account, complete an employer SHOP eligibility application, obtain an eligibility determination from the FF-SHOP, and upload an employee roster.  They will be able also to see information on available plans in the near future.  The early release will give CMS a further opportunity to ensure that the SHOP exchange website is working properly prior to its formal launch on November 15, 2014.

October 24 update: The Affordable Care Act requires HHS to establish a federal process for hearing and deciding appeals from marketplace determinations regarding eligibility to enroll in a qualified health plan through the marketplace, eligibility for advance premium tax credits and cost-sharing reduction payment, and exemptions from the individual responsibility requirement.  An appeal process is also supposed to be available to employers who are notified that they may be liable for employer responsibility payments.  HHS has promulgated a final regulation establishing standards governing these appeals, as well as eligibility appeals for employers and employees for determinations involving the SHOP program.  This regulation provides state-operated exchanges flexibility to establish their own appeal procedures in accordance with federal requirements.

Under the final regulation, appeals entities were allowed to conduct a paper-based appeals process through December 31, 2014, after which they were to use an electronic process.  Under a guidance released October 23, 2014, HHS has extended the permissibility of paper-based appeals through December 31, 2015 because of difficulties in implementing the electronic process.  HHS has also stated that the federally-facilitated marketplace will continue to use a paper-based process for the 2015 benefit year.  State-operated marketplaces may choose whether to use paper or electronic processes.  The flexibility extends to all electronic requirements included within the final regulation, including appeal requests, transfer of records, and notifications.

Original post: CMS continues to put the pieces into place that are needed for the launch of the 2015 coverage year.  On October 16, 2014, the Centers for Medicare and Medicaid Services released at its REGTAP.info website the certification agreement and privacy and security agreement that qualified health plan (QHP) insurers must sign with CMS to access the federally facilitated exchange (FFE), the federally facilitated SHOP (FF-SHOP), and CMS Data Services Hub.  The agreement focuses primarily on obligations that the QHP insurer undertakes to protect personally identifiable information and to ensure secure communications with CMS, although it also addresses the effective date and termination of the agreement and a few other issues.  Most of the terms of the agreement are unremarkable, and this post will only comment on a few.

QHP insurers undertake under the agreement to protect personally identifiable information and to ensure secure communications with CMS in conformity with applicable laws, regulations, and standards.  They must also ensure that their contractors and downstream entities comply with these requirements.  QHP insurers agree to report any personally identifiable information incidents or breaches to CMS within 72 to 96 hours.  This is a far cry from the one-hour breach reporting requirement proposed by CMS last year but never finalized, but perhaps recognizes the difficult of identifying and assessing a security breach.

The agreement expressly recognizes that QHP insurers have developed their products based on the assumption that advance premium tax credits and cost-sharing reduction payments will be available through the marketplace and that QHP insurers could have cause to terminate the agreement if this assumption ceases to be valid.  This could be interpreted as a reference to the Halbig/King litigation which currently threatens the availability of tax credits and cost-sharing reduction payments through the FFE, but could also have been included in recognition of the likely Republican takeover of the Senate and the possibility that the Republicans may accomplish through budget reconciliation or otherwise their longstanding goal of repealing the ACA.  As the agreement is renewable from year to year, this clause may contemplate contingencies in the indefinite as well as the near future. Read the rest of this entry »

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