From The Staff

New Health Policy Brief: The Two-Midnight Rule


January 23rd, 2015

A new policy brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) examines the so-called “two-midnight rule.” The rule, announced in 2013, is an effort by the Centers for Medicare and Medicaid Services (CMS) to clarify when a patient will be considered by Medicare as an inpatient for hospital billing purposes. Under this rule, only patients that a doctor expects to need two nights in the hospital would be considered inpatients for the purpose of Medicare claims.

In the past, CMS provided little guidance to hospitals on this matter. This is important because the Medicare payment structures are very different for inpatients versus outpatients: Hospitals are reimbursed with a single comprehensive payment for all care provided to an inpatient during his or her time at the hospital, but they are paid standard fees for each unique service they provide to outpatients. This brief describes the perceived need by CMS for the two-midnight rule, how it would work, the implications for Medicare payment, and the heated response to the rule by the hospital industry. Read the rest of this entry »

Health Affairs Briefing: Biomedical Innovation


January 20th, 2015

Biomedical innovation lengthens and enriches our lives through breakthroughs in medications and care, but it is has also been the leading source of health care cost growth over the past few decades. The upcoming February 2015 thematic issue of Health Affairs examines the topic from many perspectives.

You are invited to join us on Thursday, February 5, at a forum featuring authors from the new issue at the W Hotel in Washington, DC.  Panels will cover pharmaceuticals; biotechnology; medical devices; and accelerating, diffusing, and financing innovation.

WHEN: 
Thursday, February 5, 2015
9:00 a.m. – 12:30 p.m.

WHERE: 
W Hotel Washington
515 15th Street NW
Washington, DC, Great Room, Lower Level

Register Now!

Follow live Tweets from the briefing @Health_Affairsand join in the conversation with #HA_BiomedInnovation. Read the rest of this entry »

Health Affairs Web First: New Medicare Per Capita Spending Shows A Rise With Age, Then A Decline After 96


January 14th, 2015

New analysis of Medicare spending from 2000–11 found that in 2011 per capita spending increased with age, from $7,566 for beneficiaries age seventy to $16,145 at age ninety-six, and then declining for even older beneficiaries. The study authors Patricia Neuman, Juliette Cubanski, and Anthony Damico also found that since 2000, the age that Medicare per capita spending peaks has increased each year: In 2000, the highest spending was found to be among those age ninety-two.

They also found that Medicare beneficiaries ages eighty and older, who comprised 24 percent of the beneficiaries, accounted for a disproportionate share (33 percent) of traditional Medicare spending in 2011. This study, being released by Health Affairs as a Web First, is part of the journal’s re-established DataWatch series, which features timely health-related data and surveys. Read the rest of this entry »

CMS Spending Report Leads Health Affairs 2014 Top-Ten List


January 13th, 2015

A report on 2012 health spending by analysts at the Centers for Medicare and Medicaid Services Office of the Actuary was the most-read Health Affairs article in 2014. To celebrate the New Year, Health Affairs is making this piece and all the articles on the journal’s 2014 top-ten list freely available to all readers for two weeks.

Health Affairs publishes annual retrospective analyses of National Health Expenditures by the CMS analysts, as well as their health spending projections for the coming decade. In the latest installment in this series — which also made our 2014 top ten — the analysts reported on 2013 health spending and discussed their findings at a Washington DC briefing. The two reports documented continued slow growth in health spending; the 2013 report featured the slowest rate of health spending growth since CMS began tracking NHE in 1960.

Next on the 2014 Health Affairs most-read list was an article on PepsiCo’s workplace wellnesss program. John Caloyeras and coauthors at RAND and PepsiCo found that the diseases management component of the program saved money, but the lifestyle management component did not. This was followed by two Narrative Matters essays by Charlotte Yeh and Diane Meier; another Narrative Matters piece, by Janice Lynch Schuster, rounded out the list at number ten.

The full top-ten list is below. And check out the 2014 most-read Health Affairs Blog posts and GrantWatch Blog posts. Read the rest of this entry »

The Importance Of Zip Code In Determining One’s Health Tops 2014 GrantWatch Blog Most-Read List


January 9th, 2015

Happy New Year! We have compiled a list of the ten most-read posts on GrantWatch Blog during 2014, in case you missed any of them. Read the rest of this entry »

New Narrative Matters: A Mother’s Hope For A Natural Birth In A Cesarean Culture


January 9th, 2015

Health Affairs‘ January Narrative Matters essay features a physician and mother on giving birth in a culture that increasingly pushes women toward cesarean sections. Carla Keirns’ article is freely available to all readers, or you can listen to the podcast.

Read the rest of this entry »

Medicaid Expansion Post Leads Health Affairs Blog 2014 Top-Fifteen List


January 8th, 2015

As we begin 2015, we present the fifteen most-read Health Affairs Blog posts from 2014. Topping the list is “Opting Out Of Medicaid Expansion: The Health And Financial Impacts,” by Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhander. “Low-income adults in states that have opted out of Medicaid expansion will forego gains in access to care, financial well-being, physical and mental health, and longevity that would be expected with expanded Medicaid coverage,” the authors write, and they offer a state-by-state projection of these consequences.

Next on the list is Susan DeVore‘s overview of health care trends to watch in 2014, followed by David Muhlestein‘s look at the likely growth of accountable care and an examination of declining inpatient hospital utilization by Robert York, Kenneth Kaufman, and Mark Grube. The list also includes two posts from Tim Jost’s comprehensive series on implementing the Affordable Care Act, on waiting periods for employer-sponsored health insurance and Medicaid asset rules.

Stay tuned for the 2014 most-read lists for Health Affairs journal and GrantWatch Blog.

The full top-fifteen list is below: Read the rest of this entry »

Health Affairs’ January Issue: Aging And Health


January 5th, 2015

The January issue of Health Affairs includes a number of studies examining issues pertaining to aging and health or health care. Other subjects covered include: the effect of Medicare’s Hospital Compare quality reports on hospital prices; how the Affordable Care Act’s provisions impact Americans shouldering high medical cost burdens; and whether California’s Hospital Fair Pricing Act has benefited uninsured patients.

Content on aging and health was supported by the John A. Hartford Foundation. Read the rest of this entry »

Exhibit Of The Month: Federal Health Spending On Children


January 5th, 2015

Editor’s note: This post is part of an ongoing Exhibit of the Month series.

As we begin the new year and look forward to the release of our January issue later today, we also take a look back at the “exhibit of the month” from our December thematic issue on children’s health. The exhibit, from the article, “The Scheduled Squeeze On Children’s Programs: Tracking The Implications Of Projected Federal Spending Patterns,” looks at health spending on children as a percentage of total federal spending on children from 1960 to 2013. Read the rest of this entry »

New On GrantWatch Blog


December 31st, 2014

Health Affairs GrantWatch Blog brings you news and views of what foundations are funding in health policy and health care.

Here are the most recent posts: Read the rest of this entry »

Contributing Voices

Competition In Health Care Markets


January 26th, 2015

In this post, I want to focus on the key role economic analysis plays in the Federal Trade Commission (FTC)’s health care enforcement program. I use this lens to look first at how the FTC has become more successful in challenging hospital mergers, and then to rebut the notion that the Affordable Care Act is somehow a “free pass” for health care industry consolidation.

After the federal antitrust agencies successfully challenged a number of hospital mergers in the 1980s and early 1990s,[1] we suffered a string of court losses in the mid- and late-1990s, even in cases involving highly concentrated hospital markets.[2] In 2002, the FTC decided to take a step back and examine the reasons for our losses, and whether our analysis of hospital markets was correct.

We engaged in an in-depth retrospective study, used our authority to collect data from hospitals and insurance companies, and held workshops along with DOJ. (See here, here, here, and here.) Cory Capps of Bates and White, and other economists contributed significantly to our understanding as well. This intense period of reflection led to several important papers demonstrating that the consummated mergers stemming from the hospital merger challenges we lost—including those involving non-profits—resulted in anticompetitive effects, particularly increased prices. We also determined that our losses were due in part to the courts’ acceptance of faulty economic analysis of geographic and competitive effects. (See here, here, and here.) Read the rest of this entry »

Beyond Law Enforcement: The FTC’s Role In Promoting Health Care Competition And Innovation


January 26th, 2015

By now, the Federal Trade Commission’s (FTC) law enforcement efforts in the health care area are well known. We have successfully challenged several hospital and physician practice mergers in the last few years. We also continue to pursue anticompetitive pharmaceutical patent settlements, following a victory at the Supreme Court in the Actavis case. Speaking of the Court, it is currently reviewing a case we brought against the North Carolina Board of Dental Examiners, alleging that its members conspired to exclude non-dentists from providing teeth whitening services in North Carolina.

Perhaps less publicized are the FTC’s various non-enforcement efforts in health care. Arguably most significant among those is the advocacy that the agency conducts in favor of competition principles before state legislatures and other policymakers. I will discuss our advocacy efforts in the health care space in this post, and then turn to the subject of telemedicine, an area in which FTC competition policy may play a significant role. Read the rest of this entry »

Moving Beyond Wellness ROI Toward Employment-Based Cultures Of Health: Part I


January 26th, 2015

With their recent post declaring that employment-based wellness initiatives “increase rather than decrease employer spending on health care with no net health benefit,” Al Lewis and coauthors are continuing to exert a clarifying presence in a field with a history of unsubstantiated claims and suspect methods. This conclusion is not supported by the work with which we and others have been associated and is thus not one with which we agree.

Nevertheless, Lewis et al. are to be acknowledged for fueling the need for a sharper focus on the core challenge at hand for employers: how best to improve the value of their health care investment—that is, how to manage health care costs while improving employee health and productivity—in ways that are sustainable. Incremental, inconsistent and, at times, maddeningly slow progress has been made. Employment-based wellness has been at the forefront, even as the need for quality improvement continues.

Moreover leading employers with well-developed management and measurement approaches have moved well beyond calculating the return on investment (ROI) of individual wellness efforts and are demonstrating the more comprehensive value of building “cultures of health.” Read the rest of this entry »

Additional Requirements For Charitable Hospitals: Final Rules On Community Health Needs Assessments And Financial Assistance


January 23rd, 2015

On December 29, the Department of the Treasury and the Internal Revenue Service released long-awaited final regulations implementing Affordable Care Act provisions that impose additional obligations on charitable hospital organizations covered by §501(c)(3) of the Internal Revenue Code.  Published in the Federal Register on December 31 2014, the regulations are massive, consolidating a series of prior proposals into a single final body of regulatory law.  The regulations affect more than 80 percent of U.S. hospitals, both the 60 percent that operate as private nonprofit entities and the 23 percent that operate as governmental units.

Because state and local governments typically condition their own sales, property, and corporate income tax exemptions for nonprofit entities to a hospital’s §501(c)(3) status, the final regulations carry broad and deep implications from both a policy and financial perspective.  According to the Congressional Budget Office the 2002 the national value of the federal tax exemption exceeded $12 billion, a figure that undoubtedly has risen considerably. Read the rest of this entry »

Early Evidence On Medicare ACOs And Next Steps For The Medicare ACO Program (Updated)


January 22nd, 2015

Note: Pratyusha Katikaneni and Carmen Diaz also contributed to this post. They are both research assistants at the Engelberg Center for Health Care Reform, The Brookings Institution.

January 23 update comparing this analysis to one by Scott Heiser, Carrie Colla, and Elliott Fisher: Yesterday, Health Affairs Blog published two analyses of Medicare ACO results, one by Scott Heiser and colleagues and one by us (below). These analyses should be viewed as complementary.

In their post, Heiser and colleagues note a greater likelihood of early financial success (i.e., qualifying for shared savings) in relatively high-cost areas of the country. They reach this conclusion by linking each ACO to their hospital referral region (HRR) and finding a significant relationship with early shared savings. They conclude that ACOs in higher cost regions are more likely to begin the program with a higher benchmark relative to costs, making it easier to attain shared savings.

Our analysis focuses on the specific benchmark for each ACO (not the regional cost) and also concludes that there is a statistically significant correlation between ACOs with higher financial benchmarks and their total savings. However, we note that the beginning financial benchmark explains less than 10 percent of the variation in early financial performance, and note that there are many successful ACOs in lower-cost areas as well.

The results of the two analyses are not contradictory, but rather reflect that while historical spending matters in early success, many other factors matter as well.

Original post: On December 1, CMS released a Notice of Proposed Rulemaking (NPRM) for the Medicare Shared Savings Program (MSSP), which requests feedback for changes CMS is considering for the Medicare accountable care organization (ACO) programs in 2016 and beyond. The proposal suggests significant potential alterations to the program, many of which we recently reviewed, that would address major issues that ACOs and others have raised: uncertainty and inexperience at transitioning to increasing levels of risk, lack of timely and accurate data, changes in attributed patient populations from year-to-year, and financial benchmarks that fail to account for regional variations and continue to reward high ACO performance over time. Read the rest of this entry »

Unpacking The Medicare Shared Savings Proposed Rule: Geography And Policy


January 22nd, 2015

The Centers for Medicare and Medicaid Services (CMS) recently announced a Notice of Proposed Rulemaking (NPRM) for Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs). The rulemaking contains several proposals that if enacted, would fundamentally change the underlying incentives for providers to participate in the program. These proposed reforms address issues such as data sharing, renewals of participation agreements, beneficiary attribution, incentives to move to two-sided risk, and lastly, reforms to the benchmark calculations against which ACOs compete to earn savings.

The NPRM comes on the heels of a September 16, 2014 release of performance results for MSSP ACOs that began their performance years by 2013. Under the current program rules, ACOs that successfully reported quality performance data and whose savings exceeded their “minimum savings rate” were eligible to share in savings with Medicare. The MSSP program allows ACOs to choose either one-sided risk (Track 1, only upside potential to earn savings) or two-sided risk (Track 2, both upside and downside potential to earn savings/incur losses) with the final sharing amount based on achieving quality targets (up to 50 percent for Track 1 and 60 percent for Track 2). A vast majority of ACOs enrolled in Track 1, the one-sided risk option. Of the 220 ACOs in the program that participated in the first performance year, 53 earned shared savings, 52 saved money but not enough to meet the required “minimum savings rates,” and the other 115 did not accrue savings (spending on patients assigned to the ACO was greater than projected).

In February 2014, the CMS asked stakeholders for input as to how to improve its ACO programs, feedback which they used to generate the NPRM. Many ACOs and other stakeholders argued that failures to achieve savings over and above minimum savings rates were a partial result of residing in low spending areas. In this post, we examine the merits of this contention and consider the policy implications of our results and their bearing on some of the modifications of the MSSP program that CMS has proposed.

We also discuss other strategies for improving the program CMS did not mention in the NPRM. Read the rest of this entry »

Last Year Was A Wild One For Health Law — What’s On The Docket For 2015?


January 22nd, 2015

Everywhere we look, we see the tremendous impact of new legal developments—whether regulatory or statutory, federal or state—on health and health care. These topics range from insurance to intellectual property to religion to professionalism to civil rights. They remain among the most important questions facing Americans today.

This post is the first in a series that will stem from the Third Annual Health Law Year in P/Review event to be held at Harvard Law School on Friday, January 30, 2015. The conference, which is free and open to the public, brings together leading experts to review major developments in health law over the previous year, and preview what is to come.

The event is sponsored by the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School and the New England Journal of Medicine, and co-sponsored by Health Affairs, The Hastings Center, and the Center for Bioethics at Harvard Medical School. Below, we will highlight a few themes that have emerged so far. The conference’s speakers will author a series of posts that follow on more specific topics. Read the rest of this entry »

Academic Medical Centers Should Lead The Charge On Price Transparency


January 21st, 2015

A bipartisan campaign to increase price transparency in the medical world has been reverberating through the press, government, and hospitals. Recent examples include CMS’ release of datasets for inpatient and outpatient charges and North Carolina’s House Bill 834, which was signed into law on August 21, 2013 and mandates that the state’s Department of Health and Human Services publish hospital charges. In Time Magazine, Steven Brill’s article, “Bitter Pill,” provided stunning real world examples of how the lack of price transparency can create enormous uncertainty and confusion among both patients and providers.

The momentum will only continue as Section 2718(e) of the Affordable Care Act is implemented. The provision, which took effect on October 1, 2014, mandates that each hospital establish, update, and publicize a list of standard charges for items and services provided. At this critical moment, there is one set of institutions that are uniquely positioned to ensure that price transparency is implemented deliberately and successfully: Academic Medical Centers.

For good reason, there is excitement about the potential of the price transparency movement. A recent Health Affairs study by Wu et al. suggests that when patients have access to health care prices for an intervention such as an MRI, a significant number select the lower-price option. This proof of concept shows that price transparency has the potential to lead to competition between hospitals, thus reducing costs to the patient and health care system. Read the rest of this entry »

Moving From Mandate To Reality: A Roadmap For Patient And Family Engagement


January 20th, 2015

The 2010 Affordable Care Act (ACA) moved patient and family engagement to center stage in health care reform. The law mentions “patient-centered care” at least 40 times, with explicit references to patient engagement, patient experience, health literacy and shared decision making. Evidence is growing that meaningful patient and family engagement can help achieve the triple aim of better quality, better outcomes and lower health care costs and substantially reduce preventable harm.

Yet, despite these advances, the full promise of engagement remains mostly untapped, and much confusion remains about what constitutes meaningful patient and family engagement, and importantly, how to translate this evidence broadly into routine health care practice. Read the rest of this entry »

How Community Health Workers Can Reinvent Health Care Delivery In The US


January 16th, 2015

As health policy, research and practice are becoming increasingly focused on improving the health of populations and addressing social determinants of health, Community Health Workers (CHWs) may be just what the doctor ordered. As part of the public health workforce with ties to the local community, CHWs can now be reimbursed by Medicaid for providing preventive services if recommended by a physician or other licensed practitioner.

This groundbreaking CMS regulatory change, along with policy support from the Affordable Care Act, holds the promise of bridging the gap between mainstream health care and community health through expanding the CHW profession and its impact on clinical care. Much like other disruptive changes in health care, however, fulfilling this potential will require a new way of thinking among state policymakers and the health care system at large. Read the rest of this entry »

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