Health Affairs

Editor’s Note: Earlier posts by Timothy Jost provide analyses of regulations implementing provisions of the new health reform legislation governing appeals of coverage denials, coverage for preventive services, a patient bill of rights, grandfathered plans, tax exempt hospitals, the small employer tax credit, the Web portal, reinsurance for early retirees, and young adult coverage.

As of January 1, 2014, every American will have access to health insurance without regard to health status or pre-existing conditions.  Those whose household incomes fall below 400 percent of the federal poverty level will receive tax credits to help cover their premiums and subsidies to reduce their cost sharing.  Those with household incomes below 133 percent of poverty will qualify for Medicaid.  But 2014 is still far away for many Americans who are unable to find or to afford health insurance because pre-existing conditions make them uninsurable or insurable at only very high rates.

For some of these Americans, section 1101 of the Affordable Care Act offers a temporary high risk health insurance pool program, which HHS refers to as the Pre-Existing Condition Insurance Plan, or PCIP, program. This program is also described in a CRS Report issued July 28, with appendices describing the state programs implementing the high risk pool provisions.  The Act requires this program to be “established” within 90 days of enactment, that is by June 23, 2010. The 90 day goal was overly ambitious, but the federal PCIP is in fact already taking applications, as are several state plans.  On July 29, 2010, the Department of Health and Human Services published interim final regulations implementing the PCIP program.

Section 1101 of the Affordable Care Act offers insurance coverage to American citizens or persons lawfully present in the United States who have been uninsured for at least 6 months and who have a pre-existing condition.  The program can be run either by the states or by the federal government through a nonprofit entity.  Twenty-nine states plus the District of Columbia chose to operate their own plans, while HHS will administer the program in 21 states.  Plans must offer comprehensive coverage with an actuarial value of 65 percent of total allowed cost and with out-of-pocket limits no higher than those permitted for high-deductible health plans accompanying health savings accounts.  Premiums must be set at a standard rate for a standard population, and cannot vary based on age by a factor of more than 4 to 1.  Congress appropriated $5 billion to fund the program through 2013. Read the rest of this entry »

Editor’s Note: Yesterday, the Obama administration announced interim final regulations governing the temporary Pre-Existing Condition Insurance Plan created by the Patient Protection and Affordable Care Act. Below, Thomas Miller and James Capretta criticize this portion of the Act and the design of the temporary health insurance pools for high-risk individuals that it creates. For more on this subject, see Deborah Chollet’s article in the June issue of Health Affairs, and watch Health Affairs Blog for an analysis of the new regulations by Timothy Jost, who has been following the implementation of the Affordable Care Act in this space. 

Earlier this month, the Obama administration launched the latest version of high-risk pools, as authorized by the Patient Protection and Affordable Care Act (PPACA).  The new pools are off to a stumbling start – behind schedule, facing resistance (or indifference) from many state governments, structurally flawed, and substantially underfunded.  In other words, “Close enough for government work.”

But if you can’t solve a problem by first overstating it, and then underfunding it, you can at least change its name – to the “Pre-Existing Condition Insurance Plan,” increase the gaping chasm between its overreaching promises and likely results, and provide an emblematic preview of larger problems ahead in the rest of ObamaCare.

A better solution would begin with redefining the problem to avoid the temptations of trying to achieve multiple policy objectives with a single tool, which results in mission creep and failure to target scarce resources more effectively and sustainably.  True high-risk pools should be limited to covering the most likely, highest-risk individuals, as identified before the fact.  They don’t work as well as a mechanism for subsidizing the health care costs of low-income individuals more broadly, or for covering the uninsured in general. Read the rest of this entry »

Just over 1 in 4 dollars spent by the Medicare program last year was spent on someone who was in their last year of their life.  This is nothing new–the basic proportion has not changed since it was first noted in the 1970s.  Other nations that spend much less on health care nevertheless spend a similar proportion of total system spending on persons in their last year of life. 

Many believe that a health policy solution focused on reducing spending at end of life (EOL) is a practical cost-saving strategy for the United States, but this consistent proportion (across time and spending level) of total costs spent during the last year of life directly challenges the potential success of this approach.

A focus on EOL spending will likely receive increased attention over the coming months and years because the Medicare program is financially unsustainable, a fact that is exacerbated and made acute by the looming retirement of the baby boomers.  In addition, cuts in planned future Medicare spending were used to finance insurance expansions in health care reform, and a means of absorbing such cuts in a manner that does not harm patients is a necessity.  

Medicare, along with Medicaid, is the primary driver of the long-term structural federal deficit that exists and will exist in the foreseeable future unless changes are made. (See page 3, figure 1.1 of CBO’s June 2009 Long-Term Budget Outlook, linked to earlier in the preceding sentence.) This fact makes further cuts in the future growth of Medicare spending needed if the system is to become sustainable, and there are no easy choices.  The demographic effect of the baby boomers on Medicare was inevitable once they had fewer children than their parents; this reality can be lamented, but not altered.  Slowing the rate of growth in program expenditures (payment cuts) and/or an increase in taxes are the only ways to make the program sustainable. Read the rest of this entry »

Until recently, much of the humanitarian response to disasters from the volunteer sector could be characterized as committed and compassionate – and competent as well, if sometimes just barely. From the South Asian tsunami of 2004, to the devastating 2010 earthquake in Haiti, the response has been at best uneven, with some agencies performing brilliantly and others not. The complexity of many contemporary emergencies clearly requires a more professional approach to humanitarian action and a more exacting application of the ethos of professional responsibility. 

Thus, a new report calls for the establishment of a professional association for humanitarian workers. The association would be linked to a system of certification and internationally agreed-upon core competences taught through accredited training organizations around the world – with the objective of developing and ensuring standards, as well as overseeing the certification of individuals working in humanitarian settings.

The report, “Professionalising the Humanitarian Sector” was commissioned by the UK Enhanced Learning and Research for Humanitarian Assistance consortium (ELRHA). Researchers provided by the Feinstein International Center at Tufts University in partnership with RedR UK, a  training group,  surveyed aid workers around the world. Drawing upon the experience of recent quality assurance and training initiatives, the new report paints a convincing picture of the need, and demand, for the establishment of a profession of humanitarian work.

Read the rest of this entry »

Editor’s Note: Earlier posts by Timothy Jost provide analyses of regulations implementing provisions of the new health reform legislation governing coverage for preventive services, a patient bill of rights, grandfathered plans, tax exempt hospitals, the small employer tax credit, the Web portal, reinsurance for early retirees, and young adult coverage. 

On July 22, 2010, the Departments of Health and Human Services, Labor, and Treasury (Internal Revenue Service) issued interim final regulations implementing section 2719 of the Patient Protection and Affordable Care Act, providing for internal and external appeals of coverage determinations and claims.  These regulations do not apply to grandfathered plans, but they apply in both the individual and group market and to insured and self-insured plans. (A press release and a fact sheet on the regulations is also available.)

The statute and the implementing regulations provide that any plan enrollee who receives an “adverse benefit determination” can appeal the determination first internally within the plan; then, if the internal review is not satisfactory, the enrollee can appeal to an external review body.  An adverse benefit determination includes a denial, reduction, or termination of a benefit based on a determination that an individual is ineligible to participate in a plan or health insurance coverage; that a benefit is not covered; that a preexisting condition, source-of injury, or network exclusion applies; or that a benefit is experimental, investigational, or not medically necessary or appropriate. 

Appeals can challenge pre-service or post-service determinations, as well as decisions to pay less than the total amount of a claim based on cost-sharing requirements.  Decisions to rescind coverage are also appealable.  Determinations that an individual is not eligible to participate in a group plan are not subject to external appeal. Read the rest of this entry »

Partners HealthCare’s clinical and information system leaders are still poring over and absorbing the details of the U.S. Department of Health and Human Services (DHHS) program for Meaningful Use of certified interoperable electronic health record technology by the nation’s hospitals and physicians.  But two things are already clear:

1. These criteria will push provider organizations into a higher gear in their use of information systems– even organizations with a deep IT history, such as Partners.
2. These criteria are pushing all of us in the right direction – a direction that will improve the safety and quality of care, and help control costs

Partners has been a pioneer in the design, development, implementation, and evaluation of healthcare information technology (HIT).  This commitment to HIT actually predates the formation of Partners, whose founding hospitals – Mass General and Brigham and Women’s – designed some of the earliest electronic health record (EHR) and computerized provider order entry (CPOE) systems in the 1970s and 1980s.  Read the rest of this entry »

The small waiting room was packed with young mothers holding teary-eyed toddlers, older folks with resting tremors and oxygen tanks, and an obese man just stepping in from a smoke. I’m a family physician about to share my afternoon with each of them, in a working-class western Pennsylvania town. Walking quickly through the room on my way to the water cooler, I usually averted my gaze to avoid a not-so-private waiting room conversation with anyone. However, on this Wednesday afternoon I stopped to stare at the television screen not silently suspended above a pregnant woman snuggling her sniffling son.

It was January 13, 2010. Haiti was imploding and crumbling in front of us, courtesy of CNN. Pictures of crushed bodies, partial glimpses of bloody limbs, and videos of screaming family members filled the screen. A steady stream of ticker-tape text gave up-to-the-moment information on the projected death toll, warnings of aftershocks, and reactions from around the globe. Descriptions like “natural war zone” did little to humanize the enormity of devastation unfolding before us.

Then the screen changed abruptly, faces of bantering politicians serving as a backdrop for the caption “health care reform in serious jeopardy.” These two stories were related somehow, but there was little time to reflect on their shared meaning as I left the waiting room to resume dealing with the afternoon’s onslaught.

As the day dragged on, I became more distracted by thoughts of the immensity of the catastrophe in Haiti, and increasingly moved by the efforts of hundreds of international volunteers who were traveling to Haiti to help those trapped in the rubble. What motivated these health care workers and other professionals to put their own lives in danger to help others? Why did they care, and why should we? And why should we care about health care reform efforts failing yet again, when polls tell us that so many Americans are “satisfied” with their health care plan? Read the rest of this entry »

Editor’s Note: Earlier posts by Timothy Jost provide analyses of regulations implementing provisions of the new health reform legislation governing a patient bill of rights, grandfathered plans, tax exempt hospitals, the small employer tax credit, the Web portal, reinsurance for early retirees, and young adult coverage. 

On July 14, 2010, the Departments of Treasury, Labor, and Health and Human Services issued an interim final rule implementing section 2713 of the Public Health Services Act, (added by section 1001 of the Affordable Care Act), which requires group health plans and health insurers to cover specific preventive care services and to do so without patient cost-sharing obligations (coinsurance, copayments, or deductible). 

Prevention is a major theme of the Affordable Care Act.  An entire title of the Act deals with prevention and public health.  Title IV establishes a National Public Prevention, Health Promotion, and Public Health Council and a Preventive Services Task Force and calls for a national outreach and educational campaign on the benefits of preventive services.  Title IV of the Act also introduces a new Medicare benefit for a free “annual wellness visit providing a personal prevention plan” (section 4103), eliminates Medicare coinsurance for certain preventive services (section 4104), and expands Medicaid coverage of preventive services and marginally increases federal funding for states that eliminate Medicaid cost sharing for preventive services (section 4106).  Proposed regulations implementing the Medicare preventive services expansions were published on July 13, 2010. 

Prevention is popular.  It is generally believed that proper use of preventive services will save lives and save money (although the latter proposition is debatable.)  Prevention and wellness initiatives are consistent with a conservative philosophy of personal responsibility as well as with a progressive concern for public health, and both the Republican and Democratic 2008 platforms endorsed increasing access to preventive services.  Even health insurers have expressed support for preventive services. Read the rest of this entry »

Editor’s Note: In addition to Carol Levine (photo and bio above), authors of this post include Eric Coleman, Professor in the Division of Health Care Policy and Research, University of Colorado Denver School of Medicine; and Mary Naylor, Director of the New Courtland Center for Transitions and Health, University of Pennsylvania School of Nursing.

The opportunity for significant system redesign in Medicare now lies in a new entity created by health reform legislation. By January 1, 2011, the Center for Medicare and Medicaid Services (CMS) must create a Center for Medicare and Medicaid Innovation (CMI) designed to “test innovative payment and service delivery models to reduce program expenditures … while preserving or enhancing the quality of care.” In selecting the models to be tested, the Secretary of the Department of Health and Human Services (HHS) “shall give preference to models that also improve the coordination, quality, and efficiency of health care services.”

CMI’s mandate to reduce program expenditures is a critically important goal. But it is not a goal that can be achieved in isolation. Paying providers differently will not remedy the widespread and serious failures of care coordination and patient safety that are driving avoidable and costly hospital readmissions. Paying salaries instead of fee-for-service or bundling payments is only going to save money if patients and families participate fully in these innovations and are well served by them.

There is little in the health reform legislation that recognizes the complexities of providing care to its target population—vulnerable beneficiaries at risk of hospitalization and avoidable rehospitalization—or offers opportunities to serve them better. Most of these high-risk, high-cost beneficiaries are not now getting high-quality care; if they were, there would be no need for innovation and no concern about avoidable hospital readmissions. Read the rest of this entry »

Editor’s Note: For more on electronic health records and meaningul use requirements, see the April issue of Health Affairs, “Health IT: The Road To ‘Meaningful Use’“.

This morning, the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC) for Health Information Technology released the final rules that will guide electronic health record (EHR) rollouts for the next five years. CMS and ONC released final “meaningful use” requirements, spelling out how hospitals, physicians, and other medical professionals must use EHRs to improve care, in order to be eligible for Medicare and Medicaid financial incentives under the “HITECH” Act. ONC also released final rules governing standards that vendors of EHRs must meet and the process for certification of EHRs.

Key resources include information from the Depeartment of Health and Human Services on the final meaningful use and standards and certification regulations, as well as an overview of the regulations in the New England Journal of Medicine authored by national health IT coordinator David Blumenthal and CMS Principal Deputy Administrator Marilynn Tavenner.

Differences betwen final and proposed regulations. Both the meaningful use regulations and the standards regulations had earlier been issued in proposed form. Here’s my analysis of the key changes between the final and proposed meaningful use rules. Read the rest of this entry »