Blog Home

Archive for November, 2012




Report from New York State: What Is Ahead for Medicaid and Medicare?


November 30th, 2012

GrantWatch Blog invited this staffer from the Health Foundation for Western and Central New York to report on two community forums it held earlier this month in Buffalo and Syracuse. With the presidential election over and major provisions of the Affordable Care Act (ACA) going into effect just about a year from now, what does […]

Read the rest of this entry »

Trust But Verify: Why CMS Got It Right On EHR Oversight


November 30th, 2012

Yesterday’s New York Times headline read that “Medicare Is Faulted on Shift to Electronic Records.” The story describes an Office of Inspector General (OIG) report, released November 29, 2012, that faults the Centers for Medicare and Medicaid Services (CMS) for not providing adequate oversight of the Meaningful Use incentive program. Going after “waste, fraud, and abuse” always makes good headlines, but in this case, the story is not so simple.

For those not intimately familiar with the CMS policy, in 2009, Congress passed the Health Information Technology for Economic and Clinical Health (HITECH) Act. The program, administered through CMS and state Medicaid programs, created financial incentives for doctors (and other eligible professionals) and hospitals to adopt and “meaningfully use” a certified electronic health record (EHR). To receive financial incentives, which began to be paid in May 2011, doctors and hospitals “attest” that they have met the meaningful use requirements, providing an affirmation for which they are held legally accountable.

The process works as follows: health care providers visit a CMS website, register, and enter data demonstrating that their EHRs are “certified” and that they met each of the individual requirements for meaningful use. Then they attest that that all the data they entered is true. For example, a physician might have to report, to meet just one of the 20 meaningful use measures, how many prescriptions she wrote over the past 90 days, and how many she wrote electronically. My conversations with colleagues suggest that it can take a lot of time for providers to gather all the data they need to “attest” to meeting Meaningful Use. Then, CMS runs logic checks to ensure that the numbers entered make sense and, if there are no errors, they cut the provider a check. Through September, 2012, CMS paid out about $4 billion in incentives to 82,000 professionals and more than 1,400 hospitals.

Read the rest of this entry »

Health Affairs Resources On HIV/AIDS


November 29th, 2012

As we mark World AIDS Day and the Obama Administration releases its new “PEPFAR Blueprint,” Health Affairs Blog wanted to remind readers that the July 2012 issue of Health Affairs provides a comprehensive look at PEPFAR, the President’s Emergency Plan for AIDS Relief. The issue contains a wide array of articles by leading voices such as Ambassador Eric Goosby, the US Global AIDS Coordinator in the Department of State, Michael Merson, the founding director of the Duke Global Health Institute, and many others. Health Affairs also published a Health Policy Brief on PEPFAR to accompany the issue.


In addition, readers may view the release event for the July issue on the Health Affairs website. The briefing featured many of the authors from the issue as well as others such as Jim McDermott, the co-chair of the Congressional HIV/AIDS Caucus.

Read the rest of this entry »

A Call For Clarity In Health Care: The FAIR Health NPIC Database


November 28th, 2012

By all accounts, health care in America has been ailing for several decades. Americans have struggled with acquiring and maintaining adequate health insurance as costs have steadily increased. While the increased insurance coverage provided under the Affordable Care Act (ACA) will help individuals access and pay for health care services, the ACA’s impact on cost, which will be shifted but not eliminated, seems likely to be less substantial. Developing new approaches to rein in spending and improve the value of care delivery remains a critical challenge for all of the diverse players in the health care arena.

We know that there are a number of drivers of health care costs. New, more expensive medicines and technology — and particularly technology that brings with it only incremental benefits — are obvious factors. A related issue is the overuse and misuse of certain procedures and tests. Finally, the burden of treating a population with high rates of chronic illness brings with it significant costs and presents an increasing challenge as rates of chronic illness grow.

Putting clarity into the health care system. To truly bend the cost curve, we need to take a holistic approach. While the call for transparency in the health care system is a common one, we need to also be thinking about how we can move beyond transparency to insist on clarity across the health care system. Clarity is achieved by giving people information that they will find useful to their decision-making process and empowering them to act on that information. Such clarity must take place on two different levels: macro and micro.

Read the rest of this entry »

Narrative Matters: A Nurse Navigates Her Husband’s Care Transitions


November 27th, 2012

Following her husband’s stroke, it fell to Beth Ann Swan, a registered nurse and nursing school dean, to coordinate her recovering husband’s care and manage his transitions among several hospitals and home. Swan writes about her experience in the Narrative Matters section of the November Health Affairs.

Read the rest of this entry »

Resurrecting The Liberty ACA Challenge: Much Sound And Fury, But Likely Signifying Nothing In The End


November 26th, 2012

The Supreme Court created quite a stir on November 26, 2012, by resurrecting from the dead a challenge to the ACA brought by Liberty University. The Court vacated its earlier denial of Liberty’s petition for certiorari, vacated the 2011 judgment of the Fourth Circuit Federal Court of Appeals dismissing Liberty’s case for lack of jurisdiction, and remanded the case to the Fourth Circuit for further consideration in light of the Supreme Court’s June 28 National Federation of Independent Business decision.

It is important, however, not to read too much into this decision, however, which is likely to lead nowhere.

It is not uncommon for the Supreme Court to grant what are known as GVR (grant, vacate, and remand) orders in lower court cases following a major decision that changes the law. The Supreme Court granted nearly 800 of them between 2004 and 2006 following a major decision on criminal sentencing. The usual purpose of a GVR order is to allow the lower court to reconsider an earlier decision in light of a new Supreme Court opinion (or statute) that has changed or clarified the law on which its earlier decision was based.

Read the rest of this entry »

Profiles of the Ten Robert Wood Johnson Foundation Young Leader Awardees


November 26th, 2012

This post, by my colleague Chris Fleming, originally appeared on Health Affairs Blog, which is GrantWatch Blog’s “big sister” blog here at the journal. On November 21, Health Affairs released a series of Web First articles profiling the winners of the Robert Wood Johnson Foundation (RWJF) Young Leaders Awards, which were announced this Fall on […]

Read the rest of this entry »

Profiles Of The Robert Wood Johnson Foundation Young Leader Awardees


November 26th, 2012

On November 21, Health Affairs released a series of Web First articles profiling the winners of Robert Wood Johnson Foundation (RWJF) Young Leaders Awards, which were announced this Fall on the occasion of the Foundation’s fortieth anniversary. The RWJF Young Leader Awards highlight the important contributions that people can make early in their careers to improving health and health care for all Americans.

The awardees, all age forty or younger, have made exceptional contributions in a broad spectrum of activities that display their commitment to their communities:

Read the rest of this entry »

Implementing Health Reform: Wellness Programs And Medicaid FAQ


November 21st, 2012

On November 20, 2012, the federal government released a number of important and long-awaited proposed rules implementing the Affordable Care Act. Earlier posts examined proposed rules on market reform and rate review and essential health benefits, actuarial value, and accreditation. A third set of proposed regulations released by the Departments of Health and Human Services, Treasury, and Labor on November 20 relate to employee wellness programs. The agencies also released a study of wellness programs and a wellness program fact sheet.

Wellness programs are authorized under the Affordable Care Act as an exception to the general prohibition on health status underwriting. As of January 1, 2014, no health plan in any market will be able to underwrite based on health status. A limited exception, however, is authorized for wellness programs, which can grant rewards or impose surcharges based on an enrollee’s medical condition if certain requirements are met. This proposed rule sets out those conditions in greater detail.

Wellness programs were initially authorized by the Health Insurance Portability and Accountability Act of 1996. HIPAA prohibited group health plans from determining eligibility or varying premiums based on health status; however, it allowed premium discounts or rebates or modification of cost sharing of up to 20 percent of the cost of an employee’s coverage for participation in a health promotion or disease prevention program if certain requirements were met.

Read the rest of this entry »

People Post: Foundation Staff and Board News; IOM Lienhard Award to Berwick


November 21st, 2012

It’s a short holiday week. So, for some light reading, read this “people post.” You likely will recognize some of the names mentioned. Happy Thanksgiving! For more personnel news, watch for my January GrantWatch column (free access) in Health Affairs. In October 2012, Don Berwick, former administrator of the Centers for Medicare and Medicaid Services, received […]

Read the rest of this entry »

Implementing Health Reform: Essential Health Benefits, Actuarial Value, And Accreditation


November 21st, 2012

On November 20, 2012, the Departments of Health and Human Service, Labor and Treasury released a flood of proposed Affordable Care Act proposed rules and guidances. My first post examined the market reform proposed rules. This post discusses the essential health benefits, actuarial value, and accreditation rule, as well as guidance related to this rule.

These proposed rules and guidance supplement the initial set of exchange rules released in March. They put into proposed-rule form guidance that HHS had released earlier in 2012 with respect to the essential health benefits package and calculation of actuarial value. The proposed rule reflects the approximately 11,000 comments HHS received on its earlier essential health benefits bulletin. It also builds on a final rule HHS issued earlier this year addressing the collection of data elements required to support the essential health benefits standards and the recognition of accreditation entities.

There are few surprises in this proposed rule for those who have been following guidance issued to date on the issues it addresses. In general it reduces to rule form the literal requirements of the ACA. But it does give insurers additional flexibility on some issues, such as the coverage of habilitative services or setting deductibles for low actuarial value small-group plans. In other areas, the proposed rule gives consumers additional protections, such as access to a wider variety of prescription drugs.

Read the rest of this entry »

Implementing Health Reform: The Dam Bursts


November 21st, 2012

For months, states, insurers, and others who will be affected by the Affordable Care Act have been clamoring for more definitive guidance from the Department of Health and Human Services on many issues presented by ACA implementation. On November 20, 2012, the dam burst and a torrent of proposed rules, notices, data collection notices, and other forms of guidance poured out.

Proposed rules were published addressing the ACA insurance market reforms and rate review; essential health benefits, actuarial value, and accreditation standards; and wellness programs. An appendix to the essential health benefits rule was also published describing the essential health benefit benchmark plan for each of the fifty states, listing state benefit mandates (for purposes that will be discussed in my next post), and providing a guide to understanding the proposed state benchmark plans. The proposed wellness program rule was supplemented by a fact sheet and a study on current wellness programs.

HHS issued a letter to state Medicaid directors addressing the Medicaid essential health benefits, as well as a series of frequently asked questions addressing Medicaid issues presented by ACA implementation. HHS also published a notice recognizing the NCQA and URAC for accreditation of qualified health plans. HHS issued its actuarial value calculator and continuance tables and a description of its actuarial value calculator methodology. Finally, HHS published for comment a series of Paperwork Reduction Act listings addressing data collection for rate review, certification of qualified health plans, assessing market reform compliance, and recognizing accrediting entities.

The proposed rules on the market reforms and essential health benefits are subject to a 30-day comment period, while the wellness rule is open for comment for 60 days. This post will examine the market reform and rate review proposed rules. Additional posts will follow discussing the other proposed rules and guidances.

Read the rest of this entry »

At IHI Event, Discussion Of Trading Hospital Cost Reductions For Flexibility


November 20th, 2012

Hospitals have resigned themselves to an austere revenue environment but would like some things in return, Susan DeVore, president and CEO of the hospital and health systems alliance Premier Inc., said at “Out of the Blocks: Where Do We Go from Here?” a recent post-election conference convened by the Institute for Healthcare Improvement.

Premier members are not counting on revenue relief even with the Affordable Care Act’s Medicaid expansion and the arrival of the ACA’s state health insurance exchanges in 2014, DeVore said. “Many of them have already determined they are going to try to run their operations at Medicare rates; some of them are determining they’re going to run their operations at Medicaid rates,” DeVore told panel moderator Don Berwick, IHI’s former president and CEO and the former Administrator of the Centers for Medicare and Medicaid Services. Member hospitals are getting very tactical and very specific about ways to reduce costs, because “under any scenario the [needed] cost reductions are going to be very, very significant.”

“What requests would you have of the policymakers?” asked Berwick, who is now a senior fellow at the Center for American Progress. “What [other than revenue relief] would help you the most?” DeVore’s reply – “Oh my gosh, I have many requests” – generated laughter. “The regulatory environment: the certificate of participation requirements; the [health information technology] meaningful use definitions; the three-day hospital stay required before you can be paid by Medicare for skilled nursing — things that are just crazy and regulatory that get in the way of people being able to make changes.”

Read the rest of this entry »

The Million Veteran Program: Building VA’s Mega-Database for Genomic Medicine


November 19th, 2012

This year marks the fiftieth anniversary of Watson and Crick (and Wilkins) being named Nobel Prize recipients for discovering DNA, the genetic code. In the half century since, there has been an exponential growth of knowledge and accomplishment based on their findings. More recently, a confluence of scientific and technical advances have made possible vast progress in our understanding of human disease, its diagnosis, and the most effective treatment(s). Among these advances are genetic testing, high performance computing platforms, and the electronic health record (EHR), which together offer the possibility of clinically rich databases that link genetic information to treatment outcomes.

These and other advances have made it clear that the genetic predispositions to adult diseases are in many cases extremely complex. In its early phases, human genetics focused on single genes for single diseases that generally occurred in childhood; e.g., Tay-Sachs disease. The genomics of adult diseases—such as coronary heart disease—are associated with complexity resulting from multigene interactions and strong environmental influences (e.g., lifestyle and exposures), that may in some cases result in organ-specific “epigenetic” changes that modify DNA.

A prominent example of how these various factors come together can be seen by looking at diabetes. Having a gene associated with diabetes may modestly increase one’s chances of developing this condition from—let us say—6 to 12 percent. But whether diabetes actually results is influenced by additional factors, such as the sequences of other genes, environmental influences (such as diet and exercise), and age.

Read the rest of this entry »

Health Policy Brief: The Basic Health Care Program


November 16th, 2012

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation explores the issues surrounding the Basic Health Program, an option that states have under the Affordable Care Act to offer health insurance coverage for people whose family incomes are too high to qualify for Medicaid but fall below 200 percent of the federal poverty level.

This program would allow states to offer an alternative form of coverage that could cushion the effects of “churning”–that is, having a situation in which individuals’ and families’ incomes fluctuate, and they end up moving back and forth between Medicaid coverage and eligibility to purchase more costly private health insurance available through new state health insurance exchanges.

Read the rest of this entry »

Ten-Country Primary Care Survey: Progress In Health IT, Less Elsewhere


November 15th, 2012

Redesigning primary care is an integral part of health reforms in the United States and elsewhere. A new study, released today as a Web First by Health Affairs, reports the results of a survey of primary care doctors in the United States and nine other countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Switzerland, and the United Kingdom.

The survey, conducted between March and July 2012, found US and German physicians the most negative about their health care systems: only 15 percent of US and 22 percent of German practitioners thought their systems worked well. On the brighter side, the survey found that 69 percent of US doctors report the use of electronic health records, bringing use in the United States closer to the Netherlands, New Zealand, the United Kingdom, and Norway, all with near-universal capacity.

Read the rest of this entry »

After The Fall (Off The Fiscal Cliff)


November 15th, 2012

Republicans were handed a convincing defeat at the polls, not only losing the race for the presidency but also losing ground in the Senate. The good news for the country is that Republican leadership is not in denial. The day after the election, Speaker of the House John Boehner outlined a balanced approach for easing federal policy off the fiscal cliff. He offered a combination of revenue increases and spending cuts, with an emphasis on “real changes to the structure of entitlement programs.”

Two days later, President Barack Obama responded by offering his own balanced approach—more federal spending, lower taxes for everyone but the wealthy, and the certainty of much higher budget deficits for years to come unless the savings proposed by the president last February actually materialize. This draws the line where it was before the election, with no sign that this will lead to meaningful policy negotiations.

This seeming recalcitrance is likely the result of the irrational exuberance that often strikes newly elected officials. To paraphrase Alan Greenspan, irrational exuberance has unduly escalated the president’s political asset value. Contrary to his current stance, President Obama does not have a strong hand in the upcoming fiscal debate. If he wants to avoid a double-dip recession and leave a positive legacy, he will have to accept compromises and sell them to his Democratic colleagues in the Senate. That inevitably means health policy, including the Affordable Care Act (ACA), will be on the negotiating table.

Read the rest of this entry »

World Diabetes Day: Health Affairs Resources


November 14th, 2012

To mark World Diabetes Day, I wanted to call readers’ attention to the thematic issue on diabetes published by Health Affairs in January 2012. Much of the issue dealt with the diabetes crisis in the United States, but several articles dealt with the global diabetes epidemic. For example, K.M. Venkat Narayan of Emory University and colleagues argued for four “policy paradigm shifts” in the global battle against diabetes:

conceptually integrating primary and secondary prevention along a clinical continuum; recognizing the central importance of early detection of prediabetes and undiagnosed diabetes in implementing cost-effective prevention and control; integrating community and clinical expertise, and resources, within organized and affordable service delivery systems; and sharing and adopting evidence-based policies at the global level.

The issue also included a look at a diabetes pay-for-performance program in Taiwan. Interested readers can visit the Health Affairs website to view our briefing on the January issue.

Read the rest of this entry »

Elections Reveal America: Ten Takeaways From The 2012 Election


November 14th, 2012

Elections explain America. They tell us — they tell the world — who we are. And, of course, elections define government and power. The 2012 election may be especially significant. Let’s begin with the returns: President Obama won eight out nine swing states and 61 percent of the Electoral College; the Democrats took ten out of twelve contested Senate races for a ten-seat majority in the Senate; and the Republicans lost just seven seats in the House and maintain a solid 35-seat majority.

How does all that add up? Here are ten takeaways from 2012.

1. Barack Obama’s chance. Only four other Democrats have won back to back terms since the people started voting for presidents in 1824: Andrew Jackson, Woodrow Wilson, Franklin Roosevelt, and Bill Clinton. All four remade the Democratic Party. And the first three profoundly changed the United States. Now Barack Obama gets his turn.

Read the rest of this entry »

Provider Consolidation And Health Spending: Responding To A Growing Problem


November 14th, 2012

As the country faces the fiscal cliff and continued deficit challenges, controlling health care expenditures will require aggressive efforts. When we look at why costs are rising and what the remedies are, we need to examine carefully a growing and under-publicized phenomenon: provider consolidation and its role in rising prices. A new report by Catalyst for Payment Reform (CPR), an employer-led non-profit organization, describes the substantial impact this growing trend has on health care spending. Given that several aspects of health care reform indirectly and directly support consolidation, it is critical we understand this trend better and start discussing how to address it.

Health care spending is increasing, but not exclusively because patients are utilizing more, and more expensive, care. Unit prices for hospitals and doctors are rising also, driving spending up, and evidence is mounting that the major contributor is ongoing provider consolidation. By 2006, over 75 percent of U.S. metropolitan statistical areas (MSAs) had experienced enough hospital merger activity to be considered “highly consolidated.” Nationwide, payments to hospitals on behalf of the privately insured are an estimated 3 percent higher than they would be absent hospital consolidation. In some specific cases, prices have gone up as much as 50 percent post consolidation. For example, when two competing Northern California hospitals, Summit and Alta Bates, merged, prices increased between 28 and 44 percent.

Read the rest of this entry »

Click here to email us a new post.