From The Staff

Look At Consequences Of Rejecting Medicaid Expansion Leads First Quarter Health Affairs Blog Most-Read List


April 14th, 2014
by Tracy Gnadinger

Given their recent mention in Paul Krugman’s New York Times‘ column, it’s not surprising that Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhandler‘s discussion of the health and financial impacts of opting out of Medicaid expansion was the most-read Health Affairs Blog post from January 1 to March 31, 2014.

Next on the list was Robert York, Kenneth Kaufman, and Mark Grube‘s discussion of a regional study on the transformation from inpatient-centered care to an outpatient model focused on community-based care. This was followed by Susan Devore‘s commentary on changing health care trends and David Muhlestein‘s evaluation of accountable care organization growth.

Tim Jost is also listed four times for contributions to his Implementing Health Reform series on Medicaid asset rules, CMS letter to issuers, contraceptive coverage, and exchange and insurance market standards.

The full list appears below. Read the rest of this entry »

The Latest Health Wonk Review


April 11th, 2014
by Chris Fleming

Billy Wynne at Healthcare Lighthouse offers this week’s edition of the Health Wonk Review. All of the posts in Billy’s “April Fool’s” edition are an excellent read, including the Health Affairs Blog post by Dean Aufderheide on mental illness in America’s jails and prisons. Read the rest of this entry »

Takeaways From The Aspen Institute’s Care Innovation Summit


April 10th, 2014
by Matthew Richardson

Back in February, The Aspen Institute and The Advisory Board Company sponsored the Care Innovation Summit in Washington, DC. With a keynote address from Secretary of Health and Human Services Kathleen Sebelius, the daylong summit featured some of the newest data and research on the rapidly evolving U.S. health care landscape.

Featured speakers such as Jeffrey Brenner of the Camden Coalition of Healthcare Providers and Claudia Grossmann of the Institute of Medicine in addition to others from State and Federal government, insurers, hospitals, and research institutions offered insights on higher-value care and improved health for individuals and populations.

Here are five most memorable takeaways:

1. Health Care Cost Inflation Has Slowed

Perhaps the most eye-catching data trend presented was the dramatic slowing of Medicare spending showcased by Patrick Conway, Director of CMMI (presentation available here). The collapse of annual per capita spending growth is important not only because it implies significant value changes are underway in the provision of ever more services by Medicare, but also because it can further mean many things to many people. Read the rest of this entry »

Health Affairs Web First: Global Health Funding In 2013 Five Times Greater Than 1990


April 8th, 2014
by Tracy Gnadinger

Development assistance for health (DAH) to low- and middle-income countries provided by donors and international agencies are given in the form of grants, low-cost loans, and goods and services. Without this assistance, some of the poorest countries would be less able to supply basic health care.

A new study, being released today as a Web First by Health Affairs, tracked the flow of development assistance for health and estimated that in 2013 it reached $31.3 billion.

Looking at past growth patterns of these international transfers of funds for health, authors Joseph Dieleman, Casey Graves, Tara Templin, Elizabeth Johnson, Ranju Baral, Katherine Leach-Kemon, Anne Haakenstad, and Christopher Murray identified a steady 6.5 percent annualized growth rate between 1990 and 2000, which nearly doubled to 11.3 percent between 2001 and 2010 with the burgeoning of many public-private partnerships. Since 2011, however, annualized growth has dramatically dropped, to 1.1 percent, due, in part, to the effect of the global economic crisis. Read the rest of this entry »

New Health Affairs: Implications Of Alzheimer’s And The State Of Research


April 7th, 2014
by Chris Fleming

Health Affairs’  April issue addresses the litany of public and personal ramifications of Alzheimer’s disease—the most expensive condition in the United States both in terms of real costs and the immeasurable toll on loved ones. Articles examine best practices and models of care; a global view of the disease; the effects on caregivers; and what may lie ahead for a disproportionately underfunded research community.

Unnecessary hospital and emergency department (ED) visits are particularly difficult on people with Alzheimer’s—and costly to the health care system—but they experience them more often than their counterparts without dementia. Zhanlian Feng of RTI International and colleagues examined Medicare claims data linked to the Health and Retirement Study to determine hospital and ED use among older people with and without dementia across community and institutional settings. They found that in the community older people with dementia were more likely to have a hospitalization or ED visit than those without dementia, and that both groups had a marked increase in health care usage near the end of life.

Specifically, they found significant differences in hospitalizations and ED visits among community-dwelling residents, with 26.7 percent of dementia patients versus 18.7 percent of non-dementia residents experiencing hospitalization, and 34.5 percent versus 25.4 percent experiencing an ED visit. Differences were less pronounced among nursing home residents and tended to even out among all groups in the last year of life. The researchers suggest that policy makers consider promoting the use of alternative end-of-life options such as hospice care and providing supportive services and advance care planning to Medicare beneficiaries that can help reduce avoidable hospital-based care. Read the rest of this entry »

Health Affairs Briefing Reminder: Long Reach Of Alzheimer’s Disease


April 4th, 2014
by Chris Fleming

Despite decades of effort, finding breakthrough treatments or a cure for Alzheimer’s has eluded researchers. In the April 2014 issue of Health AffairsThe Long Reach Of Alzheimer’s Disease, we explore the many subjects raised by the disease: the optimal care patients receive and the testing of new models, international comparisons of how the disease is treated, families’ end-of-life dilemmas, a new public-private research collaboration designed to produce improved treatments, and others.

Please join us on Wednesday, April 9, at W Hotel in Washington, DC, for a Health Affairs briefing where we will unveil the issue.  We are delighted to welcome Dr. Richard Hodes, director of the National Institute on Aging at the National Institutes of Health to deliver the Keynote. Read the full briefing agenda.

WHEN:
Wednesday, April 9, 2014
8:30 a.m. – 12:30 p.m.

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

 REGISTER ONLINE

Follow live Tweets from the briefing @HA_Events, and join in the conversation with the hashtag #HA_Alzheimers.

Read the rest of this entry »

Recent Health Policy Briefs: Mental Health Parity And ICD-10 Update


April 3rd, 2014
by Tracy Gnadinger

The latest Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation examines the issue of mental health parity. The push to make coverage for mental health treatment equal to that of physical health has been on legislative to-do lists for some time, both in Congress and in state houses. This brief looks at the evolution of the Mental Health Parity Act, originally passed by Congress in 1996 as well as changes in mental health parity brought about by the implementation of the Affordable Care Act (ACA).

Also posted today: an update to the last month’s brief on the transition to ICD-10. Congress recently passed legislation delaying the system’s implementation. Click here to learn what the delay means for providers and payers.

Health Policy Briefs are aimed at policy makers, congressional staffers, and others needing short, jargon-free explanations of health policy basics. Sign up for an e-mail alert about upcoming briefs. The briefs are also available from the Robert Wood Johnson Foundation’s website. Please feel free to forward the briefs to any of your colleagues who are tracking health issues. And after you’ve taken a look, we welcome your feedback at: hpbrief@healthaffairs.org. Read the rest of this entry »

Responding To ‘The Hidden Curriculum’: Don’t Forget About The Patient


April 3rd, 2014
by Rob Lott

Narrative Matters readers might remember Joshua Liao’s moving essay about the dangers of the Hidden Curriculum. Liao, a resident physician at Brigham and Women’s Hospital, wrote about the consequences of making a serious mistake as a medical student on an obstetrics rotation. He read the essay for the Narrative Matters podcast and it’s a great listen.

Liao’s essay, penned with Eric Thomas and Sigall Bell, also generated some compelling responses. It inspired Tim Lahey to write about his experience leading the curriculum redesign at Dartmouth’s Geisel School of Medicine. And when the Washington Post ran an excerpt of Liao’s essay last week, it led Franca Posner to remind readers about “one missing piece of this puzzle”: the patient’s perspective.

Posner was once in a similar situation, but it was she on the hospital bed: “I was that woman 20 years ago, only I was almost 40 and had a 5-year-old child and five miscarriages in my reproductive history,” Posner wrote in a letter to the editor published in the Post’s Health and Science section on March 31. Read the rest of this entry »

Health Reform And Criminal Justice: Advancing New Opportunities


April 1st, 2014
by Chris Fleming

Community Oriented Correctional Health Services (COCHS) and Health Affairs invite you to join thought leaders from public safety, health care, philanthropy, and all levels of government to further explore the intersection of health reform and criminal justice. As implementation of the Affordable Care Act continues, it is time to take stock of how far we have come in addressing the needs of the jail population through policy and planning, and to set our direction for the future.

This national event will take place on Thursday, April 3, from 8:00 a.m. to 4:00 p.m., at the Columbus Club in Union Station, Washington, D.C. It is being organized with support from the Robert Wood Johnson Foundation, the Jacob & Valeria Langeloth Foundation, and Public Welfare Foundation. Registration for in-person attendance is closed, but a live webcast is available.

The unique health care needs of the jail-involved population are well understood. The challenges now are how best to leverage change brought about by health reform and how to connect the jail-involved population to community-based systems of care. Read the rest of this entry »

Health Policy Leader Alan Weil To Become New Health Affairs Editor-in-Chief


March 31st, 2014
by Chris Fleming

Health Affairs and its publisher Project HOPE are pleased to announce that Alan Weil will become the journal’s new editor-in-chief on June 2, 2014.

Weil, a highly respected expert in health policy and current member of Health Affairs’ editorial board, will lead the journal after serving as the executive director of the National Academy for State Health Policy (NASHP) since 2004. His work with state policymakers of both political parties put Weil at the forefront of health reform policy, implementation, innovation, and practice. Prior to his leadership of NASHP, he served in both the public and private sectors. He directed the Urban Institute’s “Assessing New Federalism” project; served as the executive director of the Colorado Department of Health Care Policy and Financing and a health policy advisor to Colorado’s then-governor, Roy Romer; and was the assistant general counsel in the Massachusetts Department of Medical Security.

“We’re delighted to welcome Alan to the Project HOPE family,” said John P. Howe III, M.D., President and CEO of Project HOPE.  “He comes to Health Affairs with more than 24 years of experience in health policy development and a stellar record of leadership and innovation in this field.  I’m confident he will lead the journal’s talented staff on a new and successful path forward.  I am extremely grateful to John Iglehart, the Founding Editor of Health Affairs for his stewardship of the journal for more than 25 years, ensuring its coveted rank as the leading health policy journal of our time.”

“Alan Weil’s extensive background in health and health care policy will serve him well in his new role as Health Affairs’ editor-in-chief,” noted John Iglehart, who currently leads the journal.  “With his position on the front lines of health system change, he is an experienced leader who has deep familiarity with and longstanding connections to the health policy, research, and health care leadership communities.  In particular, in his role as NASHP’s executive director, Alan worked on complex issues of critical importance to leaders in state and federal government and the private sector.  This background will serve Health Affairs well as it continues to grow in influence both in the US and globally.” Read the rest of this entry »

Contributing Voices

Hobby Lobby, Conestoga Wood, The ACA, And The Corporate Person: A Historical Myth Bedevils The Law


April 18th, 2014
by Malcolm Harkins

On March 25, 2014, the Supreme Court of the United States heard arguments in two cases—Sebelius v. Hobby Lobby Stores, Inc. and Conestoga Wood Specialties v. Sebelius—challenging the validity of the Affordable Care Act’s (“ACA”) mandate that employer-sponsored health plans cover all FDA-approved contraceptives (the “Contraceptive Mandate”).  In each case, closely held plaintiff corporations contend that the Contraceptive Mandate illegally infringed upon the corporations’ freedom to exercise religion.

The cases attracted attention because the Supreme Court had agreed to hear yet another challenge to the validity of the ACA’s provisions, but it has been less noticed that both cases, and others like them, implicate a fundamental question that the Supreme Court has never decided; on what basis, if any, is a corporation a “person” entitled to assert the constitutional and statutory rights of natural persons.  Without denying the significance of the challenge to the ACA’s Contraceptive Mandate, the Supreme Court’s failure to define a principled corporate person theory has had—and continues to have—important and pervasive implications for the American legal system beyond the present cases.

Typically, legal concepts creating and regulating societal rights and obligations, like the corporate personhood concept, come into being incrementally in an extended evolutionary process.  That evolutionary process is characterized by a dialectic give and take in which the principles justifying—or precluding—application of the concept in a variety of different factual scenarios are gradually clarified, defined and developed through a series of judicial decisions.  The problem confronting the Supreme Court as it considers the Hobby Lobby and Conestoga Wood cases is that the concept of corporate personhood did not develop gradually or in an evolutionary process in which the meaning of the concept was developed and defined.  Instead, the concept of the corporate person was imposed on the law ipse dixit, that is, by judicial fiat and without definition, in a series of late nineteenth century Supreme Court cases. Read the rest of this entry »

Implementing Health Reform: The Latest Affordable Care Act Coverage Numbers


April 18th, 2014
by Timothy Jost

On April 17, 2014, the White House announced that 8 million Americans have signed up for private health insurance coverage through the health insurance marketplaces, or exchanges.  This significantly exceeds the White House’s original goal of 7 million enrollees.  It is far more than the Congressional Budget Office’s recent projections of 6 million.

The number of actual enrollees will be smaller than this number.  The CBO’s projections are for the average number of those actually enrolled in coverage over the course of a calendar year.  To calculate the average number of enrollees, one must subtract from the 8 million the number of individuals who fail to pay their premiums and thus are never actually enrolled in coverage, as well as those who will drop coverage at some later point during the year. To that reduced number, then, must be added back the number who become newly covered through special enrollment periods during the remainder of the year.  In the end, 6 to 7 million average enrollees is probably a reasonable estimate.

This does not, however, exhaust the number of Americans who are now covered under the Affordable Care Act.  The fact sheet states that 3 million young adults are covered under their parents’ plans because of the ACA.  This number is probably high, but it is clear that the ACA has dramatically increased coverage of  Americans between the age of 19 and 25 — the age group most likely to lack health insurance prior to the ACA (and still). Read the rest of this entry »

Development Assistance For Global Health: Is The Funding Revolution Over?


April 17th, 2014
by Jennifer Kates

In many ways, the last twenty years have been somewhat of a “revolution” in global health, as marked by rising attention, growing funding, and the creation of new, large scale initiatives to address global health challenges in low and middle income countries.  Indeed, the 1990s brought a steady increase in global concern about health, largely centered on the HIV epidemic and due to civil society organizing to draw attention to the growing crisis, leading to the creation of the Millennium Development Goals, and soon thereafter, the GAVI Alliance, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and the U.S. President’s Emergency Plan for AIDS Relief, and other efforts.

A key driver of increased funding has been donors – governments and multilateral agencies, non-governmental organizations (NGOs), and foundations.  And tracking their funding has become one of the critical measures of the global health response.

A new analysis from Dieleman et al., published as a Health Affairs Web First on April 8, provides a needed contribution to the literature on donor funding for health, including an understanding not just of where donor funding is going but of the relationship between aid, burden, and income. Read the rest of this entry »

Four Years Into A Commercial ACO For CalPERS: Substantial Savings And Lessons Learned


April 17th, 2014
 
by Glenn Melnick and Lois Green

Background:  In a very short period of time, Accountable Care Organizations (ACOs) have become an important and widespread part of the US health care landscape. A recent Health Affairs Blog post estimates the total number of public (Medicare) and private ACOs at more than 600 nationally, covering more than 18 million insured population. Despite their rapid and widespread adoption, relatively little is known about how ACOs actually work and how successful they have been. This is due in part to their relative “newness,” as many reported ACOs are just getting up and running. Others have been operational for short periods of time and have yet to produce meaningful or long-term sustainable results.

This Health Affairs Blog post helps fill some of this void by reporting on the operational experiences of one of the oldest (4+ years) and largest commercial ACOs in the nation. A previous Health Affairs Blog post reported on its initial planning and start-up phase, and a subsequent Health Affairs article reported on its early financial results.

In 2007, Blue Shield of California, along with provider and employer partner organizations, began exploring development of one of the first ACO-like programs in the country to serve Commercial patients. It launched in 2010 and, as reported below, has been generating savings to consumers throughout the period. Located in the competitive Sacramento market of northern California, the ACO is an example of an innovative shared savings model involving a large insurer—Blue Shield of California; a purchaser—the California Public Employees Retirement System (CalPERS); a physician group—Hill Physicians Medical Group (HPMG); and a hospital system—Dignity Health. The population served approximately 42,000 CalPERS employees and their families covered by Blue Shield. Read the rest of this entry »

We’ll Need A Bigger Boat: Reimagining The Hospital-Physician Partnership


April 17th, 2014
 
by Francis J. Crosson and John Combes

Change is underway in the delivery and financing of American health care, and it is manifested in the evolving relationship of hospitals and physicians across the U.S. These developments are most striking in California, but are appearing in various forms in almost all states. Physicians and hospitals are being both “pushed” and “pulled” together in new ways by a variety of market forces, including the development of Accountable Care Organizations (ACOs) for both Medicare and commercially insured patients, increased direct employment of physicians by hospitals, the emergence of new payment mechanisms such as global payments, and, in general, by the need for physicians, physician groups and hospitals to deliver greater “value.”

All of this presents the opportunity to redesign care to be more coordinated, efficient, patient-driven, and effective. These integration forces could lead to the kind of organizations envisioned 15 years ago in the Institute of Medicine report “Crossing the Quality Chasm”, resulting in the Triple Aim of better health, better patient care experiences and outcomes, and improved affordability — driven, in part, by new patient care models and payment methods including incentives for improving the value of health care services.

Many physicians are uncomfortable with the idea of physician-hospital integration for several reasons. The long tradition of “professional autonomy”– perhaps best described as “the need for physicians to be able to make appropriate and scientifically based patient-by-patient decisions in the best interest of those patients” — can raise fears among some physicians about becoming part of a larger practice or institution and losing that autonomy. Additionally, some physician groups have shown that they can develop a successful ACO without the need for hospital and insurance partners, preferring to manage the clinical and financial risk alone. Read the rest of this entry »

Families Under Stress: Reflections On April’s Narrative Matters Essay On Dementia


April 16th, 2014
by Carol Levine

Editor’s note: This post responds to the April Narrative Matters essay by Gary Epstein-Lubow, a geriatric psychiatrist, which recounts the life-changing stress experienced by relatives who care for loved ones with dementia. Epstein-Lubow’s essay is freely available to all readers, or you can listen to him read it. You can also read an abridged version of the essay published April 15 in the Washington Post.

When my daughters were five and six years old, I took them to visit my grandmother in the Rosa Coplon Home in Buffalo, New York.

“Bubbie,” I said, “These are my little girls. Do you remember when I was this age?”

She looked at me and at them and finally held out her arms to embrace us and said (in Yiddish), “I don’t know who you are, but I know you belong to me.”

That experience so affected my elder daughter that when she was a teenager she undertook a project interviewing older people and creating a radio program from the tapes.

I thought of this moment when I read Gary Epstein-Lubow’s Narrative Matters essay, “A Family Disease: Witnessing Firsthand The Toll That Dementia Takes on Caregivers,” published in the April issue of Health Affairs. Read the rest of this entry »

Companies Must Approach Advanced Health Events As A Business Issue


April 16th, 2014
 
by J. Brent Pawlecki and Dan Morhaim

Editor’s note: For more on this topic, see the April issue of Health Affairs, which features a series of articles on Alzheimer’s disease.

In the corporate world, every company has a chief financial officer charged with ensuring that the organization meets all tax and accounting mandates and to report the data to officers of the company, shareholders, employees and the general public.

Yet, while organizations expend great effort addressing these matters, many miss another opportunity to protect their employees’ well-being by failing to talk about end-of-life care.  Most companies consider advanced illness to be a private matter. But in fact, this hands-off approach most assuredly affects the financial health of any organization – and the emotional well-being of its workforce.

Beyond its direct impact on individuals’ health and well-being, advanced illness can take a heavy economic toll, including its effects on productivity, health and benefits costs, employee potential and engagement.  According to the MetLife Mature Market Institute study, the total estimated cost to employers for all full-time employed caregivers is a staggering $33.6 billion.  The average cost per employee for caregiving responsibilities ranges from $2,100 to $2,400. Read the rest of this entry »

Implementing Health Reform: CBO Projects Lower ACA Costs, Greater Coverage


April 15th, 2014
by Timothy Jost

On April 14, 2014, the non-partisan Congressional Budget Office, together with the staff of the Joint Committee on Taxation, released an updated estimate on the Effects of the Insurance Coverage Provisions of the Affordable Care Act.  The CBO report brings good news for the ACA.   The CBO projects now that the ACA’s coverage provisions will cost $5 billion less for this year than it projected just two months ago.  Over the 2015 to 2024 period, CBO projects that the ACA will cost $104 billion less than it projected in February.  At the same time, the CBO projects that the number of uninsured Americans will in fact decrease by an additional one million over the next decade, by 26 rather than 25 million, as it estimated in February.

The CBO report estimates that the net cost of the ACA’s coverage provisions will be $36 billion in 2014, $1,383 billion over the 2015 to 2024 period.  This estimate consists of $1,839 billion for  premium tax credits and cost-sharing reduction payments, Medicaid, CHIP, and small employer tax credits, offset by $456 billion in receipts from penalty payments, the excise tax on high-premium insurance plans, and the effects on tax revenues of projected changes in employer coverage. The CBO report does not include an estimate of the total reduction in the federal deficit attributable to the ACA, as the CBO has concluded that it is no longer possible to estimate the net effect of ACA changes on existing federal programs, but the most recent CBO estimate from 2012 projected that the ACA would reduce the federal deficit over the 2013 to 2022 period by $109 billion.   Given projected further reductions in Medicare spending projected in a CBO budget report also released on April 14, it is reasonable to believe that the ACA’s impact on the budget may be even greater than earlier estimated. Read the rest of this entry »

Payment and Delivery Reform Case Study: Congestive Heart Failure


April 15th, 2014
by Darshak Sanghavi

Editor’s note: In addition to Darshak Sanghavi (photo and bio above), this post is coauthored by Meaghan George, a project manager at the Engelberg Center for Health Care Reform at the Brookings Institution. The post is adapted from a full-length case study, the first in a series of case studies made possible through the Engelberg Center’s Merkin Initiative on Physician Payment Reform and Clinical Leadership, a special project to develop clinician leadership of health care delivery, payment and financing reform under the leadership of Mark McClellan. The case studies will be presented using a “MEDTalk” format featuring live story-telling and knowledge-sharing from patients, providers, and policymakers. The event series will kickoff on Wednesday, April 16 from 10 a.m. – Noon EST.

Introduction

Clinicians and hospitals across the nation struggle with providing and paying for optimal care for their congestive health failure (CHF) patients. However, there are opportunities to make care better. In fact, of the more than 10,000 pages in the Affordable Care Act (ACA) implementing regulations, the least talked about are the dozens of small experiments led by the Center for Medicare and Medicaid Innovation (CMMI) that test new ways to pay for medical services.

We use a case study approach to investigate and tell the story of what two academic medical centers, Duke University Health System (“Duke”) and University of Colorado Hospital (“Colorado”), are doing to innovate and improve CHF care while implementing alternative payment models offered by CMMI. Read the rest of this entry »

The Case For Global Health Diplomacy


April 14th, 2014
by Bill Frist

At the end of February, I had the pleasure of speaking about global health diplomacy at the Nursing Leadership in Global Health Symposium at Vanderbilt University. Nurses are one of the specialties that we support in the Frist Global Health Leaders program facilitated by Hope Through Healing Hands, a nonprofit dedicated to advancing peace by supporting health care services and education in some of the world’s most vulnerable communities. Nurses, including the men and women I met at Vanderbilt, have an enormous opportunity to affect health and global health diplomacy. Indeed, everyone in the medical profession can play a crucial role in health diplomacy.

Global Health Diplomacy And Foreign Policy

For several years now I’ve been thinking about—and speaking about—global health diplomacy. The term started appearing around 2000 and has many definitions, representing the complexity of the issue itself. Diplomacy, at the simplest level, is a tool used in negotiating foreign policy. Health diplomacy is different, though. As a physician, the overall goal of health is clear: improve quality of life by improving health and meeting overall patient goals of care. As a diplomat and policymaker, the goal is more complicated.

Foreign policy, in general, is a dance—a negotiation of shared goals and identification of conflicts between nations, always with inherent tension. For example, what we want for the government of Afghanistan may not align with their complex political and cultural ideologies. Read the rest of this entry »

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