April 24th, 2014
With open enrollment completed and regulations largely in place for 2014 and 2015, implementation efforts at the federal level have quieted down. The Centers for Medicare and Medicaid Services, however, continue to issue technical guidance both to clarify outstanding 2014 issues and to clear the way for 2015. Much of this guidance appears at the CMS REGTAP website.
On April 22, 2014, CMS updated at REGTAP a series of slides, published initially on April 1, 2014, describing their proposed enrollment and payment process for the 2015 federally facilitated SHOP (FF-SHOP), which will begin to offer employee choice and premium aggregation in 2015. These slides expand on information previously provided in the 2015 federal exchange letter to issuers regarding the federal SHOP. CMS states that it intends to update the procedures set out in the slides with formal guidance before QHP certification begins in May. Read the rest of this entry »
April 23rd, 2014
Since enactment of the Affordable Care Act in March 2010, a strange, relatively unnoticed phenomenon has occurred: Congress has passed bipartisan changes to it. These amendments were generally to such esoteric components of the law that they dodged the political block-aid that otherwise surrounds it.
But what would happen if things were different? If Congress could act to change the ACA in a meaningful way, what would it do? Here we briefly review the previous sub rosa changes to launch into a broader examination of macro ACA reforms that have a fighting chance of enactment in the not too distant future.
Tinkering. Most recently, in the Medicare “doc fix” in March, both parties acted to repeal the section of the ACA that capped deductibles for small group health plans. That legislation also delayed, again, implementation of the ACA’s Medicaid cuts to disproportionate share hospitals. Read the rest of this entry »
April 22nd, 2014
The February issue of Health Affairs features a series of articles on connected health and highlights the potential for telehealth and telemedicine to reshape how health care is delivered, consumed, tracked, and even paid for.
With funding support from Kaiser Permanente Community Benefit, the Center for Health Care Strategies (CHCS) recently conducted a series of focus groups that showed how one key Medicaid population — medically and socially complex, low-income individuals — stands to gain from these advances.
The four focus groups were designed to better understand the issues driving these individuals’ health care utilization, their current level of comfort with technology, and how technology might be able to help them better manage their challenges. Participants were actively receiving services from of one of four case management/care coordination programs in New York City, Long Island, the Hudson Valley, and Philadelphia, and all were Medicaid beneficiaries with multiple medical and/or behavioral health conditions.
According to a recent Health Affairs article by John Billings and Maria Raven, these individuals frequent emergency departments and have a high incidence of chronic disease. They typically have chaotic, unstable, and socially isolated lives, and many lack permanent housing and live on the street, or in homeless shelters. Read the rest of this entry »
April 22nd, 2014
Medicare beneficiaries with multiple chronic conditions, certain types of serious conditions (e.g. heart disease, pulmonary disorders, mental disorders, cancer), and functional limitations have higher health and long-term care costs and more adverse outcomes than other beneficiaries.
One of the biggest opportunities for savings for Medicare, Medicaid, and beneficiaries themselves, is through reducing hospitalizations, readmissions, and institutional care, especially for these high-risk beneficiaries. Achieving these savings and serving this population will require innovative delivery models and a clear business case to convince organizations to implement those new models.
The Affordable Care Act set aside $10 billion for experiments in innovative care delivery and payment systems. With these funds, the Centers for Medicare and Medicaid Innovation (CMMI) is launching and evaluating several initiatives, primarily Accountable Care Organizations (ACOs), bundled payment for care innovation, and primary care transformation. These initiatives change financial incentives for health care providers so that while they bear some financial risk for the costs of providing care, they also stand to benefit from any savings produced.
Historically, it has taken additional legislative action to apply successful delivery models more broadly across the Medicare program. Now, the health care law has removed this barrier, giving the Secretary of Health and Human Services the ability to expand successful innovations that improve quality or lower costs. While early results show improvements in quality and modest savings, most CMMI pilots and demonstrations to date are not specifically targeted on high-risk beneficiaries, where the biggest gains can be expected. Read the rest of this entry »
April 21st, 2014
The sheer magnitude of the Affordable Care Act and its implementation seems to have briefly preempted the attention of the health policy community, distracting it from its perennial and inescapable preoccupation with spending growth. Everyone knew, of course, that when the dust settled, access and insurance market reforms would set off in ever starker relief the menace of the spending dragon. But in the meantime, an eerie 4-year lull in growth seemed to dull the edge of the problem.
There was research suggesting that structural changes, some in anticipation of payment and delivery system reforms encouraged by the ACA, might continue to restrain growth as the health economy joined a recovery from recession. This hopeful scenario got a boost as the lull outlasted a return to improved GDP growth. Flagging growth in pharmaceutical spending and unexpectedly low premiums in many state and federal insurance exchanges were other favorable straws in the wind. Could a generation-long growth trend averaging nearly two-and-a-half points above GDP finally be at an end? Some saw cause for cautious optimism.
This month, however, the Michigan-based Altarum Institute released an analysis based on government data that showed health spending growth began to surge last October, when it reached a 5-percent annual rate, and has continued to accelerate to a 6.7 percent pace in February, 2.4 percent above GDP and a 7-year high. Growth over the fourth quarter of 2013 was 5.6 percent, a 10-year high. Read the rest of this entry »
April 18th, 2014
On March 25, 2014, the Supreme Court of the United States heard arguments in two cases—Sebelius v. Hobby Lobby Stores, Inc. and Conestoga Wood Specialties v. Sebelius—challenging the validity of the Affordable Care Act’s (“ACA”) mandate that employer-sponsored health plans cover all FDA-approved contraceptives (the “Contraceptive Mandate”). In each case, closely held plaintiff corporations contend that the Contraceptive Mandate illegally infringed upon the corporations’ freedom to exercise religion.
The cases attracted attention because the Supreme Court had agreed to hear yet another challenge to the validity of the ACA’s provisions, but it has been less noticed that both cases, and others like them, implicate a fundamental question that the Supreme Court has never decided; on what basis, if any, is a corporation a “person” entitled to assert the constitutional and statutory rights of natural persons. Without denying the significance of the challenge to the ACA’s Contraceptive Mandate, the Supreme Court’s failure to define a principled corporate person theory has had—and continues to have—important and pervasive implications for the American legal system beyond the present cases.
Typically, legal concepts creating and regulating societal rights and obligations, like the corporate personhood concept, come into being incrementally in an extended evolutionary process. That evolutionary process is characterized by a dialectic give and take in which the principles justifying—or precluding—application of the concept in a variety of different factual scenarios are gradually clarified, defined and developed through a series of judicial decisions. The problem confronting the Supreme Court as it considers the Hobby Lobby and Conestoga Wood cases is that the concept of corporate personhood did not develop gradually or in an evolutionary process in which the meaning of the concept was developed and defined. Instead, the concept of the corporate person was imposed on the law ipse dixit, that is, by judicial fiat and without definition, in a series of late nineteenth century Supreme Court cases. Read the rest of this entry »
April 18th, 2014
Editor’s note: The conclusion of this post was updated on April 22, 2014 to discuss regulatory guidance on casework — the handling of consumer complaints by qualified health plans on matters other than adverse benefit determinations.
On April 17, 2014, the White House announced that 8 million Americans have signed up for private health insurance coverage through the health insurance marketplaces, or exchanges. This significantly exceeds the White House’s original goal of 7 million enrollees. It is far more than the Congressional Budget Office’s recent projections of 6 million.
The number of actual enrollees will be smaller than this number. The CBO’s projections are for the average number of those actually enrolled in coverage over the course of a calendar year. To calculate the average number of enrollees, one must subtract from the 8 million the number of individuals who fail to pay their premiums and thus are never actually enrolled in coverage, as well as those who will drop coverage at some later point during the year. To that reduced number, then, must be added back the number who become newly covered through special enrollment periods during the remainder of the year. In the end, 6 to 7 million average enrollees is probably a reasonable estimate.
This does not, however, exhaust the number of Americans who are now covered under the Affordable Care Act. The fact sheet states that 3 million young adults are covered under their parents’ plans because of the ACA. This number is probably high, but it is clear that the ACA has dramatically increased coverage of Americans between the age of 19 and 25 — the age group most likely to lack health insurance prior to the ACA (and still). Read the rest of this entry »
April 17th, 2014
In many ways, the last twenty years have been somewhat of a “revolution” in global health, as marked by rising attention, growing funding, and the creation of new, large scale initiatives to address global health challenges in low and middle income countries. Indeed, the 1990s brought a steady increase in global concern about health, largely centered on the HIV epidemic and due to civil society organizing to draw attention to the growing crisis, leading to the creation of the Millennium Development Goals, and soon thereafter, the GAVI Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and the U.S. President’s Emergency Plan for AIDS Relief, and other efforts.
A key driver of increased funding has been donors – governments and multilateral agencies, non-governmental organizations (NGOs), and foundations. And tracking their funding has become one of the critical measures of the global health response.
A new analysis from Dieleman et al., published as a Health Affairs Web First on April 8, provides a needed contribution to the literature on donor funding for health, including an understanding not just of where donor funding is going but of the relationship between aid, burden, and income. Read the rest of this entry »
April 17th, 2014
Background: In a very short period of time, Accountable Care Organizations (ACOs) have become an important and widespread part of the US health care landscape. A recent Health Affairs Blog post estimates the total number of public (Medicare) and private ACOs at more than 600 nationally, covering more than 18 million insured population. Despite their rapid and widespread adoption, relatively little is known about how ACOs actually work and how successful they have been. This is due in part to their relative “newness,” as many reported ACOs are just getting up and running. Others have been operational for short periods of time and have yet to produce meaningful or long-term sustainable results.
This Health Affairs Blog post helps fill some of this void by reporting on the operational experiences of one of the oldest (4+ years) and largest commercial ACOs in the nation. A previous Health Affairs Blog post reported on its initial planning and start-up phase, and a subsequent Health Affairs article reported on its early financial results.
In 2007, Blue Shield of California, along with provider and employer partner organizations, began exploring development of one of the first ACO-like programs in the country to serve Commercial patients. It launched in 2010 and, as reported below, has been generating savings to consumers throughout the period. Located in the competitive Sacramento market of northern California, the ACO is an example of an innovative shared savings model involving a large insurer—Blue Shield of California; a purchaser—the California Public Employees Retirement System (CalPERS); a physician group—Hill Physicians Medical Group (HPMG); and a hospital system—Dignity Health. The population served approximately 42,000 CalPERS employees and their families covered by Blue Shield. Read the rest of this entry »
April 17th, 2014
Change is underway in the delivery and financing of American health care, and it is manifested in the evolving relationship of hospitals and physicians across the U.S. These developments are most striking in California, but are appearing in various forms in almost all states. Physicians and hospitals are being both “pushed” and “pulled” together in new ways by a variety of market forces, including the development of Accountable Care Organizations (ACOs) for both Medicare and commercially insured patients, increased direct employment of physicians by hospitals, the emergence of new payment mechanisms such as global payments, and, in general, by the need for physicians, physician groups and hospitals to deliver greater “value.”
All of this presents the opportunity to redesign care to be more coordinated, efficient, patient-driven, and effective. These integration forces could lead to the kind of organizations envisioned 15 years ago in the Institute of Medicine report “Crossing the Quality Chasm”, resulting in the Triple Aim of better health, better patient care experiences and outcomes, and improved affordability — driven, in part, by new patient care models and payment methods including incentives for improving the value of health care services.
Many physicians are uncomfortable with the idea of physician-hospital integration for several reasons. The long tradition of “professional autonomy”– perhaps best described as “the need for physicians to be able to make appropriate and scientifically based patient-by-patient decisions in the best interest of those patients” — can raise fears among some physicians about becoming part of a larger practice or institution and losing that autonomy. Additionally, some physician groups have shown that they can develop a successful ACO without the need for hospital and insurance partners, preferring to manage the clinical and financial risk alone. Read the rest of this entry »