From The Staff

The Latest Health Wonk Review


August 15th, 2014

At Wright on Health, Brad Wright offers some health policy insight in his August recess edition of the Health Wonk Review. Brad highlights the Health Affairs Blog post by Jon Kingsdale and Julia Lerche on the “one-two punch” threatening the ACA’s second open enrollment period, as well as a variety of other great posts.  Read the rest of this entry »

Health Affairs Web First: Small Medical Practices Had Fewer Preventable Hospital Admissions


August 14th, 2014

The Affordable Care Act and other federal policy initiatives have created incentives for smaller practices to consolidate into larger medical groups or be acquired by hospitals. It is often assumed that larger practices provide better care. However, a new study, recently released as a Web First by Health Affairs, showed unexpected results: Practices with 1-2 physicians had 33 percent fewer preventable hospital admissions than practices with 10-19 physicians.

This study, which used data from the National Study of Small and Medium-Sized Physician Practices (NSSMPP) and surveyed 1,745 physician practices between July 2007 and March 2009, is believed to be the first of its kind in the United States. The study sample was limited to practices where at least 60 percent of the physicians were primary care providers, cardiologists, endocrinologists, and pulmonologists. Read the rest of this entry »

New Health Policy Brief: Interoperability


August 13th, 2014

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) looks at the issue of health information exchange. The Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law at the very beginning of the Obama administration, bringing with it significant investments in health information technology (IT)—$26 billion to date.

While the adoption of electronic health records (EHRs) has increased considerably since 2009, there is very little electronic information sharing among clinicians, hospitals, and other providers. New models of care delivery, designed to improve quality and reduce costs, require both interoperable EHRs and electronic information sharing to be effective. This Health Policy Brief looks at the efforts the federal government has made to improve interoperability and increase the level of electronic information sharing, as well as the barriers to achieving these goals.

Topics covered in this brief include: Read the rest of this entry »

Health Affairs Web Firsts: Two Studies Find Mixed Results On EHR Adoption


August 11th, 2014

Since the Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted in 2009, Health Affairs has published many articles about the promise of health information technology and the challenges of promoting broad adoption and “meaningful use.”

Last week, on August 7, the journal released two new Web First studies, “More Than Half Of US Hospitals Have At Least A Basic EHR, But Stage 2 Criteria Remain Challenging For Most” and “Despite Substantial Progress In EHR Adoption, Health Information Exchange And Patient Engagement Remain Low In Office Settings.” These studies focus on the latest trends in health information technology adoption among U.S. physicians and hospitals. Both studies, which will also appear in the September issue of Health Affairs, show that while basic electronic health record (EHR) adoption plans have moved forward, more significant implementation remains a daunting challenge for many providers and institutions. Read the rest of this entry »

Narrative Matters: How Acute Care Training Is Failing Patients With Chronic Disease


August 8th, 2014

In the August Health Affairs Narrative Matters essay, a doctor questions how well acute care medical training serves those with chronic disease while watching the decline of two patients with kidney failure, one healthier and one frail. Dena Rifkin’s article is freely available to all readers, or you can listen to the podcast. Read the rest of this entry »

Posts On ACA Legal Challenges Lead Health Affairs Blog July Top Ten


August 7th, 2014

Two posts regarding legal challenges to the Affordable Care Act were the most-read Health Affairs Blog posts in July. In the top spot: Tim Jost’s discussion of Supreme Court actions that were arguably at odds with the Court’s Hobby Lobby decision. Next on the list: another post by Jost analyzing two federal appellate court decisions taking conflicting positions on whether consumers may receive premium tax credits under the ACA in states using the federally facilitated exchange.

Number three on the July top-ten list is Suzanne Delbanco’s post on bundled payment, part of her ongoing series on payment reform; Jennifer DeCubellis and Leon Evans’ post on investing in care coordination is next.

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

Health Affairs August Issue: Variations In Health Care


August 4th, 2014

Health AffairsAugust variety issue includes a number of studies demonstrating variations in health and health care, such as differing obstetrical complication rates and disparities in care for diabetes. Other subjects in the issue include the impact of ACA coverage on young adults’ out-of-pocket costs; and how price transparency may help lower health care costs.

For mothers-to-be, huge differences in delivery complication rates among hospitals.

Four million women give birth each year in the United States. While the reported incidence of maternal pregnancy-related mortality is low (14.5 per 100,000 live births), the rate of obstetric complications is nearly 13 percent.

Laurent Glance of the University of Rochester and coauthors analyzed data for 750,000 obstetrical deliveries in 2010 from the Healthcare Cost and Utilization’s Nationwide Inpatient Sample. They found that women delivering vaginally at low-performing hospitals had twice the rate of any major complications (22.55 percent) compared to vaginal deliveries at high-performing hospitals (10.42 percent). Read the rest of this entry »

Five Engagements That Will Define The Future Of Health


July 31st, 2014

I recently had the pleasure of opening and moderating the first day of the 2014 Colorado Health Symposium, which had as its theme “Transforming Health: The Power of Engagement.”  I found thinking about engagement, well, engaging, and in this post I summarize the keynote presentation I gave at the conference.

Engagement has many meanings, including some negative ones (such as “a hostile encounter between military forces”).  I focused on engagement as “emotional involvement or commitment” and described five engagements that will define the future of health. Read the rest of this entry »

Exhibit Of The Month: A Big Data Understanding Of Health Care Trends


July 30th, 2014

Editor’s note: This post is part of an ongoing “Exhibit of the Month” series. Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

This month we look at two exhibits from “Four Health Data Networks Illustrate The Potential For A Shared National Multipurpose Big-Data Network,” published in the July issue of Health Affairs.

These exhibits demonstrate how the effects of expanding health data availability and processing have the potential to dramatically alter our understanding of trends in the health care environment.

Emerging programs, such as the Food and Drug Administration’s Mini-Sentinel presented here, collect data from disparate and otherwise uncoordinated sources, which can also be made available for research purposes. Programs such as Mini-Sentinel are able to layer data, in this case from health care provider data from a single period, but collected over time: Read the rest of this entry »

Recent Health Policy Brief: Site Neutral Payments


July 28th, 2014

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) describes the different proposals designed to eliminate differences in Medicare’s payment systems that depend on where care and services are delivered. Currently, services that can be provided in a variety of clinical settings may sometimes be paid for at dramatically different payment rates.

Recently, the Centers for Medicare & Medicaid Services (CMS) and the Medicare Payment Advisory Committee (MedPAC) proposed eliminating this differential payment for certain services. This brief explains the origin of these differential payments and the debate over approaches that have been proposed for developing so called “site neutral” payments.

Topics covered in this brief include: Read the rest of this entry »

Contributing Voices

Whither CHIP?


August 19th, 2014

In a day all but lost to Affordable Care Act prehistory, on November 7, 2009, the House of Representatives passed the Affordable Health Care for America Act. Among the bill’s many differences with its Senate counterpart, it would have allowed the Children’s Health Insurance Program (CHIP) to expire at the end of 2013, with children covered under that program enrolled in either Medicaid or commercial Exchange plans.

On December 24, the Senate passed the Patient Protection and Affordable Care Act (ACA). Their bill extended CHIP through fiscal year 2015 while, curiously, enhancing the Federal match rate for the program beyond that date and instituting a maintenance of effort (MOE) requirement for states to keep CHIP kids covered through 2019.

At the time, drafters of the respective chamber’s versions of health reform anticipated heading to conference to negotiate and resolve their differences, with the disposition of CHIP one of the top considerations. Read the rest of this entry »

It’s Hard To Be Neutral About Network Neutrality For Health


August 18th, 2014

Note: In addition to Mark Gaynor, this post is also coauthored by Leslie Lenert, Kristin Wilson, and Scott Bradner. 

Network Neutrality (NN) has been in the news because the FCC is considering two options related to a neutral Internet: either regulation forcing NN, or an approach that creates a “fast lane” on the Internet for those content providers that are willing to pay extra for it.

Network Neutrality reflects a vision of a network in which users are able to exchange and consume data, as they choose, without the interference of the organization providing the network basic data transport services. The second option, preferential service, entertains the possibility that the Internet could become what the National Journal describes as “a dystopia run by the world’s biggest, richest companies.”

However, the problem of network neutrality is more complex. Full network neutrality could also lead to a tragedy of the commons in which application developers compete for the use of “free” bandwidth for services to win customers while clogging networks and lowering performance for all. Key stakeholders providing basic transport Internet service such as Comcast, Verizon, or AT&T, and large Internet savvy content providers like Google have a clear understanding of the debate and what they stand to gain or lose from network neutrality. Read the rest of this entry »

Spokane County: A Community Comes Together To Improve Health And Education For Every Child


August 18th, 2014

Editor’s Note: This post is part of an ongoing series written for Health Affairs Blog by local leaders from communities honored with the annual Robert Wood Johnson Foundation Culture of Health Prize. In 2014, six winning communities were selected by RWJF from more than 250 applicants and celebrated for placing a priority on health and creating powerful partnerships to drive change. Interested communities are encouraged to apply for the 2015 RWJF Culture of Health Prize. Applications are due September 17, 2014.

Spokane County is a metro area of more than 470,000 people, yet it’s still driven by the spirit of a small town. That sense of community is an essential part of the county’s ongoing work to improve the health of all residents by focusing on education.

In 2006, Spokane Public Schools’ high school graduation rate was less than 60 percent overall, while Spokane County’s rate was 72.9 percent. Spokane County educators were increasingly concerned about the future health and well-being of the county’s children, especially the 18 percent living in poverty. Read the rest of this entry »

Remembering Jessie Gruman


August 15th, 2014

Jessie Gruman, founding president of the Center for Advancing Health, died on July 14 after a fifth bout with cancer. Jessie was a hero to patients, families, and health care providers for her selfless work to help people better understand their role and responsibilities in supporting their own health.

Jessie was an extraordinary soul and a pioneering activist in the person-centered care movement. She used her personal experience with illness to inspire a life’s work aimed at developing practical resources that support peoples’ engagement with their health care. She improved care and improved lives.

Jessie was first diagnosed with cancer at the age of twenty. She was thrown into a world that spoke in a foreign tongue: “medicalese.” She was expected to self-administer a complex medication regime, which she openly admits she sometimes skipped. Jessie described the hard-working health care professionals who fought to make her better all relying on her, a scared twenty-year-old, to understand what they said and implement their plan. She realized the enormous power of people who are engaged in their own health, while also recognizing the challenges to such engagement. Read the rest of this entry »

Hospital Readmission Reduction Program Reignites Debate Over Risk Adjusting Quality Measures


August 14th, 2014

Note: In addition to Eva DuGoff, Shawn Bishop and Purva Rawal also coauthored this post. 

Do safety net hospitals categorically under perform the national average in terms of managing readmissions? Or is something else triggering higher rates of readmissions in these facilities?  These questions are essential for policymakers to answer as pay-for-performance (P4P) penalties are having a disparate impact on hospitals that serve low-income areas.

Medicare’s Hospital Readmission Reduction Program (HRRP), for example,  links risk-adjusted hospital readmission rates to financial penalties. Hospitals with risk-adjusted readmission rates that fall below the national average are penalized by having their annual Medicare payments reduced by up to 2 percent. In 2015, hospital payments are scheduled to be reduced by up to 3 percent.

But the program’s current system for measuring readmission rates may be flawed. Numerous analyses have found that safety net hospitals, which care for low-income patients, are more than twice as likely to be penalized than hospitals caring for higher-income patients. Read the rest of this entry »

Key Takeaways From The Medicare Trustees’ Report


August 14th, 2014

Note: In addition to Keith Fontenot, Kavita Patel also coauthored this post. 

Depending on which article you read, either the Medicare Trustees think the program is coming to an end, or the news is great and we don’t need to do anything.

The reality is that the recent Trustees’ report contains both positive and sobering news: while costs have been flat for the last two years and growth is expected to moderate for some years to come, Medicare’s financing is still not in good shape over the long run. Current law benefits exceed financing to pay for them, and the Hospital Insurance Trust Fund will be unable to pay full benefits in 2030.

We cannot assume the problem will resolve itself, and action is needed to ensure the program’s stability.  Moreover, health care remains a substantial portion of the national budget – a whopping 25 percent — and addressing federal fiscal imbalances must include health programs.

Below we provide our key takeaways from this year’s Trustees’ report. Read the rest of this entry »

Implementing Health Reform: ACA-Related Litigation, Special Enrollment Periods, And Navigator Certification And Training (Updated)


August 13th, 2014

Update, August 17, 2014: Navigator, non-navigator assister, and certified application trainer certification and training. Navigator grants for 2013-2014 expired on August 14, 2014.  Grant awards for 2014 will not be announced until September 8, 2014.  In the interim, consumers continue to need assistance with signing up for special enrollment periods and for sorting out ongoing issues with the marketplaces.  Navigators and certified application counselors (CACs) must also be trained and certified for 2015. On August 15, 2014, the Centers for Medicare and Medicaid Services issued a bulletin outlining certification and training requirements for navigators, non-navigator assisters, and CACs for 2015, as well as provisions for interim navigator certification of the fall of 2014.

CMS regulations require all navigators in the federally facilitated marketplace to obtain continuing education and to be recertified on at least an annual basis.  Navigators are certified by CMS.  Navigators who completed training during the 2013-2014 grant period were certified through August 14, 2014.  Some navigator programs received a no-cost extension of their 2013 grant.  (A no-cost extension is “a noncompetitive extension of time to the final budget period of a competitive segment, without additional Federal funds, to complete the work under a grant or avoid a hiatus while a competing continuation application is under consideration.”) CMS will issue provisional certificates lasting from August 14 to November 15, 2014, to eligible staff of no-cost-extension navigator programs who wish to continue to carry out navigator functions.  Provisionally certified staff must complete 2015 training by November 15 to remain certified, but are encouraged to complete it sooner.

Navigators with new navigator programs must complete the 2015 navigator training program before they can begin assisting consumers.  Individual navigators with 2013 programs that did not receive a no-cost extensions must cease providing services as of August 14, 2014.  They may not begin providing services until they complete navigator training and are certified for 2015, and then only if their program receives a 2014-2015 program grant. Read the rest of this entry »

The Evolution Of A Two-Tier Health Insurance Exchange System


August 13th, 2014

Note: In addition to Rosemarie Day, this post is also coauthored by Pamela Nadash and Angelique Hrycko.

Health reform has been a catalyst for change. It has fostered the creation of public health insurance exchanges and accelerated existing trends in health insurance coverage for employees. Many employers are reevaluating their coverage offerings, some employers are no longer providing insurance coverage, and, among those who continue to offer it, high deductible plans with restricted networks are becoming the norm.

In addition, employers are increasingly outsourcing health insurance benefits management by moving employees to private health insurance exchanges – often in combination with a shift toward a defined contribution approach. Estimates vary, but surveys show that anywhere from 9 to 45 percent of employers plan to implement private exchanges in the future.

Accenture (see Figure 1) has predicted that by 2018, private exchange enrollment will outpace public exchange enrollment. Read the rest of this entry »

Better Measurement Of Maternity Care Quality


August 12th, 2014

A thought-provoking paper published this month in Health Affairs shows stunning variation in rates of obstetrical complications across U.S. hospitals. This type of research is important and necessary because focusing on averages masks potentially large differences in how patient care is provided and how clinical decisions are made.

From a policy perspective, it’s crucial to identify and learn from hospitals that are “positive deviants,” that is – hospitals with better-than-expected quality of care. From a pregnant woman’s perspective, having information on hospital rates of hemorrhage, infection, or laceration during childbirth is a high priority.

Authors Laurent Glance and colleagues add to a growing literature on variation in hospital-based maternity care. Having useful quality measurement and reporting strategies to guide policy and patient decisions is an essential next step. Indeed, Glance and colleagues conclude by urging clinicians and policymakers to “develop comprehensive quality metrics for obstetrical care and focus on improving obstetrical outcomes.” Read the rest of this entry »

Implementing Health Reform: Medicare And The ACA Marketplaces (Updated)


August 12th, 2014

Editor’s note: This post was updated on August 12, 2014 to discuss steps by the federal government to resolve inconsistencies in immigration and citizenship status for some enrollees in qualified health plans offered in the federally facilitated marketplace, and on August 15 as reflected immediately below.

August 15, 2014 update: On August 13, 2014, CMS released Bulletin 11, which informs qualified health plan insurers in the individual market federally facilitated marketplace how to handle individuals who are determined not qualified to enroll in qualified health plans because of data matching issues.   If individuals from whom documentation has been requested to verify information on their applications fail to submit this documentation on time (by September 5), their eligibility will be determined based on information that CMS has available in trusted electronic data sources.  This may result in termination of qualified individual status if the issue is citizenship or lawful residence status, since an unlawful resident does not qualify for marketplace coverage.

In these cases, marketplace coverage will end on the last day of the month during which CMS determines that the individual is not qualified.  The individual will be directed to its QHP insurer to request coverage outside the marketplace without premium tax credits or cost-sharing reduction payments.  He or she will qualify for a special enrollment period based on loss of coverage or change in eligibility for premium tax credits.  The insurer is encouraged to work with the individual to avoid gaps in coverage and to credit any amounts paid toward deductibles or out-of-pocket limits for the individual’s coverage outside the marketplace.

If some members of an enrollment group remain eligible for coverage (for example, because one member of a family is determined ineligible but the remaining members are qualified), marketplace coverage should continue for the remaining family members.  Any amounts previously paid by the member who is removed should be credited toward the deductible and out-of-pocket limits of those members remaining.  If the members of the family that remain eligible do not qualify for the QHP in which they were enrolled, they must be given a special enrollment period to enroll in a QHP for which they are eligible.

If individuals are determined not to be qualified individuals because requested documentation was not received in a timely manner, they can reenroll with retroactive coverage within 60 days if they attest that they in fact submitted documentation on time and are in fact subsequently determined eligible.  They will not be penalized due to time lags in mailing or processing of documents.  If an individual does not submit documentation on time, but does so within 60 days after termination, and the individual is subsequently determined eligible, the individual will be given a special enrollment period to reenroll, although coverage will not resume until the first day of the month following plan selection.  The insurer is expected to apply any amounts previous paid toward the deductible and out-of-pocket limits of the coverage in which the individual enrolls during the special enrollment period.

Original post. On August 1, 2014, the Centers for Medicare and Medicaid Services released a set of frequently asked questions on the relationship between Medicare and the marketplaces. This is not the first guidance CMS has published on this topic, and much of the information in the FAQ was already available. The FAQ is also quite repetitive, as it answers the same questions under different headings, such as “general enrollment FAQs” and “consumer messaging,” but does contain useful information. This post briefly summarizes the FAQ.

The FAQ emphasizes the fact that Medicare and marketplaces operate independently, with little overlap. The marketplaces do not enroll individuals in Medicare or in Medicare Advantage plans and do not sell Medicare supplement plans. Indeed, exchanges cannot legally sell coverage to Medicare beneficiaries. Read the rest of this entry »

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