From The Staff

Viable — And Reliable — Alternatives To Colonoscopies


July 29th, 2010
by Chris Fleming

According to the American College of Gastroenterology, colorectal cancer is currently the third leading cause of cancer-related deaths in the United States. The colonoscopy is considered the “gold standard” for colon cancer detection. However, a new Health Affairs Web First study by researchers from RTI International demonstrates that for screening programs with limited budgets, using fecal occult blood tests — even though they are less accurate than colonoscopies — would result in more individuals getting screened and more life-years gained across an overall population.

RTI senior health economist Sujha Subramanian and her colleagues developed a simulation model using Any-Logic software to assess the cost and effectiveness of screening with guaiac-based fecal occult blood tests and colonoscopy. The base-case costs used in the analysis were $23.00 for each blood test and $699.00 for each colonoscopy. The authors assumed a fixed budget of $1 million for a hypothetical lifetime colorectal cancer screening program, with the budget covering the costs of screening, diagnosis, treatment, and surveillance. 

Assuming 100 percent compliance with screening recommendations and follow-up testing, the authors found that 474 people could be screened using colonoscopy in their hypothetical screening program, with a total of 40.9 life-years gained. If the hypothetical program used the high-sensitivity fecal-occult blood test Hemoccult SENSA instead, 604 people could be tested and 52.8 life-years would be saved; using Hemoccult II (a different test), 715 people would be screened and 50.9 life-years gained. Read the rest of this entry »

Health Policy Brief: Accountable Care Organizations


July 27th, 2010
by Chris Fleming

Americans will soon be hearing more about a new type of entity: accountable care organizations. That’s because the health care reform legislation enacted earlier this year authorizes Medicare to contract with accountable care organizations, or ACOs, to provide care for enrollees. Accountable care organizations are designed to focus on delivering care to a particular population of patients, with an emphasis on improving their health and reducing the rate of growth of health care costs.

The latest Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) `provides “a straight-forward description of what exactly an ACO is.” It describes the ACO concept as defined in the legislation and examines the challenges and opportunities facing health systems, physicians, administrators, insurers, patients, and policy makers as ACOs take shape. Some of the areas discussed include:

  • Why the ACO concept was created and what the intent is.
  • Models of different organizations that could be transformed into ACOs, such as integrated delivery systems, multispecialty group practices, physician-hospital organizations, independent practice associations, and virtual physician organizations.
  • How the Medicare shared savings program for ACOs is supposed to work when it takes effect by January 2012.
  • How ACOs would be paid to provide care.
  • The long road ahead for crafting federal regulations that will flesh out the details of ACOs.

For more on ACOs, see “How The Center For Medicare And Medicaid Innovation Should Test Accountable Care Organizations,” by Stephen M. Shortell, Lawrence P. Casalino, and Elliott S. Fisher, in the July issue of Health Affairs, as well as other pieces on ACOs in Health Affairs and on Health Affairs Blog. Read the rest of this entry »

Wonk Review Features Reinhardt On Insurers And Cost Control


July 23rd, 2010
by Chris Fleming

Over at the Workers’ Comp Insider, Julie Ferguson presents some of the best examples of recent health policy blogging in the latest edition of the Health Wonk Review. Among the posts included is Uwe Reinhardt’s Health Affairs Blog post asking whether increasing the number of health insurers would decrease health care cost growth. Other posts in Julie’s “Dog Days of Summer” edition of the Wonk Review include Maggie Mahar’s Healthbeat reply to the Cato Institute’s critique of the Patient Protection and Affordable Care Act, and Joe Paduda’s piece on Managed Care Matters asking why those who call health reform socialism don’t have more faith in the free market’s ability to control costs and improve quality.

Who Stands To Gain From Health Reform?


July 22nd, 2010
by Chris Fleming

As the United States begins implementing health reform, many aspects of the new law will be experienced differently depending on an individual’s current health insurance status. Joseph Newhouse, an internationally renowned Harvard economist, assessed health reform from the perspective of four different groups. He reports in a Health Affairs Web First article that the new law will probably reduce the number of uninsured Americans, but the steady rate of growth of health care costs is unlikelly to be curtailed absent further efforts.

The four groups Newhouse identified were those who are uninsured or eligible for Medicaid or the Children’s Health Insurance Plan (CHIP); purchasers of individual health policies and those insured through a small business employer; employees of midsize or large employers offering benefits; and Medicare enrollees. Although we can expect significant issues to arise concerning financing and administration, and perhaps the capacity of the delivery system, individuals in the first group will benefit greatly from the new law, Newhouse says. So will those in the second group, which he estimates could grow to become one sixth or more of the population.

Those belonging to the third group are generally unaffected by health reform at the moment, according to Newhouse. Those in the fourth group, Medicare enrollees, will gain from the law’s new benefits (especially concerning long-term care and the closing of the doughnut hole). But they also may find their access to care diminished; Newhouse warns that reduced reimbursement could cause some physicians to turn away Medicare patients who lack supplemental insurance or other means of making additional payments. Read the rest of this entry »

The Fight Against HIV/AIDS: Becoming More Efficient


July 20th, 2010
by Chris Fleming

The International AIDS Conference is currently taking place in Vienna. One of the major themes of the conference, voiced by such notables as Bill Gates and Bill Clinton, is the need for the fight against HIV/AIDS to become more efficient. In the face of declining resources, and more competitors for those resources, there is simply no other choice.

The need for greater efficiency in fighting HIV/AIDS, and opportunities to become more efficient, were major themes of the November/December 2009 issue of Health Affairs, which featured several articles on the international HIV/AIDS epidemic. For example, on her editor’s page, Health Affairs Editor-in-Chief Susan Dentzer described the work of Robert Hecht and colleagues, which was featured in the issue and at a Washington D.C. briefing:

Modeling they carried out for the AIDS 2031 project suggests that in the worst-case scenario, funding needed to fight the pandemic could reach $35 billion annually by 2031, up from the nearly $16 billion spent in low- and middle-income countries in 2008. But this scenario is not inevitable; the outcome can be shaped by intelligent human action. We need to make better use of what’s been shown to work in prevention and to deliver treatment far more efficiently and cost-effectively. Together with wise investments in developing new prevention and treatment tools, the world could cut the costs facing it by more than half.

And that’s without a ”game changer,” such as an effective HIV vaccine or a treatment that eliminates the virus from the body, Dentzer noted. This year’s conference has brought news of advances that, while they fall well short of “game changer” status, at least offer some hope after some well-publicized research disappointments. Read the rest of this entry »

Debating The Lessons Of Massachusetts


July 19th, 2010
by Chris Fleming

What does the Massachusetts experience tell us about the prospects for success of national health reform? That’s the subject of an ongoing debate that relies heavily on research published in Health Affairs by Urban Institute researchers.

The pessimistic view on Massachusetts. In a column in today’s Washington Post, Robert Samuelson cites a June 2010 Health Affairs article by Sharon Long and Karen Stockley of the Urban Institute for the proposition that access to care has increased, but only slightly, in the aftermath of Massachusetts’ landmark 2006 reform, which in many respects provided a model for the Patient Protection and Affordable Care Act, recently passed by Congress: 

People have more access to treatment, though changes are small. In 2006, 87 percent of the non-elderly had a “usual source of care,” presumably a doctor or clinic, Long and Stockley note in the journal Health Affairs. By 2009, that was 89.9 percent. In 2006, 70.9 percent received “preventive care”; in 2009, that was 77.7 percent. Out-of-pocket costs were less burdensome.

But much didn’t change. Emergency rooms remain as crowded as ever; about a third of the non-elderly go at least once a year, and half their visits involve “non-emergency conditions.”

Samuelson says improvements in health stemming from the Massachusetts reforms most probably lie in the future, since many of the newly covered Bay Staters were young and healthy. Finally, and most damningly in Samuelson’s eyes, health costs continue to soar in Massachusetts, and he sees no evidence that the Affordable Care Act will perform any better in restraining costs. “The lesson from Massachusetts is that genuine cost control is avoided because it’s so politically difficult. It means curbing the incomes of doctors, hospitals and other providers. They object,” says Samuelson.

The optimistic view on Massachusetts. Over at his blog CitizenCohn, the New Republic‘s Jonathan Cohn responds with a post titled “The Bum Rap On Massachusetts Health Reform.” “Samuelson has consulted the right source. The Urban Institute’s surveys are the best data we have on how reform in Massachusetts is going,” Cohn says. But he cites a 2009 Health Affairs article by Long and Stockley to argue that Samuelson is unfairly minimizing the benefits of the Massachusetts reforms: Read the rest of this entry »

Health Policy Brief: Extra Federal Medicaid Support


July 16th, 2010
by Chris Fleming

As the annual August congressional recess approaches, one of the issues still to be resolved is whether to extend into the first six months of 2011 a temporary increase in federal contributions to states for Medicaid funding. This provision was enacted as part of the 2009 American Recovery and Reinvestment Act (ARRA), which prevented anticipated reductions in federal contributions to state budgets and provided increased additional contributions to states that had significant unemployment.

The latest Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) examines this issue. Some of the areas discussed include:

  • How the federal contribution to states, known as the federal medical assistance percentage (FMAP) is normally calculated.
  • How the additional FMAP contributions have helped offset state deficits, since most state budgets by law must be balanced.
  • Proponents’ and opponents’ views: the necessity to avoid serious harm to state budgets versus the impact on the federal deficit if the additional assistance isn’t offset with spending cuts or revenue increases.
  • Why Congress is currently deadlocked on the provision, and what might happen to state budgets if the provision is not extended.

Health Policy Briefs are aimed at policy makers, congressional staffers, and others who need short, jargon-free explanations of health policy basics. The briefs include competing arguments from various sides of policy proposals and the relevant research supporting each perspective.

Read the rest of this entry »

Getting the Care Needed for PTSD


July 16th, 2010
by Chris Fleming

As the nation continues to wage war in Iraq, Afghanistan, and elsewhere, post-traumatic stress disorder (PTSD) looms as an ever-more pressing issue. Earlier this week, the Obama administration made it easier for veterans to obtain disability benefits and treatment for PTSD by eliminating the requirement that they document a specific attack or other incident that triggered the condition.

The new Narrative Matters essay in the July issue of Health Affairs brings the policy issues of PTSD into sharp relief.  Ron Capps details his struggles with PTSD resulting from his service as a soldier and Foreign Service officer in multiple venues. Capps cites the huge unmet need for PTSD treatment among active soldiers and veterans, and he explains the barriers that prevent so many PTSD sufferers from seeking treatment.

You can read Capps’ full essay in Health Affairs or listen to him read his story online. You can also listen to Capps read a shortened version of the piece on NPR’s All Things Considered, broadcast on public radio stations around the country on July 14. The broadcast is part of a collaboration between Narrative Matters and NPR that brings Narrative Matters essays on-air as NPR commentaries. Also featured recently on NPR was emergency department physician Boris Veysman’s Narrative Matters essay discussing end-of-life issues. Narrative Matters is supported by a grant from the W.K. Kellogg Foundation.

Read the rest of this entry »

Court Voids Federal Rejection Of Health Benefits For Same-Sex Spouses


July 9th, 2010
by Chris Fleming

Portions of the federal Defense of Marriage Act (DOMA), which bars the federal government from recognizing same-sex marriages, are unconstitutional, Judge Joseph Tauro of the United States District Court in Boston ruled in two cases yesterday. The cases arose in Massachusetts, which recognizes same-sex marriages, and they revolved around the obstacle DOMA creates when members of same-sex unions attempt to access federally funded health benefits.

In a paper recently published in Health Affairs, UCLA researcher Ninez Ponce and coauthors found that partnered gay men and lesbians in California are less likely than their heterosexually married counterparts to get dependent health coverage, in part due to federal policies such as greater taxation of health benefits for same-sex spouses and partners. A challenge to the constitutionality of any ban on same-sex marriage is pending in federal court in California. Read the rest of this entry »

July Health Affairs: The Impact Of Health Reform


July 8th, 2010
by Chris Fleming

The new health reform law charges the U.S. Department of Health and Human Services (HHS) with testing new payment and delivery models intended to improve health outcomes and restrain costs. But as the July issue of Health Affairs, published yesterday, points out, implementing all of these activities will require a combination of flexibility, leadership, coordination, and political adroitness if reform is to succeed and stay on schedule.

An as yet untested, but potentially promising, aspect of health reform is stimulating the formation of new accountable care organizations (ACOs) in the Medicare program. The design of ACOs is a work in progress, but in essence, they would constitute a new way of paying for and delivering care to a group of patients at a sustainable cost. Stephen M. Shortell of the School of Public Health at the University of California, Berkeley, and his colleagues argue that ACOs could offer advantages to patients, providers, and payers. However, a key issue will be how to structure and implement the organizations so those potential benefits are maximized. That means structuring flexible models and payment approaches that are adapted to local needs and market conditions. The authors suggest that the government create three tiers of qualification criteria for ACOs, which would allow practices to assume greater risk and receive larger rewards over time. Such a system would also promote a more rapid diffusion of successful models nationally, they say.

ACOs are just one of several potentially promising payment models under consideration by the Centers for Medicaid and Medicare (CMS). In his analysis of proposed reforms, Jeff Goldsmith of Health Futures says there is probably no “silver bullet” to replace Medicare fee-for-service payment but notes that major reform models do allow for sharing of financial risk by hospitals or physicians, a critical factor in reducing Medicare expenses. Read the rest of this entry »

Contributing Voices

Implementing Health Reform: Pre-Existing Condition Coverage


July 30th, 2010
by Timothy Jost

Editor’s Note: Earlier posts by Timothy Jost provide analyses of regulations implementing provisions of the new health reform legislation governing appeals of coverage denialscoverage for preventive services, a patient bill of rights, grandfathered plans, tax exempt hospitalsthe small employer tax creditthe 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 »

Changing The Name — But Not The Political Game


July 30th, 2010
 
by Thomas Miller and James C. Capretta

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 »

End-Of-Life Savings: The ‘Fool’s Gold’ Of Reform?


July 28th, 2010
 
by Donald Taylor and Amy Abernethy

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 »

Humanitarian Assistance: Turning Commitment And Competence Into Professionalism


July 26th, 2010
 
by Peter Walker and Karen Hein

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 »

Implementing Health Reform: The Appeals Process


July 25th, 2010
by Timothy Jost

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 hospitalsthe small employer tax creditthe 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 Applauds EHR Meaningful Use Regs


July 23rd, 2010
 
by Gary Gottlieb and Thomas Lee

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 »

Calculating Caring


July 21st, 2010
by Jonathan Han

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 »

Implementing Health Reform: Preventive Services


July 15th, 2010
by Timothy Jost

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 hospitalsthe small employer tax creditthe 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 »

Medicare Innovation: Whose Priorities, Whose Interests?


July 14th, 2010
by Carol Levine

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 »

Meaningful Use And EHR Standards: The Final Rule


July 13th, 2010
by John Halamka

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 »

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