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The Value of Workplace Health Promotion (Wellness) Programs


December 22nd, 2014

The recent Health Affairs Blog post by Al Lewis, Vik Khanna, and Shana Montrose titled, “Workplace Wellness Produces No Savings” has triggered much interest and media attention. It highlights the controversy surrounding the value of workplace health promotion programs that 22 authors addressed in an article published in the September 2014 issue of the Journal of Occupational and Environmental Medicine titled, “Do Workplace Health Promotion (Wellness) Programs Work?”  That article also inspired several follow-up discussions and media reports, including one published by New York Times columnists Frakt and Carroll who answered the above question with: “usually not.”

There are certainly many points of contention and areas for continued discussion on this topic. It turns out that Lewis et al. and I agree on many things, and there are other areas where we see things differently.

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New Health Policy Brief: Reenrollment


December 22nd, 2014

This year open enrollment under the Affordable Care Act (ACA) began on November 15, allowing new customers to sign up for health insurance. Open enrollment also provided current policyholders the chance to change plans and request a redetermination on the amount of subsidy they received. During this second year of open enrollment for the ACA’s insurance Marketplaces, insurers and policy makers are working to keep last year’s enrollees in the system — and the Department of Health and Human Services (HHS) estimates that 95 percent of them are eligible for automatic renewal.

A new policy brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) examines the pros and cons of reenrollment options for consumers, whether they are using the federal Marketplace or live in states that operate their own exchanges. Automatic reenrollment means that almost seven million people already enrolled will not necessarily need to flood HealthCare.gov and exchanges during open enrollment. On the other hand, it also may discourage consumers from exploring alternative coverage that might better fit their needs and get a more accurate determination of eligibility for subsidies.

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Implementing Health Reform: Wraparound Coverage Excepted Benefits And Draft 2016 Letter To Issuers (Updated)


December 20th, 2014

In December 19, 2014, in what one hopes were their last major regulatory actions before the holidays, the Departments of Labor, Health and Human Services, and Treasury released a proposed rule on a new excepted benefit for wraparound coverage, while the Centers for Medicare and Medicaid Services released a Draft 2016 Letter to Issuers in the Federally Facilitated Marketplace.

This post will describe the wraparound coverage proposed rule.   It will be updated in the next day or two to analyze the letter to issuers (issuers being the Affordable Care Act word for insurers.)  I will note briefly, however, that the letter to issuers is very similar to the 2015 letter to issuers, with two major exceptions.  First, because open enrollment for 2016 begins on October 1, rather than November 15, as in 2015, the time frame for completing regulatory review begins earlier and is quite compressed.  Second, the 2016 letter picks up on a few new regulatory initiatives for 2016, such as attempts to provide more accurate provider directories and formulary information.  These changes will be explored more thoroughly in the update to this post.

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New Findings About The ACA’s Impact On Employer-Sponsored Health Insurance


December 19th, 2014

Since the Affordable Care Act (ACA) was signed into law, some of its critics have predicted that businesses would discontinue offering employer-sponsored health insurance, moving employees into the individual Marketplaces. If widespread dropping of employer-sponsored health insurance were to occur, government costs could increase since many low-wage workers would qualify for federal subsidies in the Marketplaces.

A new study, released today as a Web First by Health Affairs, examined data from the Health Reform Monitoring Survey for June 2013 through September 2014, assessing any early changes of employer-sponsored insurance under the ACA. Authors Fredric Blavin, Adele Shartzer, Sharon Long, and John Holahan report that the percentage of workers with employer offers for health insurance was basically unchanged between June 2013 and September 2014: 82.7 percent versus 82.2 percent. The authors are all affiliated with the Health Policy Center at the Urban Institute, in Washington, D.C. 

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Request For Abstracts: Health Affairs Non-Communicable Disease Theme Issue


December 19th, 2014

Health Affairs is planning a theme issue on non-communicable diseases (NCDs) in September 2015. The issue will present work that describes the burden of NCDs, approaches to prevention and treatment of NCDs, and analysis of policies and initiatives aimed at prevention and treatment. The issue will have a global perspective.

We invite interested authors to submit abstracts for consideration for this issue.

We are using a broad definition of NCDs to include cancer, cardiovascular disease, respiratory illness, diabetes, mental illness, and the like. The issue will not focus on injuries, per se, but will address disability as an element of the disease burden of NCDs.

We plan to publish 15-20 peer-reviewed articles including research, analyses, and commentaries from leading researchers and scholars, analysts, industry experts, and health and health care stakeholders. Some papers will provide an overview of an issue relevant to NCDs, but we are particularly interested in empirical analyses of specific policies, care models, and other approaches to addressing NCDs. All papers must focus on issues of interest to public policy makers and private leaders in health care and related sectors.

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The Medicare Shared Savings Program: CMS Turns To Stakeholders On Incentivizing ACO Risk


December 19th, 2014

On December 1, 2014, the Centers for Medicare & Medicaid Services (“CMS”) released its long awaited Proposed Rule to update regulation and operation of the Medicare Shared Savings Program (“MSSP”). In response to concerns raised by participating accountable care organizations, CMS proposes to revise the MSSP program in several ways to provide greater flexibility for ACOs.

However, in important areas CMS may not have gone far enough. This post describes the framework CMS has set forth and then suggests several ways in which the proposal could, in our view, be improved to achieve the CMS objective of encouraging ACOs to bear more risk. In particular, CMS should consider using its waiver authority more robustly; allowing Medicare beneficiaries to designate their primary care providers, and by extension their ACO; and revising the MSSP risk-adjustment methodology to better reflect the changing risk profiles of ACOs.

CMS is actively seeking stakeholder input, which may indicate agency recognition that further changes beyond those in the propose rule are needed. By all indications, stakeholder input will be seriously considered; more than any time in recent memory, stakeholder comments will make a difference in the shape of the Final Rule. This presents a unique opportunity for stakeholders and we urge concerned parties to share their perspectives through comments – the deadline for submitting comments is February 6, 2015.

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The Dane Difference: Why Are Dane County’s Exchange Premiums Lower?


December 18th, 2014

During the next few years, states and the federal government will likely seek solutions to control costs and improve quality in the Affordable Care Act (ACA) health insurance marketplaces. State and federal policymakers should look carefully at the decades-long success of the Wisconsin State Employee Health Plan (WSEHP) in controlling the rapid rise of health insurance costs in Dane County—where Madison, Wisconsin’s state capital, and the University of Wisconsin, are located—as they seek to improve the effectiveness of the ACA’s marketplaces and health insurance costs in general.

The WSEHP consistently obtains substantially lower health insurance premiums in Dane County than in Wisconsin’s 71 other counties. In 2013, an individual plan in the WSEHP was about $1,400 cheaper annually in Dane County, or 16 percent less than the average in the rest of the state; and a family plan was about $3,500 cheaper, also a 16 percent difference. This Dane difference has existed for at least a decade, with the gap slowly widening over that time.

Why does WSEHP get much lower premiums in Dane County than in the state’s 71 other counties, and what lessons can policymakers learn from this difference?

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How To Succeed At Payment Reform (By Really Trying)


December 18th, 2014

Editor’s note: This is part 2 of a blog post adapted by the author from his recent keynote address at the New York State Health Foundation Conference, “Payment Reform: Expanding the Playing Field.” You can watch his half-hour speech, beginning around the eight-minute mark.

In my previous post, I explained “Why I Oppose Payment Reform.” Despite the reservations I laid out in that post, I do not actually oppose payment reform.

To summarize the case for payment reform, fee-for-service payment has supported a fragmented delivery system with little accountability for cost or quality.  As there is growing consensus that we want to move from our current system toward one that maximizes the health outcomes we achieve relative to the resources we expend, alternative payment models may provide us with a path. We should remember, however, that payment reform is a tool, not an end in itself; and we should be clear about our goals and then deploy the tool where it can help us achieve those goals.

Achieving payment reform is a process.  Here are five elements that are necessary for a successful process.

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ACO Quality Results: Good But Not Great


December 18th, 2014

On September 23, 2014, the Centers for Medicare and Medicaid Services (CMS) released Year 1 Quality Performance results for Accountable Care Organizations (ACOs) that began participating in the Medicare Shared Savings Program (MSSP) in 2012 or 2013. Another report, released shortly before, outlined financial performance of the ACOs and showed that only 49 ACOs, or 22 percent of those ACOs, qualified for shared savings payments by successfully reducing total spending.

Opportunity for continued quality improvement aside, a troublesome snag for the program could be a very low correlation between improved quality and earned savings: our analysis shows that, in performance year one, improved quality and earned savings only correlate at 8.6 percent, so low that it is statistically insignificant (Figure 1).

In practice, this means that better quality is not associated with better financial results. Twenty-one of the 49 ACOs that did earn shared savings actually scored below the average quality of the group. For the first year, quality outcomes did not affect the size of shared savings payments, but in future years ACOs that perform poorly on quality measures will lose a portion of any shared savings.

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Health Affairs Web First: The Bottom Line On Different Management Models In State Health Exchanges


December 17th, 2014

The Affordable Care Act gives states discretion as to how they design their health insurance Marketplaces. Some states run their own Marketplace; others are part of the federally facilitated exchange; and a few chose a state-federal partnership. All states have plan management responsibilities, and if a state runs its own Marketplace, it has management choices. A “clearinghouse” model of management is when all health plans meeting published criteria are accepted into the exchange.

This model is used by some state-run exchanges and all the state-federal partnerships and federally facilitated exchanges. The alternative is the “active purchasing” model, allowing a state to directly negotiate premiums, provider networks, and other details. This model has been adopted by ten of the seventeen state-run exchanges.

A new study, released today as a Web First by Health Affairs, found that in the 2013–14 open enrollment period, state-based Marketplaces using a clearinghouse model had significantly lower adjusted average premiums for all plans within each metal tier (bronze, silver, and gold) compared to state-based Marketplaces having active purchasing models. This study offers the first attempt to assess the premium differences across Marketplace models.

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Shared Decision Making And The Use Of Patient Decision Aids


December 17th, 2014

More than 30 years ago, a Reagan-era Presidential Commission urged the national adoption of “shared decision making” (SDM) as a way to improve communication and informed consent in health care. Since then, many patient decision aids (PDAs) have been developed — tools that present information about common medical choices in standardized, user-friendly formats. More than 100 published, randomized trials using PDAs have shown many benefits.

Summarizing these benefits, a recent Cochrane review concluded that using PDAs can lead to patients gaining knowledge, having a more accurate understanding of risks, harms and benefits, feeling less conflicted about decisions and rating themselves as less passive and less often undecided. But there remains a lack of evidence that these tools actually change the way clinicians and patients communicate, and it is unclear to what extent more medical decisions are actually being shared.

A discussion paper recently published by the Institute of Medicine (IOM) reviewed the literature on the implementation of PDAs in clinical practice and concluded that, despite some areas of progress, “the promise of SDM remains elusive.” In this blog post, we expand on some ideas raised in the recent Discussion Paper and provide specific recommendations in three areas: technological support for shared decision making, recognition that failure of shared decision making comprises a medical error, and a transformation in how we conceptualize “informed consent.”

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The Strategic Challenge Of Electronic Health Records


December 16th, 2014

Despite a 2005 prediction that electronic health records (EHRs) would save $81 billion, RAND Corporation just validated clinicians’ complaints in a report describing EHRs as “a unique and vexing challenge to physician professional satisfaction.” The American Medical Association also published EHR “usability priorities” – strong evidence that current EHRs don’t support doctors in practicing medicine.

In a world of Apple-typified simplicity, why is it so hard to get the right EHR? Because, unlike Apple, EHR designers haven’t started with the question of how value can be created for users of the technology. Technology isn’t the problem. The challenge is in articulating clinicians’ information needs and meeting them by making the right tradeoffs between corporate and business unit strategies.

EHRs can, and should, provide relevant information when and where clinicians need it, recognizing that care is not a commodity and that different care processes have different information needs. User interfaces must anticipate clinicians’ needs rather than require individual user design. EHRs need to eliminate low-information pop-ups and alarms and instead provide alerts and reminders that are both timely and relevant. They must be designed with assiduous attention to data entry requirements, replacing blind mandates with thoughtful assignment of the task and the timing.

In this post I look at how rethinking the design of EHRs can better balance the different strategic needs within care delivery organizations.

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Implementing Health Reform: Enrollment And Reenrollment For 2015 (Updated)


December 16th, 2014

The December 15, 2014 deadline for reenrolling in qualified health plan (QHP) coverage to assure continuous coverage as of January 1, 2015 has come and gone.  Individuals who were enrolled through the federally facilitated marketplace (FFM) for 2014 but did not return to the marketplace to shop for 2015 plans will be passively reenrolled in their 2014 plan or in a plan similar to it.  The 2015 open enrollment period lasts through February 2015, and individuals can return to the FFM at any time before then to change plans.  But the change will not be effective for January 1.

A number of state-operated exchanges—including New York, Massachusetts, Idaho, Rhode Island, Washington, Minnesota, and California—have reportedly either extended the date by which individuals can enroll or reenroll and still have coverage effective January 1 or given individuals who had begun the enrollment process as of December 15 extra time to complete the process for January 1 coverage.  The FFM has not extended the deadline.

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New Health Policy Brief: Physician Compare


December 16th, 2014

A new policy brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) looks at the evolution and current development plans for Physician Compare, a website mandated by the Affordable Care Act (ACA). A simple version of the site first launched in 2010.

Since then the Centers for Medicare and Medicaid Services (CMS) has slowly been adding limited sets of data listing the various physician groups participating in a number of Medicare quality improvement initiatives. In 2015 the site will expand to include more recent and extensive information about physician performance and quality of care, in a format that’s similar to the other ACA-generated websites — Hospital Compare, Nursing Home Compare, Home Health Compare, and Dialysis Facility Compare.

These sites, which encompass tens of thousands of facilities nationwide, are credited with advancing accountability and motivating improvements in care and quality. They are also faulted as poorly organized and inadequately audited when the data are submitted by facilities.

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Investing In The Health And Well-Being Of Young Adults


December 15th, 2014

Young adulthood — ages approximately 18 to 26 — is a critical time in life. What happens during these years has profound and long-lasting implications for young adults, and — because many are parents — for the next generation.  Healthy, productive, and skilled young adults are critical for the nation’s workforce, global competitiveness, public safety, and national security.

Although young adults are resilient and adaptable, they are surprisingly unhealthy, showing a worse health profile than both adolescents and adults in their late 20s and 30s. Recent national attention on young adults has focused primarily on enrolling them in health care insurance to offset the higher costs associated with care for older adults under the Affordable Care Act 2010 provisions — mistakenly implying that it is not in their own interest to have health insurance. Unfortunately, too little attention has been paid to young adults’ specific health needs and the transitions they face once they are in the health care delivery system.

The Institute of Medicine and National Research Council recently released a new report titled Investing in the Health and Well-Being of Young Adults, which reviews what is known about the health, safety, and well-being of young adults and offers recommendations for policy and research. It was prepared by a committee with expertise in multiple disciplines, including public health, health care, behavioral health, sociology, social services, human development, neuroscience, economics, business, occupational health, media, and communications. We served as chair and a member of the committee, respectively.

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Narrative Matters: Shining A Light On Child Health


December 15th, 2014

Last month, a group of writers, clinicians, policy makers and other experts gathered at Airlie House in Warrenton, Virginia, for the 2014 Narrative Matters Symposium. About an hour outside the city, the scenic fall setting—rolling farm land and trees with auburn and gold leaves—was the perfect backdrop to take attendees outside of their normal day-to-day work and introduce them to others who also are deeply passionate about improving the health of vulnerable children.

The focus of this year’s symposium was “Vulnerable Children: Using Stories to Shine a Light on Child Health.” Manuel Pastor, professor of Sociology and American Studies & Ethnicity at the University of Southern California, delivered a keynote address in which he discussed the changing demographics of the United States, which by 2043 is projected to be a “majority minority” nation — driven, not by immigration itself, but by the rising number of children born in this country to immigrants. Economists have noted that inequality in the nation causes slower economic growth, Pastor pointed out, concluding that if we reduce income disparities, we are actually contributing to national prosperity.

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Implementing Health Reform: Beneath The Hood Of The ‘Cromnibus’


December 12th, 2014

The “Consolidated and Further Continuing Appropriations Act, 2015” or “Cromnibus” legislation moving through Congress contains a number of provisions that relate to the implementation of the Affordable Care Act (ACA).

Risk Corridors

The provision that has been most widely noted so far requires the risk corridor program to be budget neutral for 2014. The risk corridor program moves funds from qualified health plans (QHPs) that have lower than anticipated allowable costs to those with higher than anticipated allowable costs. Section 1342 of the ACA, which creates the risk corridor program, contains no explicit appropriation.

A report issued earlier this year by the Government Accountability Office (GAO), which is the final authority on the legitimacy of government expenditures, determined that the continuing resolution for 2014 permitted the Centers for Medicare and Medicaid Services (CMS) to fund the risk corridor program for 2014 both from payments collected from plans with lower than anticipated costs, which were properly characterized as user fees, and from funds transferred from other CMS accounts. No risk corridor payments were in fact payable in 2014, however, as risk corridor payments will first be made in 2015 for 2014.

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The Innovation Conundrum In Health Care


December 12th, 2014

Editor’s note: This post is part of a series of several posts related to the 4th European Forum on Health Policy and Management: Innovation & Implementation, to be held in Berlin, Germany on January 29 and 30, 2015. For more information or to request your personal invitation contact the Center for Healthcare Management.

It is never too early for new technology in health care. In contrast to the innovator’s dilemma in other industries where the adoption can be sluggish because current customers may not be able to use the future’s toolbox, in medicine innovators always can be assured of an audience when announcing the “life-saving impact” of something new.

Coverage and widespread implementation usually are a different story, but creating hype and demand for unusual and unfamiliar medical technology has never been hard. But who then drives the invention, diffusion, application, and evaluation of such innovation?

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Why I Oppose Payment Reform


December 12th, 2014

I recently gave the keynote address at the New York State Health Foundation Conference “Payment Reform: Expanding the Playing Field.” This blog post is adapted from those remarks (you can watch the half-hour speech beginning around the eight-minute mark).

I had my epiphany shortly after I announced my departure from the National Academy for State Health Policy (NASHP) about nine months ago. In an effort to help find my successor, I contacted some executive search firms. One firm quoted what they referred to as the “market price.” When I pressed them to tell me how much effort this price represented, they declined to do so. Ultimately, I recommended that NASHP contract with a search firm that charged by the hour.

It was then that I realized that, given the choice between capitation (a fixed fee for the outcome I desired) and fee-for-service (an hourly rate with no accountability for the outcome), I, as a purchaser, chose fee-for-service. Only a hypocrite would go around talking about the importance of payment reform, while secretly conducting business the old way!

Having given the matter some further thought, I present my five reasons for opposing payment reform:

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Preparing US Hospitals To Safely Manage Ebola Virus-Infected Patients: At What Cost?


December 11th, 2014

Since Ebola first reached US shores this summer, hospitals nationwide have attempted to prepare. National guidance has been helpful, but no such guidance can deal with the fastidious attention to every minute and mundane aspect of caring for a patient with Ebola virus infection that could place a healthcare worker at risk if a breach occurs. Simulation training has helped to uncover defects and to assess our capacity to mitigate those defects.

Additionally, innumerable hours of countless healthcare workers, hospital administrators, infection control staff, facilities and environmental services providers, communications specialists, security personnel and others have been brought to bear focused on the task at hand. Despite this effort, in the 30 years since becoming a physician, I have never witnessed a greater, more palpable level of stress and anxiety among my peers.

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