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Archive for January, 2013




People Post: Promotions, a New CEO, and New Board Members at Foundations around the Country


January 31st, 2013

It is time for another People Post with news of comings and goings at foundations. Also, watch for more people news in my GrantWatch column in the February issue of Health Affairs—it will be released next week! Roger Fine, former corporate vice president and general counsel of Johnson & Johnson, has been elected chairman of […]

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Where Is Health Spending Headed? Some Reactions To The CMS Report


January 31st, 2013

For the third year in a row, national health spending in 2011 grew less than 4 percent, according to the CMS Office of the Actuary. However, the report said modest rebounds in pharmaceutical spending and physician visits pointed toward an acceleration of costs in 2012 and beyond. CMS’s analysts make much of the cyclical character of health spending’s relationship to economic growth and also forecast a doubling of cost growth in 2014 to coincide with the implementation of health reform.

This non-economist respectfully disagrees and believes the pause could be more durable, even after 2014. Something deeper and more troublesome than the recession is at work here. As observed last year, the health spending curve actually bent downward a decade ago, four years before the economic crisis. Health cost growth has now spent three years at a pre-Medicare (indeed, a pre-Kennedy Administration) low.

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Implementing Health Reform: Shared Responsibility Tax Exemptions And Family Coverage Affordability


January 31st, 2013

On January 30, 2013, the Departments of Treasury and Health and Human Services issued what I believe may be the last major set of proposed rules necessary to implement that 2014 Affordable Care Act reforms. The proposed rules define who is exempt from the ACA’s shared responsibility (individual mandate) tax, how eligibility for an exemption will be determined, and how the amount of the tax will be calculated and collected.

Treasury (the IRS) and HHS each play a role in defining exemptions and determining eligibility, so both are publishing distinct proposed rules simultaneously. The agencies also published a fact sheet and a question and answer sheet covering the proposed rules.

The Implications Of Unaffordable Family Coverage

Perhaps more importantly, Treasury also published on January 30 a final rule on what had been an unresolved issue involving premium tax credits. The final rule addresses the question of eligibility for premium tax credits when an employee has an offer of employment-based coverage. The ACA provides that an employee is not eligible for a premium tax credit if the employee is offered adequate and “affordable” employee coverage. “Affordable” employer coverage is defined by the ACA as coverage for which the employee is not required to pay more than 9.5 percent of modified adjusted gross household income.

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Reconsidering Primary Care: A View from a Foundation President


January 30th, 2013

The author is the president and CEO of the Blue Shield of California Foundation, a statewide funder located in San Francisco. Since the passage of the Affordable Care Act , there has been a persistent, urgent call to produce more primary care physicians. With many provisions of the health reform law to be implemented less […]

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Not Even Discussed In Private Rooms: Childhood Sexual Abuse and Abuse Survivors


January 30th, 2013

There is a health crisis in this country (as well as worldwide) that adversely affects one-fifth of the US population. Consequences of this crisis manifest in a wide variety of serious disease conditions. Physically it can exhibit as cancer and/or as any number of equally severe mental illnesses. Socially the disease is, in a word, criminality. Costs are estimated at over $100 billion per year, or similar to the annual expense of the war in Afghanistan. Investment in its prevention is estimated at a nickel on every $100 in research, compared to $2 for cancer. (See Note 1)

Despite considerable attention drawn to this issue this past year — the Surgeon General termed it an “epidemic” well over a decade ago — the crisis was not discussed during the presidential campaign. It remains largely ignored by the Congress (though just prior to adjourning sine die an innocuous bill to evaluate child welfare systems was passed), was unaddressed by the Affordable Care Act, and has been ignored as well to date by the Center for Medicare and Medicaid Innovation. “The leading journal of health policy thought and research,” Health Affairs, has never published on the topic.

The health crisis is child sexual abuse, which adversely affects the health status of 50 million survivors.

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On Workplace Wellness, Don’t Throw The Baby Out With The Bath Water: A Reply To Lewis And Khanna


January 29th, 2013

This commentary is in response to a January 16, 2013 Health Affairs Blog post entitled “Is It Time to Re-Examine Workplace Wellness ‘Get Well Quick’ Schemes?” by Al Lewis and Vik Khanna. After the initial blog appeared, my email box was filled with messages asking for a rebuttal to the initial posting, which, to many, seemed like a condemnation of the worksite health promotion (wellness) field and its lack of credibility and honesty in reporting program savings. Instead of just immediately posting a response, I called Al Lewis to discuss the value of worksite health promotion in order to “set the record straight.” It turns out that we agree on many issues but there are also differences.

We agree that there are unscrupulous wellness vendors who claim very large and often implausible savings from worksite health promotion programs. The return-on-investment (ROI) figures bantered about, sometimes as high as 10:1, are not credible. At the same time, I believe it would be wrong to “throw out the baby with the bath water.” In this case, the “baby” refers to well-designed, evidence-based, comprehensive, appropriately resourced, non-gimmick, and well-executed worksite health promotion programs.

Stated positively, good worksite programs deserve credit and should be supported by the business community, not condemned. This is because there is good and growing evidence, reported in a rigorous scientific literature, that “best-practice” worksite health promotion programs improve population health and save money for businesses. Savings are realized from lower health care cost trends, reduced absenteeism, and heightened worker productivity.

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A New Feature for Narrative Matters: The Policy Checklist


January 28th, 2013

Health Affairs readers may have noticed something a little different about the Narrative Matters essay in January’s issue. The essay, “To Fight Bad Suga’, Or Diabetes, My Neighborhood Needs More Health Educators,” by Joseph West of Sinai Urban Health Institute, is the first to include the Policy Checklist, a new feature that will accompany all of our Narrative Matters essays going forward.

The feature points readers to related readings, enacted or proposed legislation, current or planned governmental and private initiatives, and other resources that can help to round out perspectives on a given health policy issue. In the case of the checklist accompanying West’s essay, about the need for more community health workers to serve residents in one poor Chicago community devastated by diabetes, the checklist points to Affordable Care Act grants for outreach to medically underserved populations, community-based diabetes management projects like the CDC’s Project DIRECT, and Health Affairs papers on a national diabetes prevention strategy and on the measured benefits of community health workers.

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Implementing Health Reform: Health Reimbursement Arrangements And More


January 25th, 2013

The months of November and December of 2012 and January of 2013 have been a very busy season in the implementation of the Affordable Care Act. The Departments of Health and Human Services, Treasury, and Labor have released a series of proposed rules dealing with the market reforms, essential health benefits, actuarial value, employer responsibility, Medicaid eligibility, the exchanges, and other topics. Another proposed rule on the individual mandate requirement is under review at the Office of Management and Budget and should be released momentarily.


eleventh series of frequently asked questions addressing some seemingly small but important questions that have arisen concerning the ACA. Perhaps the most important, to my mind, involve the status post-2013 of stand-alone health reimbursement arrangements.

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Antibiotics: When Science And Wishful Thinking Collide


January 25th, 2013

Antibiotic resistance is a major concern confronting our health care system, and there is tremendous pressure on the Food and Drug Administration (FDA) to “do something” about it. Unfortunately, the FDA is responding by approving drugs that are likely to do more harm than good.

FDA advisory committees are supposed to provide independent advice from experts across the country, but recent meetings have left observers wondering whether too many FDA advisory committee members are providing neither scientific nor independent advice, and whether the committee process itself is fundamentally flawed. These concerns dovetail with essential questions about FDA objectivity and scientific judgment in its review of antibiotics.

For example, a few weeks ago, the FDA approved a new drug for multidrug-resistant tuberculosis (TB) — bedaquiline, to be sold under the name Sirturo — shortly after data reviewed by FDA scientists indicated a higher death rate for the new drug compared to the usual standard of care. The FDA’s Anti-Infective Drugs Advisory Committee had publicly reviewed the TB antibiotic on November 28, 2012.

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Health Affairs Briefing: New Era Of Patient Engagement


January 24th, 2013

You are invited to join us on Wednesday, February 6, when Health Affairs will hold a briefing to discuss its February 2013 issue, “New Era Of Patient Engagement.”

It is widely agreed that meeting the goals of the famed Triple Aim – better health, better health care and lower health care costs – will compel more and different responses from consumers and patients in a number of areas, and far more effort on the part of providers to share decision making and take other steps to more fully engage patients in their care. In this thematic issue of Health Affairs, authors from across the health care and policy spectrum explore the evidence on patient engagement; the challenges in changing the behavior of patients and providers; and the opportunities that exist to enhance patient engagement and activation in a transformed health care system.

Please join us for a briefing at the W Hotel Washington on February 6, 8:00 a.m. – 2:30 p.m., as we unveil the issue. The thematic volume and briefing received funding support from The Robert Wood Johnson Foundation, the Gordon and Betty Moore Foundation, PCORI, and the California HealthCare Foundation.

WHEN:

Wednesday, February 6, 201
8:00 a.m. – 2:30 p.m.

WHERE:

W Hotel Washington
515 15th Street NW (Metro Center)
Washington, DC

REGISTER NOW

GET MORE INFORMATION

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

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SCAN Foundation CEO Envisions Opportunity for Long-Term Care Solutions in New Commission


January 24th, 2013

This post first appeared on Health Affairs Blog on January 23. Great struggles sometimes result in unexpected opportunities.  In the waning moments of 2012, Congress remained in session to bridge partisan divides to solve the fiscal cliff impasse with the passage of the American Taxpayer Relief Act (ATRA). Signing the ATRA into law also achieved policy change on […]

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Creating Realistic Long-Term Care Solutions As Part Of The Entitlement Reform Debate


January 23rd, 2013

Great struggles sometimes result in unexpected opportunities. In the waning moments of 2012, Congress remained in session to bridge partisan divides to solve the fiscal cliff impasse with the passage of the American Taxpayer Relief Act (ATRA). Signing the ATRA into law also achieved policy change on items far beyond the tax code.

For example, the new law repealed the Community Living Assistance Services and Support (CLASS) provision in the Affordable Care Act, which would have created a new, national, voluntary, long-term care insurance product. Yet the problem of how to best finance and deliver care for our vulnerable loved ones has been looming for years and endures. As a much-needed acknowledgment of this, the Congress created a new Commission to propose policy solutions to address the long-term care challenges that a growing number of Americans face.

Given the sheer magnitude of this issue, the current political climate, and the short time span for turning around a meaningful legislative proposal (six months), the Commission’s charge is nothing short of colossal. However, its creation in the wake of the CLASS repeal is an important step towards system transformation that will enable Americans to age with dignity, independence, and choice. The Commission will consist of 15 appointees, nine Democrats and six Republicans, to be named in the next month, who will report back to Congress by the summer. They must devise a plan on the financing and delivery of a comprehensive and coordinated system that ensures available long-term services and supports for people in need today, and options for Americans to plan for their future needs.

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The Complex Economics Of Disease Prevention And Longevity


January 22nd, 2013

In August, the Center for Sustainable Health Spending (CSHS) was awarded a grant from the Robert Wood Johnson Foundation to, among other things, examine the relationship between disease prevention and health care costs. This project heightened my interest in the wonderfully-researched report from the Congressional Budget Office (CBO) entitled Raising the Excise Tax on Cigarettes: Effects on Health and the Federal Budget, and its excellent summary in the New England Journal of Medicine (NEJM).

The report was years in the making and is noteworthy for its original research and its thorough and insightful literature review. As the title suggests, its economic focus is on the federal budget. In some ways this is a very broad perspective as it brings into play smoking’s impact on employment and earnings (hence tax payments), as well as health care costs and Social Security payments. But in other ways it is quite narrow, being limited to federal revenues and costs. Before discussing this CBO report, and the complex economics of disease prevention and longevity it underscores, I’d like to create some context.

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Critiquing The Medicare Part D Low-Income Drug Rebate Proposal: A Response To Richard Frank and Jack Hoadley


January 18th, 2013

In a recent posting Richard Frank and Jack Hoadley argue in support of a proposal that would introduce Medicaid-style rebates into Medicare’s Part D drug program for the low-income subsidy population. The evidence argues against such a policy.

At the outset, however, it is important to note that we agree on the basic goal: a Part D program that displays effective cost containment in a very tight federal budgetary environment. The good news is that the existing program is quite successful in this regard. Since 2007 per capita costs in Part D have grown at a compound annual rate of 1.8 percent, while costs in Part A and B have grown at 3.6 percent and 3.7 percent, respectively. The program’s negotiated rebates between large purchasers and drug manufacturers, and the ability for consumers to compare plan prices and benefits, have resulted in lower than expected Part D spending overall. (In contrast, note that from 1990 to 2005, average annual drug cost growth in the Medicaid program was about 13.1 percent per year.)

What would the proposed policy do to improve on this record? Impose a rebate of $137 billion over the next 10 years (according to the Congressional Budget Office). On its face, imposing a Medicaid-style rebate to the low-income subsidy Part D population may sound appealing. Of course, just like the Medicaid rebate program, the Part D rebate proposal isn’t a market-driven negotiation between businesses seeking to serve a common market — it’s a government fiat.

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New in the Journal: Foundation Funding to Educate, Train, and Expand the Health Professions Workforce


January 18th, 2013

My GrantWatch column in the recently released January 2013 issue of Health Affairs focuses on the workforce and foundations’ efforts to strengthen it. The column provides a snapshot of what foundations around the United States are funding. A variety of funders are interested in health professions workforce topics. In my small sampling, it appears that […]

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Individual And Group Coverage Under The ACA: More Patches To The Federal-State Crazy Quilt


January 17th, 2013

Throughout the 2012 Presidential campaign, Republican contenders criticized the Affordable Care Act (ACA) as a “federal take-over of health care” for its promotion of national uniformity in health coverage and access. Yet long before passage, the architects of the ACA quickly rejected a federal single payor system, or even a federal public plan to complement the private sector plans due to forceful opposition to national reform. Instead, they traveled the only politically viable road to reform: maintaining the fragmented and complex system of health care coverage, where federal and state governments as well as the private sector play pivotal roles. The ACA’s expansion of coverage is accomplished by continuing and even increasing state oversight, reinforcing the private market, and involving both employers and individuals. As enacted, therefore, the ACA’s fragmented approach to health reform is clearly not a federal take-over.

As implementation unfolds, however, the ACA’s impact on the roles of federal, state, and private actors is uncertain. Given the statute’s ambitions and complexity, uncertainty may be inevitable. Nevertheless, recent developments demonstrate that implementation may bring surprising results which, at least in some instances, are both unintended and problematic. We address two that pose particular challenges to achieving the ACA’s goals of expanding and harmonizing coverage among and between states: 1) the establishment of state exchanges, and 2) the determination of essential health benefits. We will leave the related topic of legal challenges to the so-called “employer mandate” for future discussion.

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Health Wonk Review: The Inauguration Edition


January 17th, 2013

For the previous Health Wonk Review, Brad Wright chose a Baby New Year theme. However, there were some problems with the new beginning represented by the turnover from 2012 to 2103. For example, with the New Years fiscal cliff deal, one might have hoped that we would leave our budget crisis behind for a while and start with a fresh fiscal slate. But of course, that did not happen. Not only did we not escape our budget crisis, it multiplied into three crises: the debt ceiling, the still looming sequester, and the coming expiration of government funding –“The Trouble With Trillions,” one might say.

So I decided to give us a fresh chance at a new start by choosing an “Inauguration” theme for this Wonk Review, referring both to Monday’s celebration of a new presidential term but also to the word’s broader meaning of a formal beginning. And in the spirit of looking forward, we’ll lead with a post from Health Wonk Review cofounder Joe Paduda laying out his health policy predictions for the coming year. At Managed Care Matters, Joe offers five predictions, including these: most states will end up expanding Medicaid, and there will be a lot more mergers and acquisitions at the highest levels, among providers, health care systems, and payers.

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Serving Pregnant Women: An Upstream Approach to Preventing Cavities


January 16th, 2013

A foundation in Seattle that focuses on oral health has been working to go where their partners in health have long focused: on addressing the health of children before they are born. The mission of the Washington Dental Service Foundation is to prevent dental disease and improve overall health for residents of the state of […]

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Is It Time To Re-Examine Workplace Wellness ‘Get Well Quick’ Schemes?


January 16th, 2013

Editor’s note: Readers interested in sources listed as available from authors, or in other information relating to this post, may contact Al Lewis at alewis@dismgmt.com or Vik Khanna at vik.khanna.health@gmail.com.

Virtually unheard of thirty years ago, workplace wellness is now embedded in large self-insured companies. These firms pay their workers an average of $460/year to participate in worksite wellness programs. Further, wellness is deeply enough engrained in the public policy consciousness to have earned a prominent place in the Affordable Care Act, which allows large employers to tie a significant percentage of health spending to employee health behavior and provides direct subsidies for small businesses to undertake these workplace wellness programs.

Yet the implausible, disproven, and often mathematically impossible claims of success underlying the “get well quick” programs promoted by the wellness industry raise many questions about the wisdom of these decisions and policies. In this post, we lay out the evidence demonstrating that the industry consistently mis-measures and overstates the direct healthcare cost savings. We suggest several strategies to prevent this and to re-allocate wellness dollars from “get well quick” schemes to the much more challenging, but ultimately more rewarding, task of truly creating a culture of wellness, a workplace that can attract and retain healthier, presumably more productive, people than competitors do. There is no guarantee that strategy would work and no easy way to implement it, but clearly the easy approach isn’t working.

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Implementing Health Reform: Medicaid And Premium Tax Credit Eligibility And Appeals (Part II)


January 16th, 2013

Editor’s note: This post discusses the second half of a January 14 proposed rule addressing Medicaid and premium tax credit eligibility and appeals, as well as other subjects, under the Affordable Care Act. The first half of the rule was analyzed in a post yesterday.

CHIP And Medicaid Coordination With The Exchanges For 2013

Open enrollment will begin in the exchanges on October 1, 2013, for coverage beginning January 1, 2014. To ensure seamless streamlined eligibility, state Medicaid and CHIP agencies must also be ready to accept Medicaid and CHIP applications and electronic accounts from the exchanges as of that date. They must also begin accepting Medicaid determinations made by the exchange as of that date, to be effective on January 1, 2014, or be capable of making their own determinations based on information received from the exchanges by that date.

Medicaid agencies must be capable of making MAGI-based determinations by October 1, whether or not they expand adult Medicaid coverage. (MAGI stands for “modified adjusted gross income.”) State Medicaid agencies must also begin transferring to the exchange electronic accounts of applicants who are not eligible for Medicaid but may be for premium tax credits as of October 1, 2013. States are encouraged, but not required, to determine 2013 eligibility based on the single streamlined application submitted after October 1, 2013. HHS is still considering to what extent states will have to implement 2014 changes for the 2013 open enrollment period, and may consider 1115 waiver requests to allow states to apply MAGI-based standards beginning on October 1, 2013.

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