Health Affairs

The first few days of the week of May 20, 2013 were quiet on the regulatory front, with no new Affordable Care Act regulations or guidance (at least that I could find).  HHS released power point slides from an earlier webinar that usefully describe the different kinds of assisters who will be available in the marketplaces (navigators, in-person assisters, certified application counselors, and agents and brokers).  It also has apparently updated its navigator and assister frequently-asked-questions paper, although most of these FAQs were released earlier.

In other news, however, the Fourth Circuit Federal Court of Appeals has released the recording of the May 17, 2013, oral argument in the case of Liberty University v. Jacob Lew.  The Liberty University case aroused quite a stir in November of 2012, when the Supreme Court reversed its earlier decision to deny certiorari in the case, granted certiorari, vacated the earlier decision of the Fourth Circuit rejecting the plaintiff’s case, and remanded the case to the Fourth Circuit for further proceedings.

In the case’s first incarnation, Liberty University challenged the authority of Congress under its constitutionally enumerated powers to adopt the Affordable Care Act’s individual and employer mandates.  Liberty also claimed that the ACA violated the Constitution’s Establishment Clause, by granting privileges to certain religious groups but not to Liberty, and the Free Exercise Clause (and Religious Freedom Restoration Act), by requiring Liberty to purchase insurance that covered abortion.  Liberty was joined by two individual plaintiffs in the case, who asserted similar rights for themselves. Read the rest of this entry »

It is increasingly well-known that improper payments cost taxpayers as much as $50 billion each year. These include reimbursements for billing for non-existent patients, falsified diagnoses, non-covered procedures, services not rendered or simply upcoded, as well as billing errors in favor of providers. Steps are being taken to address these issues through increased acceptance of approaches, tools and techniques from private industry and from industries outside of healthcare. More than just technology, some of the most powerful ideas to come along are that incentives matter, decentralization may achieve results faster and better, and stretch goals are crucial.

Scale of the problem

Safeguarding taxpayer resources and maintaining access to healthcare are clear public policy priorities. The Government Accountability Office (GAO) has long designated Medicare as a high-risk federal program due to its vulnerability to waste, fraud and abuse. Conservative estimates by the National Health Care Anti-Fraud Association are that improper payments represent 3 percent of national health care spending. The GAO and others estimate nearly 10 percent of the more than $500 billion in current annual Medicare payments are improper. At the same time, Medicare provides necessary — and often much needed — access to health care for 48 million Americans. Read the rest of this entry »

As life spans increase and birth-rates decrease, the world’s population is aging. From 2000 to 2025, the over-60 demographic segment will double from 600 million to almost 1.2 billion. By 2050, it will nearly double again, surpassing two billion and accounting for an incredible 22% of the total global population. A society this “old” has never before existed, and it is a social, ethical, and economic imperative to keep older adults healthy and engaged. It is timely for the global public health community to re-align its thinking, policies and activities to this new demographic reality.

Organizations at national and global levels have begun to pursue initiatives to promote healthy aging, and these efforts are going to intensify in the coming years. Thus far, the progress has been admirable, with the World Health Organization, the United Nations, the Organisation for Economic Co-operation and Development, and others taking leadership roles. Yet, despite many promising developments, the potential of “life-course immunization,” which stresses the administration of vaccines throughout all stages of life – including for adults – to prevent disease and promote health, has been largely overlooked, especially among adults.

This is a missed opportunity. There is a growing body of research and data to show that immunizations against some of the more specific age-related health challenges – such as pneumococcal disease, herpes zoster, and others – are economically feasible investments that can create large public health benefits. Read the rest of this entry »

Performance measurement — if done right — can be a core activity to move the health care system to higher value for the American public, while rewarding health professionals and health care institutions for doing the right thing for their patients. Yet, policy makers, private and public, have a duty to the public, patients, and providers to get it right — to measure and report accurately and meaningfully.

Harlan Krumholz and Peter Pronovost have been among the most important contributors to the development of performance measures for quality and safety of health care.  At the same time, each has written powerful critiques of particular aspects of the current measurement enterprise with suggested improvements.  I work mostly inside the Beltway in a world of policy makers who, despite good intentions, by their actions often display a lack of understanding of the challenges associated with measures, measurement, public reporting, and pay-for-performance.  For example, the physician value-based modifier, which was mandated as part of the Affordable Care Act and now must be implemented by CMS, cannot produce a valid snapshot of an individual physician’s “value” but will be imposed nevertheless, unfortunately feeding those within the physician community who resist all efforts to improve accountability and transparency of performance.

With the encouragement of the Robert Wood Johnson Foundation, Harlan, Peter, and I joined in a collaborative endeavor to produce a comprehensive look at the state of play of performance measurement and public reporting — their conceptual underpinnings and limitations, successes and failures, and, perhaps most importantly, recommendations for major steps that are needed now to put the measurement enterprise on track to achieve its potential to improve the value of U.S. health care without doing harm. Read the rest of this entry »

Dr. Jonathan Welch’s Narrative Matters essay in the December, 2012 edition of Health Affairs, regarding the cascade of errors and omissions he witnessed in connection with the care provided to his mother, should raise profound questions about how the hospital allowed those failures of care to happen.  Dr. Welch, an emergency medicine physician, watched helplessly as his mother received indifferent care from various nurses and doctors and ultimately died.  Despite having classic signs of evolving sepsis, she was not closely monitored by the nursing staff which ignored alarming signs, was not put on a sepsis treatment protocol by her oncologist, and was not put in an intensive care unit where she could receive more intense monitoring and aggressive treatment from specialists.

While it is tempting to blame the nurse (for not taking vital signs frequently enough and not reacting to abnormal vital signs) and the oncologist (for not following the patient closely enough, not initiating appropriate treatment, and not involving other specialists), Dr. Welch’s story suggests that there were more deeply rooted systemic problems at the hospital that went beyond the shortcomings of the individuals involved in his mother’s care.

As health care attorneys who represent hospitals and physicians, we believe there are some fundamental questions which should be asked by this hospital’s administration, medical staff leadership and governing body to ensure Dr. Welch’s experience is not repeated.  Those questions, which the leaders in all hospitals should consider, include the following: Read the rest of this entry »

Editor’s note: Health Affairs Blog has been proud to host Tim Jost’s series of posts, “Implementing Health Reform, tracking the implementation of the Affordable Care Act.  In recent days the implementing agencies — Health and Human Services, Labor, and Treasury — have been issuing regulations, proposed regulations, frequently asked questions, and other guidances on an almost daily basis, and new posts by Tim have consequently often appeared almost daily as well.  Going forward, to keep up with the flow of ACA guidance in an orderly fashion, Tim’s posts will generally appear twice a week, usually Mondays and Thursdays.  When major rules or proposed rules are released, such as the final rules on eligibility and appeals, wellness, and the SHOP marketplaces currently under final review by the Office of Management and Budget, we will feature additional posts in Tim’s series.

You can continue to look to Tim’s posts for current information on ACA implementation.  When new guidance appears, Tim will update his most recent post (a practice we have in fact already begun); we will note that there has been an addition at the beginning of the updated post and normally add the new material at the end of the post, so you can skip rereading the rest.  We will also Tweet significant updates. From time to time, we correct a post when we find a typographical error or Tim receives new information as to the meaning of an issuance.  If the correction is more than trivial, we will note this as well. 

We hope that this new approach will make this series even more useful to our readers.

On May 17, 2013, at the end of an otherwise quiet week, CMS released an interim final rule on the Preexisting Condition Insurance Plan (PCIP).  CMS also released a letter to state Medicaid directors on Facilitating Medicaid and CHIP Enrollment and Renewal in 2014.  This post will discuss these issuances. Read the rest of this entry »

Medicare is caught between two countervailing impulses: the desire of beneficiaries (and providers and the adult children of beneficiaries) to have a benefit package that covers more, rather than less, and the desire to restrain program spending due to its impact on the federal budget. This tension is heightened by the transition of the Baby Boomers from paying taxes into Medicare to receiving benefits.

The default is that Medicare covers acute care therapies, tests, and procedures if there is a patient that wants to receive them and a provider who is willing to deliver them, whether there is evidence of any benefit to the patient or not. As I tell students in my Introduction to Health Policy Course, while Medicare sets payment rates (and is therefore like Marlon Brando in The Godfather: “I have an offer you can’t refuse”), when it comes to what is covered in the acute care setting, it is more like my Grandmother serving lunch (“whatever you would like, honey.”)

There are exceptions. Recently, the Medicare Evidence Development and Coverage Advisory Committee decided not to approve the payment of PET scans to aid in the diagnosis of Alzheimer’s disease. However, such a move is rare, and both provider and patient groups are protesting this decision. Read the rest of this entry »

The release of average charges for common procedures in more than 3,000 U. S. hospitals last week by the Centers for Medicare and Medicaid Services (CMS) elicited divergent reactions – not surprisingly.  On one hand, it was front-page news for most of the major newspapers: “Hospital Billing Varies Wildly, Government Billing Data Shows,” was the headline in the New York Times.  The article went on to speculate that these new data would likely “intensify a long debate over the methods that hospitals use to determine their charges.”

On the other hand the data were “old hat” to most health policy analysts.  Several colleagues mentioned to me that “this is old news” and “it isn’t meaningful at all because we all know that charges don’t mean anything.”

“No one pays charges” is the common refrain.  “Charges are merely an accounting fiction.”

Charges Do Matter — They Matter A Great Deal

Counter to the belief of both hospital industry representatives and many of my colleagues, hospital charge levels and rapidly escalating charges matter a great deal. While individual states and the Affordable Care Act (ACA) have instituted limits on the amounts low-income uninsured patients pay hospitals, insured patients that receive care at hospitals that are “Non-Par” or “out-of-network” are still victims of hospital’s exorbitant charging practices. When patients receive emergency services at an out-of-network hospital, the patient and/or insurance company (depending on insurer cost sharing for out-of-network care) pay full charges.

High and increasing hospital charges, combined with increasing proportions of cases admitted through the hospital Emergency Department (ED), are major factors behind the ever-declining negotiating leverage of private health insurers. This situation, coupled with the increased pricing power of the ever-more-concentrated provider industry, will be a major contributor to the almost certain rapid escalation in total U.S. health care costs in coming years. Read the rest of this entry »

Affordable Care Act guidance is now literally arriving on a daily basis from the implementing agencies, particularly HHS.  Major rules remain to be finalized, including a lengthy eligibility and appeals rule, a rule on wellness, the employer and individual responsibility rules, and a number of shorter rules.  More proposed rules or amendments to rules are also promised.  These could arrive any day.  But in the meantime there is the steady flow of frequently asked questions (FAQs) and other guidances, which often appear unannounced.

This post deals with three sets of FAQS released by HHS on May 13 and 14. (It may be updated on May 15 or May 16 to note further guidance released over the course of those days.)  Two of the FAQs concern the use of section 1311 funding, one dealing with section 1311 funding in state partnership marketplaces and in states with federally facilitated marketplaces, the other addressing the use of such funding in consumer partnership marketplaces.  The third FAQ is simply titled “Frequently Asked Questions on Health Insurance Marketplaces,” but primarily deals with enforcement, reporting, and administration requirements.  (Since HHS seems irrevocably committed to the unfortunate term “marketplace,” I am going to try to use the term from now on, rather than “exchange,” in these posts.)

Section 1311 of the ACA establishes the marketplaces.  It also appropriates an unspecified amount of funding, to be determined by the Secretary of HHS, to make awards to the states as necessary to establish the exchanges.  HHS has issued more than $3.5 billion in establishment grants to date.  Section 1311 is one of the few uncapped sources of implementation funding available to the agencies, which are otherwise being starved by Congress of necessary ACA appropriations. Read the rest of this entry »

The Affordable Care Act survived the Supreme Court and a presidential election, so why does it face such an uncertain future?  One reason is that it was essentially silent on how to control costs.  This has led many pundits — including the likes of Paul Krugman and Robert Reich — to argue that the best approach would be to extend Medicare to everyone.  A January National Research Council report on the relative disadvantage of America in global health outcomes, especially compared to countries with national health insurance, added further fuel to the fire.  But is a larger government role in health insurance the best approach?

The idea of universal Medicare is powerful and attractive. Mr. Krugman points out that in the last forty years, average Medicare costs per person have grown by 400 percent while those for private insurance have increased more than 700 percent. His numbers suggest that if everyone had Medicare for the last 40 years, we might now spend only 14 percent of GDP on health care instead of nearly 18 percent, while also reaching universal coverage. Mr. Reich argues that “Medicare-for-All” would save between $58 billion and $400 billion annually, and similarly concludes: “Medicare isn’t the problem. It’s the solution.” Critics of the U.S. system are also quick to point out that Americans don’t live as long as their counterparts in countries that spend much less, suggesting universal Medicare could save money and improve our health.

The argument for universal Medicare basically comes down to three key claims:  (1) Medicare gets lower prices; (2) Medicare’s administrative costs are lower; and (3) greater spending does not mean better health.  Each of these deserves closer attention. Read the rest of this entry »