March 30th, 2015
Editor’s note: This post is part of a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on a recent volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.
As our health system faces dramatically rising numbers of people living longer with complex chronic conditions, we have an unprecedented opportunity to mobilize a “quality-of-life” movement promoting patients’ choices and priorities about how they want to live at all stages of illness. Most of the current public policies and discourse about quality of life in health care focuses on the end of life. That tradition may actually impede delivery of person-centered and goal-directed quality care from the onset of illness. It also falls short in supporting shared decision-making, which requires early and continuing identification of what is most important to seriously ill patients and their families, and what they are hoping for as they progress along the continuum of care.
All people want to live healthy and disease-free lives for as long as possible. When serious illness does strike, patients and families want to achieve, cure, or keep disease progression in check. In addition, they place a high premium on maintaining good functioning and quality of life for as long as possible so they can continue to pursue life goals and enjoy what matters most to them. They want coordination and connection, including clear communication and quality time with their health care team to help them understand treatment options and the implications of those treatments in terms of survival, functioning, and quality of life. In addition, they want support to make informed decisions during and after treatment that align with their personal preferences and goals. Read the rest of this entry »
March 27th, 2015
This past January 20th, the Department of Health And Human Services established national Medicare pay-for-value goals. By 2016, the Department intends to tie 30 percent of Medicare payments, and by 2018 50 percent of payments, to quality or value through alternative payment models. Medicare Accountable Care Organizations (ACOs) are expected to make a significant contribution toward meeting these goals. With current ACOs accounting for 7.8 million beneficiaries and 15 percent of Medicare spending, it will be essential for the current 405 ACOs to stay in the Medicare Shared Savings Program (MSSP) through 2016, and for a substantial number of new ACOs to join the program.
However, common concerns about the MSSP became apparent a year ago when stakeholders submitted comment letters in response to the Centers for Medicare and Medicaid Services’ “Evolution of ACO Initiatives at CMS” RFI (Request for Information). These concerns were reinforced last July after CMS announced proposed changes to ACO quality measure set and quality performance benchmarking, and again in November when the National Association of ACOs reported survey data showing nearly two-thirds of member ACOs would leave the program unless substantial improvements were made.
Recognizing these concerns, this past December CMS published a proposed rule offering many possible improvements to the Shared Savings Program. Public comments were due February 6th. CMS now has the opportunity to use stakeholder input to redesign the program in a way that will allow ACO providers to drive payment and delivery reform and thereby enable DHHS to meet its newly established pay-for-value goals. Read the rest of this entry »
March 26th, 2015
For years now it has become apparent that the Sustainable Growth Rate (SGR) system is not sustainable. However, fixing the SGR will require increases in budgeted costs, and so one of the major barriers to replacing the SGR is figuring out how to pay for the fix. Towards this end, it is important to understand the appropriate cost-comparison.
Federal scorekeepers (appropriately) assess the cost of the SGR fix relative to current law, which assumes that fees will follow a trajectory defined by current policy. But as near as I can tell, few advocate for that path or believe it will occur; rather the current system will continue to require regular “patches.” Therefore, the appropriate measure of the cost of the doc fix is spending with the fix relative to spending without it. The latter includes the costs of future “patches” necessary to ensure continued operation (as well as any savings that can be achieved because of continued SGR related negotiations). Substituting this realistic alternative into the cost calculus likely substantially lowers the incremental cost of any SGR fix. Read the rest of this entry »
March 26th, 2015
Editor’s note: This post is part of a series stemming from the Third Annual Health Law Year in P/Review event held at Harvard Law School on Friday, January 30, 2015. The conference brought together leading experts to review major developments in health law over the previous year, and preview what is to come. A full agenda and links to video recordings of the panels are here.
The relationship between medicine and capital punishment has been a persistent feature of this past year in health law, both at the level of medical ethics and Supreme Court review.
Our story starts in Oklahoma, where the execution of Clayton Lockett was botched on April 28, 2014. National Institutes of Health (NIH) bioethicist Seema Shah described the events in question: Read the rest of this entry »
March 25th, 2015
Six years ago, President Obama signed into law the HITECH Act, which spelled out a path to a nationwide health information technology infrastructure. The goal was simple: every doctor, nurse, and hospital in America should use electronic health records — and do it in a way that leads to better care delivered more efficiently. The Act provided $30 billion in incentives for providers and hospitals who met the criteria for “Meaningful Use”, which the Obama administration was given the authority to define. The rules were set up to be rolled out in three stages, and while the first two stages have been out for a while, the criteria for the third and final stage of Meaningful Use (MU) were finally released on March 20.
David Blumenthal, the first national coordinator under HITECH, used the analogy of the Meaningful Use program as an escalator — with the first stage focused on just getting people on board and each stage requiring a higher level of use — which would focus on demonstrating better care through advanced EHR use. Put more simply, the goal of the three stages was to first get providers to just start using EHRs, and then over time to get them to use the systems more frequently, more robustly, and ultimately, in ways that lead to better, more efficient care.
The new stage 3 rule reflects both the successes and the failures of the first two stages. It moves toward making the EHR market more open and competitive, and providing more choices, in ways that I think are helpful — but possibly not helpful enough. Read the rest of this entry »
March 25th, 2015
The findings from a recent synthesis of the literature about the effectiveness of prevention initiatives focused on reducing the risk of Type 2 diabetes among high-risk populations (people already obese or inactive or diagnosed as having prediabetes) are largely encouraging.
The synthesis includes a comprehensive and systematic review of the medical, diabetes, and public health literature for evaluation studies of interventions published between 2002 and 2013. The search was undertaken using medical subject headings and keywords related to diabetes and its risk factors.
A number of interventions—such as the National Institutes for Health’s Diabetes Prevention Program and the Group Lifestyle Balance Program—focused on helping people eat better and become more physically active are effective in reducing the risk of diabetes onset. Robust studies show that these interventions work even better than medication to prevent diabetes. Read the rest of this entry »
March 24th, 2015
Anticipating the upcoming Supreme Court decision on King v. Burwell, which could halt health insurance subsidies available through the federal exchange, Republican Senators Richard Burr and Orrin Hatch joined with Representative Fred Upton to propose a comprehensive replacement for the Affordable Care Act (ACA). The Patient Choice, Affordability, Responsibility, and Empowerment Act, or Patient CARE Act, is modeled on a proposal of the same name offered last year by Senators Burr, Hatch, and Tom Coburn, who has retired from the Senate. The Burr-Hatch-Upton plan, like its predecessor, adopts consumer-based reforms of the insurance market, modernizes the Medicaid program, and makes other changes intended to lower cost and increase choices.
In an earlier post, we described in detail the provisions of the Burr-Coburn-Hatch bill. In this post, we discuss how the Burr-Hatch-Upton plan differs from the earlier proposal. We also discuss the impact of the new proposal on health insurance coverage, premiums, and the federal budget based on a new analysis from the Center for Health and Economy (H&E), a non-partisan think tank focused on producing informative analyses of trends in U.S. health care policy and reform ideas. We conclude by commenting on the direction Republicans are likely to take in reforming the health system in the aftermath of a Supreme Court decision in the King v. Burwell case. Read the rest of this entry »
March 24th, 2015
Having saved US consumers over $1.5 trillion in the past decade, generic drugs are one of the most cost-effective interventions in our entire health care system. Using generic drugs instead of brand-name drugs, when a generic is available, has been shown to increase medication adherence and improve health outcomes for chronic conditions.
Importantly, generic drugs offer these advantages without sacrificing quality; the Food and Drug Administration’s bioequivalency standards are met and often exceeded by generic-name manufacturers, and no randomized controlled trials—the gold standard of medical evidence—have identified clinically significant variations in outcomes between brand-name and FDA-approved interchangeable generic drugs. Read the rest of this entry »
March 24th, 2015
Oral health is an important but often overlooked part of health and insurance coverage. State Medicaid and the Children’s Health Insurance Program (CHIP) are required to cover children’s dental services (and children’s access to care has been improving over the last ten years), but coverage for adults is optional. As noted in a recent Health Affairs GrantWatch Blog post, only about 15 states offer extensive coverage for adult dental services in Medicaid.
Medicare does not cover most dental services. And most private dental coverage is offered through stand-alone dental products that are separate from medical plans. Overall, this has resulted in more than 2.5 times as many Americans going without dental coverage as medical coverage.
Inadequate access to dental care is costly. Many low-income individuals turn to the emergency department as their primary and only source of care for oral health needs. The American Dental Association estimates that emergency room visits for avoidable oral health-related visits cost the U.S. health care system as much as two billion dollars per year. A recent Narrative Matters feature in Health Affairs (“Navigating Veronika”) highlighted the steep barriers that low-income individuals can face in navigating the dental safety net and finding a provider who will treat them, even when Medicaid covers the costs of care. Read the rest of this entry »
March 23rd, 2015
It has been a while since I last had the opportunity to analyze the slowdown in health spending and the extent to which it represents a lasting bend in the cost curve, as opposed to lingering effects of the “Great Recession or other temporary changes.” (See Note 1)
Distinguishing Health Care Cost Curves
When we discuss bending the health care cost curve, two questions arise: “Which curve?” and “Short run or long run?” In this post, I focus on the curve represented by the growth rate in national health expenditures (NHE) pre- and post-recession. Other curves of interest include “excess growth” (health spending growth in excess of gross domestic product [GDP] growth) and the closely related health spending share of GDP. For analysis of all three curves over the very long run, including a provocative “big bang” theory about the origins of excess growth, see Tom Getzen’s blog. A fourth curve that has gotten my attention, through the work of Gene Steuerle, is the health spending share of the growth in real per capita GDP. (See Note 2)
I now turn to the present topic, the record low growth in NHE that began in 2009 (the year in which the recession ended) and continued through 2013 (the most recent year for which we have official data). There has been extensive discussion about whether these low rates are the result of temporary cyclical factors, such as the recession, or more permanent structural factors. As detailed below, I conclude that, to a surprisingly large extent, the answer is neither: the bulk of the decline in the health care spending growth rate resulted from lower economy-wide price inflation and some temporary factors not tied to the recession. Read the rest of this entry »