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Archive for February, 2013




Health Affairs Web Firsts: Primary Care Shortages And Rx Drug Monitoring


February 28th, 2013
by Chris Fleming

Primary care access. With insurance coverage set to expand under the Affordable Care Act (ACA), 44 million people live in areas where the projected increase in demand for primary care providers is greater than 5 percent of current baseline supply. Of those, seven million people live in areas where demand for primary care providers will exceed supply by more than 10 percent, Elbert Huang and Kenneth Finegold write in a February 20 Health Affairs Web First study.

With the national average for this shortage expected to be in the range of 1.5-2.4 percent, the findings of this study emphasize the need to promote policies that encourage more primary care providers to practice in areas where shortages will be exceedingly high, say Huang, an associate professor at the Pritzker School of Medicine at the University of Chicago, and Finegold, an analyst in the Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services.

Rx drug monitoring. A February 13 Health Affairs Web First study finds that prescription monitoring programs, although originally designed to help law enforcement and regulatory agencies spot possible illegal activity, are now also helping health care providers improve patient safety and quality of care.

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Health Policy Brief: The CO-OP Health Insurance Program


February 28th, 2013
by Chris Fleming

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation discusses the Consumer Operated and Oriented Plan (CO-OP) program, a provision of the Affordable Care Act. Starting in October, many Americans will be able to enroll in health plans through the health insurance exchanges in their states. Recognizing that in some states a person’s options for insurance plans may be limited, the CO-OP program was designed to increase competition among health plans and improve consumer choice by creating new, nonprofit insurance plans governed by consumers. The federal government has awarded nearly $2 billion in loans to help create 24 new CO-OPs in 24 different states.

This policy brief describes the rationale for creating the CO-OP program and the way the program will be structured. It also lists some of the plans approved thus far. Other topics include:

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Howard Koh On Health Literacy: Proposing A New Model Of Care


February 28th, 2013
by Chris Fleming

Health literacy is the essential backbone of informed patient engagement, said Howard Koh, Assistant Secretary for Health at the Department of Health and Human Services, at a February 6 Health Affairs briefing. The event was held to unveil the journal’s February issue, “New Era Of Patient Engagement.”

Health literacy is particularly important now as tens of millions of Americans are faced with new choices about coverage and treatment under the Affordable Care Act, said Koh, a physician who also has a master’s degree in public health. Yet only about 12 percent of Americans have the skills necessary to navigate the health care system, leaving the vast majority of Americans at greater risk for unnecessary hospital admissions and readmissions, medication errors, and failure to manage their health conditions effectively.

Physicians and other health care providers often assume that patients understand what they are told unless they indicate otherwise, Koh noted. But the health system has gotten so complex that it challenges the comprehension even of sophisticated patients. The answer is to change the paradigm from a focus on correcting individual deficits in understanding to a systems approach: “The assumption is that everybody is at risk for not understanding, and that we should institute what we call ‘health literacy universal precautions.’”

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The Evolution of Health Philanthropy—What Next?


February 28th, 2013
by Faith Mitchell

The author is the new president of Grantmakers In Health, an organization of health funders. It is based in Washington, D.C. In the past thirty years, health philanthropy has undergone major changes, and the field continues to evolve. In its role of advising and informing health funders, Grantmakers In Health (GIH) has been an active […]

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A Health Care Entitlement Worth Ending


February 27th, 2013
by Arthur Kellermann

The “fiscal cliff” deal raised taxes on households earning more than $450,000 a year and sheltered everyone else from an automatic income tax increase. Tough decisions about spending were put off until March 1, the new deadline by which Congress must take deficit-cutting action if it is to avoid automatic across-the-board sequestration cuts.

As both sides return to the negotiating table, one of the biggest bones of contention is what to do about entitlement spending, particularly Medicare. Many Republicans want to raise the age of Medicare eligibility to 67. President Obama and congressional Democrats do not.

It will be difficult, if not impossible to meet a reasonable fiscal target without addressing federal health care spending. However, the current fight is misplaced. The health care “entitlement” we need to reform is the notion that America’s health care system is entitled to an ever-growing share of America’s wealth.

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From The Health Affairs Archives: An Interview With C. Everett Koop


February 27th, 2013
by Chris Fleming

In 2004, Health Affairs’ Fitzhugh Mullan interviewed C. Everett Koop, who passed away on Monday. The full interview is freely available to all readers, as is a 1998 Health Affairs article coauthored by Dr. Koop evaluating health education programs designed to reduce health risks and costs. Health Affairs Blog will carry more about Dr. Koop’s life and work in the coming days.

Koop is probably best-known for his pioneering work as Surgeon General under President Ronald Reagan, but his interview with Mullan begins with a discussion of children’s health, reflecting Koop’s role in helping to found the discipline of pediatric surgery. Koop sounds a warning about the nation’s treatment of its children. “We always talk about children being our future,” he notes,

but I’m afraid we don’t always deliver … the older I get, the more I understand the relationship of poverty in a child and poor outcomes in everything else. I’m not beating a socialist kind of drum here. I think as we look to the future, unless we take into account what a severe role poverty plays in the lives of many children, we will never be able to achieve good child health in the United States.

Since children can’t vote or lobby as seniors do, “In the long run, child health is about advocacy,” says Koop, who also highlights the challenge of pediatric obesity.

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Not In My Name: Real Patient-Centeredness Means Sharing Power


February 26th, 2013
by Michael Millenson

It is as natural for doctors, hospitals, health plans and others to aggressively affirm their “patient-centeredness” as it is for politicians to loudly proclaim their fealty to the hard-working American middle class. Like the politicians, the health care professionals no doubt believe every word they say.

The most accurate measure of “patient-centered” care, however, lies not in intentions but implementation. Ask one simple question ­– what effect does this policy have on patients’ ability to control their own lives? ­­­– and you start to separate the revolutionary from the repackaged. “A reform is a correction of abuses,” the 19th-century British Parliament member Edward Bulwer-Lytton noted. “A revolution is a transfer of power.”

With that in mind, which purportedly patient-centric policy proposals portend a true power shift, and which are flying a false flag?

Falling Short Of Shifting Power

The two most prominent examples of initiatives whose names suggest power sharing but whose reality is quite different are so-called “consumer-driven health plans” (CDHP) and the “patient-centered medical home” (PCMH). Both may be worthy policies on their merits, but their names are public relations spin designed to put a more attractive public face on “defined contribution health insurance” and “increased primary-care reimbursement.

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Now For The Rest Of The Story On Massachusetts Cost Control


February 25th, 2013
by Josh Archambault

A bureaucracy-centric governing philosophy is spreading in health care, and with it comes heavy reliance on “experts” to determine how to curb costs outside the normal legislative and democratic process. This was embodied at the national level by the Affordable Care Act (ACA), and most recently at the state level in a new Massachusetts growth-capping […]

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Implementing Health Reform: The Final Market Reform Rule


February 23rd, 2013
by Timothy Jost

The time is quickly approaching when health insurers must file the rates and forms they will need to put in place for 2014. The Department of Health and Human Services is rapidly releasing the final rules that insurers will need to determine the coverage and price of those plans, and that the states and exchanges will need to approve or disapprove them. On February 22, 2013, HHS released the final market reform regulations, which establish the ground rules under which insurers will market their products in the reformed health insurance market. (The fact sheet is here.)

Whereas health insurance underwriting in the individual and small group market is currently based heavily on health status and gender, health insurers in the reformed market will only be able to consider age, tobacco use, geographic area, and family unit size in setting premiums. Insurers will also have to guarantee the availability and renewability of coverage. Proposed rules implementing these reforms were published on November 26, 2012 and were covered by this blog. This post discusses the final version of these rules.

On February 22, 2014, the Department of Labor also issued interim final regulations on procedures for addressing complaints by employees that they have suffered retaliation from their employers because they reported violations of the ACA’s consumer protections, or because they have received advance premium tax credits. (See the press release here.)

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The US Health Disadvantage And Clinicians: An Interview With Paula Braveman


February 22nd, 2013
by Rishi Manchanda

The US spends far more per person on health care than any other nation. But a growing body of research demonstrates that Americans – rich or poor, minority or not – suffer from a widening “health disadvantage” when compared to citizens of other high-income countries. On January 9, the Institute of Medicine (IOM) and the National Research Council released “U.S. in International Context: Shorter Lives, Poorer Health.” Commissioned by the National Institutes of Health, a panel chaired by Professor Steven H. Woolf at Virginia Commonwealth University painstakingly investigated whether Americans of all ages were affected by a growing health gap previously observed between older Americans and their foreign counterparts.

The panel examined several decades of data from the US and 16 comparable high-income countries, most of which are European. What they found is, or should be, alarming, even for seasoned health advocates and policymakers. The report’s authors sound the alarm at the outset: “We uncovered a strikingly consistent and pervasive pattern of higher mortality and inferior health in the United States, beginning at birth.”

What does this report mean for clinicians and health systems, especially at a time when doctors, nurses and other health care professionals are adjusting to a shifting landscape of structural reforms? Is this a clarion call for clinicians, educators and policymakers to engage in realigning the way we deliver care? Or will this news drive clinicians to sound a retreat from the front lines of population health-oriented system change?

On January 11, two days after the release of the IOM report, I talked with one of the IOM panelists behind the report, Paula Braveman MD MPH, Professor of Family and Community Medicine and Director, Center on Social Disparities in Health at UCSF. I spoke with her on behalf of HealthBegins, a social enterprise and online community of clinicians and others committed to improving health care and the social determinants of health. We discussed the report and what it means for America’s clinicians.

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Medicaid Expansion: Benefits For Women of Childbearing Age And Their Children


February 22nd, 2013
 
by Cynthia Pellegrini and Nicole Garro

States are in the midst of deciding whether and how to expand their Medicaid programs to nonelderly individuals with income below 133 percent of Federal Poverty Level (FPL), as permitted under the Affordable Care Act (ACA). The group that perhaps stands to benefit the most from Medicaid expansion is women of childbearing age and their future children.

One of the ACA’s main goals was to address the upstream determinants of health, shifting the focus of the health care system “sick care” to “well care.” However, the promise of preventive care will not be realized if women of childbearing age are denied access to health insurance coverage. Medicaid expansion has the potential to drive meaningful improvements in maternal and child health by promoting health at every stage of life, including before and between pregnancies.

Today, Medicaid coverage is unavailable in most states to childless women who are not pregnant.

As a result, low-income women may have little or no source of regular health care before or between pregnancies, or after their childbearing is concluded. These women often lack a medical home and go without both regular preventive care and acute care for illness or injury. This lack of preconception and interconception care can have a significant impact on women’s health, and on the health of future pregnancies and children. The ACA has the potential to transform this dynamic.

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Call For Papers: NBER Conference On Hospital Organization And Productivity


February 21st, 2013
by Chris Fleming

The National Bureau of Economic Research (NBER) is organizing a conference on how organizational structure, management practices, and related innovations affect the costs, cost-effectiveness, and outcomes of health care, focusing on the hospital industry and health systems that have hospitals at their core. The organizers of the two-day conference, which will bring together economists, physicians, and policymakers, are Amitabh Chandra, David Cutler, Robert Huckman and Elizabeth Martinez.

Completed papers or detailed outlines and abstracts for potential presentation at the conference may be uploaded here. Papers, outlines, or abstracts must be submitted by February 28, 2013; authors will be notified about whether their paper has been included on the program by March 15, 2013. Accepted papers will also be invited for submission to a special issue of Health Affairs. Questions should be directed to confer@nber.org.

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Rapid Learning For Precision Medicine: A Big Data To Knowledge (BD2K) Initiative


February 21st, 2013
by Lynn Etheredge

Proposal

The National Research Council’s Precision Medicine report found that it is imperative to create a new scientific base for biomedical research, clinical care, and public health that accurately reflects the genetic variations in diseases and in individual responses to therapies.

This proposal calls for using the nation’s rapidly expanding capabilities for computerized biomedical research to accomplish this goal as quickly as possible. Research databases and analyses for most diseases would be completed over the next three years (by the end of 2015).

Background

The US-led Human Genome Project was finished ten years ago (2003). In the past several years, key elements for moving forward on a Precision Medicine-type initiative have been coming together.

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Implementing Health Reform: The Essential Health Benefits Final Rule


February 20th, 2013
by Timothy Jost

The march toward 2014 continues, as the Department of Health and Human Services issued on February 20, 2013 a final regulation covering the essential health benefits, actuarial value, and accreditation requirements of the Affordable Care Act. (See a fact sheet on the rule here.)

The ACA requires non-grandfathered health plans in the individual and small group market to cover ten categories of essential health benefits (EHBs). The EHB requirement is intended both to ensure that consumers in these markets have adequate coverage and to improve competition among health plans by standardizing coverage choices. Most of the EHBs are services already covered by most health plans, such as hospitalization or pharmaceuticals, but some, such as habilitative services or pediatric oral and dental care, are not commonly covered and thus represent a coverage expansion. The EHB requirement will also improve mental health coverage in the individual and small group market, as noted in a separate issue brief released with the final rule.

The proposed regulation now finalized was published on November 26, 2012, and was discussed in an earlier post.

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Winners And Losers From The Zaltrap Price Discount: Unintended Consequences?


February 20th, 2013
 
by Rena Conti and Ernst Berndt

Soon after Sanofi Pharmaceuticals’ Inc. August 2012 launch of the biologic drug ziv-aflibercept (brand name Zaltrap) into the U.S. market, its price triggered an unusual act of defiance on the part of oncolAogists. Physicians from Memorial Sloan-Kettering Cancer Center stated in a New York Times op-ed piece that they wouldn’t prescribe the drug because it cost twice as much as Genentech’s Avastin (bevacizumab), a competing biologic drug with similar expected clinical outcomes for colorectal cancer patients. In response, Sanofi said they would reduce the price of the drug by 50 percent.

Doctors and prescribing hospitals stand to benefit hugely from Sanofi’s pricing move, while payers and patients do not, at least over the next several months and likely much longer.

To understand why involves questions about pharmaceutical price setting and the arcane world of ‘buy and bill’, the system for physician-administered drugs under which doctors first buy drugs at one price and then submit for reimbursement for the drug to a third party payer (and the patient). The system as applied in fee for service Medicare, the public insurer of adults aged 65 and older and the largest insurer of cancer-related treatment in the U.S., is illustrative of larger concerns. In 2009, Medicare spent approximately $11 billion on physician-administered drugs.

Below, we explain how this “buy and bill” pricing system works, and how it operates in the case of ziv-aflibercept. We also examine the policy implications of the ziv-aflibercept episode and offer some thoughts on how Medicare could improve the way it sets pharmaceutical reimbursement rates.

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Continued Growth Of Public And Private Accountable Care Organizations


February 19th, 2013
by David Muhlestein

On January 10, 2013 the Centers for Medicare & Medicaid Services (CMS) announced that 106 Accountable Care Organizations (ACOs) will join the Medicare Shared Savings Program (MSSP). CMS reports that this brings the total number of MSSP ACOs to “more than 250” and that they cover up to 4 million Medicare beneficiaries.

These new Medicare ACOs, though, only tell part of the accountable care story. ACO growth has also continued apart from the Medicare program with 428 total ACOs now existing in 49 states. Additionally, physician groups have overtaken hospital systems and have now become the largest backer of ACOs.

Background Of The ACO Program

Public sector. ACOs are health care entities intended to lower health care costs, improve quality outcomes and improve the experience of care. The premise of the ACO is that each of these results can be obtained by moving away from volume-driven fee-for-service based reimbursement toward payment models that reward care coordination and quality outcomes.

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Weight Watchers, Mayors Support Healthy Lifestyles in Low-Income Communities


February 19th, 2013
by David Kirchhoff

The author, the CEO of Weight Watchers International, describes a new initiative that the company launched with the U.S. Conference of Mayors. Cities can apply now (please see below). Cities today face huge health challenges. For residents, cities are the guardians of public health. For municipal employees, cities serve as health care providers. In both cases, mayors […]

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A Valentine’s Day Health Wonk Review


February 15th, 2013
by Chris Fleming

Over at the Healthcare Talent Transformation blog, Peggy Salvatore hosts a Valentine’s Day edition of the Health Wonk Review. Among the posts Peggy highlights is David Rothman’s Health Affairs Blog essay on patient engagement and Americans’ deep-seated fondness for medical treatments and tests, even when they are not supported by the evidence.

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Health Policy Brief: Patient Engagement


February 15th, 2013
by Chris Fleming

A new Health Policy Brief summarizes the key findings in the field of patient engagement and draws on the February 2013 issue of Health Affairs, entitled “New Era Of Patient Engagement.”

A growing body of evidence demonstrates that patients who are more actively involved in their health care have better outcomes and incur lower medical costs. This finding is motivating health care organizations to better inform patients about their conditions and care choices, so they can be more fully involved in maintaining their health and making decisions about their care.

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Video Of HA Patient Engagement Briefing Is Available


February 15th, 2013
by Chris Fleming

If you are looking for something to watch over the long weekend and missed the recent Health Affairs briefing on our February issue, “New Era Of Patient Engagement,” video and speaker materials from the event are available on the Health Affairs website. The video is broken down by panel and speaker, so you can watch the whole event or select portions of particular interest.

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