Health Affairs

Health Affairs plans a thematic issue on Alzheimer’s disease in April 2014. We plan to cover a range of topics with the aim of providing “one stop shopping” for our policy-oriented audience. Topics include overview papers on the state of the science of causes and treatment, costs, screening and diagnosis, drug development, medical and non-medical management, caregiver populations, federal and state roles, and more.

Request for abstracts

In addition to the papers we have already invited, we are seeking papers on several additional topics and therefore welcome proposals for papers, analyses, and commentaries on the following topics:
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• Exemplary models from around the globe (either individual countries or comparative pieces with lessons for other countries)
• Exemplary state or local approaches to care and treatment
• Opportunities for primary prevention

In order to be considered, abstracts must be submitted by August 1, 2013. We regret that we will not be able to consider any abstracts submitted after that date.

As a longtime physician, I know that having access to stable, affordable health coverage is a critical step in achieving better health outcomes.

That view is underscored in a study that appeared in today’s (May 2) New England Journal of Medicine (NEJM) on the effects of Medicaid coverage on individuals’ health and finances. Led by researchers at Harvard and MIT, the study—the Oregon Health Insurance Study—offers a good snapshot of how being insured can help low-income Americans.

Here’s the background: In 2008, Oregon officials created a lottery giving uninsured, low-income adults a chance to apply for Medicaid. Nearly 90,000 people signed up, and approximately 30,000 were selected. By randomly providing health insurance to some, but not all, Oregon effectively established both treatment and control groups, presenting a unique opportunity to analyze the effects of having public health insurance.

The study in NEJM highlighted the latest data from the experiment. It showed that enrollment in Medicaid, after about two years, profoundly increased patients’ use of needed medical services, and vastly reduced the financial strain that previously limited their care.

Three years after wellness was hailed as perhaps the only truly bipartisan component of the Affordable Care Act, both lay and trade commentators have begun observing that the assumptions behind it were incorrect while downsides were overlooked. As a predictable result, savings have proven elusive even in seemingly ideal baseline circumstances for health improvement. For example, a wellness program at BJC HealthCare in St. Louis reduced hospitalizations for wellness-sensitive medical events, but the savings were limited (and offset by other cost increases) by the fact that older employees there on average were hospitalized for a wellness-sensitive medical event only once every 12 years to begin with. (See Note 1.)

Consistent with that finding, commentators (including the authors) have noted that every vendor claiming savings from what the Affordable Care Act (ACA) terms “health contingent” wellness programs has employed obviously flawed study design (like comparing the results from active motivated participants to non-motivated non-participants, and crediting the program, rather than the obvious difference in motivation, for the savings) and/or has simply made up or misinterpreted their own outcomes .

One reason for the absence of savings is that the biometric screenings themselves on which wellness economics are based cost far more money than they can conceivably save, due to both the likelihood of overdiagnosis and the marginal benefit of taking frequent measurements in generally healthy adults. Routine screening lacks an evidence basis and is eschewed by the medical community. For example, the federal government recommends lipid screening only once every five years.

More than two-thirds of Medicare beneficiaries have multiple chronic conditions, such as heart disease and diabetes, and that number is projected to rise significantly in the U.S., given our aging population. The Chronic Conditions Dashboard, recently launched by the Centers for Medicare & Medicaid Services (CMS), is the first in a series of planned web-based enhanced data analytic and visualization tools.

Use of the data available from the Dashboard can help policymakers, local health leaders, and health systems improve care coordination and health outcomes, and can help slow the increase in expenditures for Medicare beneficiaries living with multiple chronic conditions. The Dashboard was developed to be user-friendly and incorporated strong health information privacy protections, as individually-identifiable information cannot be accessed. The release of the Chronic Conditions dashboard supports the Administration’s Health Data Initiative that seeks to release more health-related data in more usable formats to support health promotion and care innovation.

Editor’s note: The February issue of Health Affairs was a thematic issue focused on patient engagement. In conjunction with the Patient-Centered Outcomes Research Institute (PCORI), the journal launched a new initiative inviting questions from patients and others via Facebook for Health Affairs authors on patient-centeredness and patient engagement. Questions are then answered on Health Affairs Blog.

Below, Ming Tai-Seale of the Palo Alto Medical Foundation Research Institute answers a reader query; previously, Jessie Gruman and Rachael Fleurence answered questions. Watch for a Health Affairs Facebook post tomorrow inviting questions for Benjamin Moulton of the Foundation For Informed Medical Decision Making.

Paul Gionfriddo: Ming, you’ve concluded both that we need a better system of communication between clinicians and patients with less variation in clinicians’ responses and that clinicians appear to be out of their comfort zone communicating with patients about mental health concerns. Would you argue that more universal use of screening tools like the PHQ-9, coupled with better training of primary care clinicians about how to interpret results, respond to patients, and refer (via collaboration to or integration with) behavioral health professionals would create more effective give-and-take with patients and address some of the issues you raised in your paper?

Ming Tai-Seale: Thank you, Paul, for your thoughtful question. Indeed, the United States Preventive Services Task Force (USPSTF) has recommended that screening adults for depression be done in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.

The recent moves by states to bring their Medicaid prescription drug benefits under managed Medicaid plans has fully taken root: the percentage of Medicaid prescriptions filled under managed Medicaid plans jumped from 19 percent in September 2011 to 46 percent in June 2012. As yet, the impact this might be having on patient care has not been examined. While it is early days to see the impact on health outcomes and whether better preventive services are being provided at lower cost, any changes in the utilization of prescription drugs can be an early indicator of longer term impact.

At the IMS Institute for Healthcare Informatics, we have looked at four states — Kentucky, New Jersey, New York and Ohio — and compared changes in the use of anti-psychotic, respiratory and diabetes medications between patients who switched to managed Medicaid coverage and those who remained in fee for service. Although this is a limited-scale review, we thought this could be a useful contribution at a time when state (and federal) decision-makers are crafting plans that will have important long-term impacts on many Americans from 2014 on.

While our analysis shows there are early signs indicating a change in care received by patients, the lack of consistent measureable change suggests that states’ efforts to bring better care at lower costs to their Medicaid beneficiaries has yet to be fully realized.

In today’s Q and A on Patient Engagenment, we feature Rachael Fleurence, a Senior Scientist at PCORI where she leads the research prioritization initiative to help identify important patient and stakeholder generated questions and establish a rigorous research prioritization process to rank these questions. (Also, check out her recent blog post and follow the link to her February Health Affairs article here.)

The numbers are disturbing and disappointingly familiar. According to the federal government, one in five elderly patients winds up back in the hospital within 30 days of leaving. The cost is troubling, too. The readmission of Medicare patients alone costs $26 billion annually, $17 of which is spent on return trips that wouldn’t need to happen if patients received proper care during their first visit.

The Centers for Medicare & Medicaid Services calls avoidable readmissions one of the leading problems facing the U.S. health care system, and in an effort to turn things around is now penalizing hospitals with high rates of readmissions for patients with certain conditions.

In America, we should be doing better. We need to pinpoint why this problem persists. What are the human factors behind these numbers?

That is why the Robert Wood Johnson Foundation commissioned a report, “The Revolving Door: A Report on U.S. Hospital Readmissions,” to take a closer look at the issue of readmissions through the eyes of those grappling with the problem. The report is part of our Care About Your Care initiative, devoted to improving the transition from hospital to home.

No one expects a scalpel to perform surgery by itself. Similarly, no one should be surprised by the conclusion of a widely cited article in the January 2013 edition of Health Affairs (“What It Will Take To Achieve The As-Yet-Unfulfilled Promises Of Health Information Technology”) about the unrealized promise of health IT to lower costs and improve care.

Electronic health records (EHRs) are a tool, not a solution. But our experience at the New York City Department of Health and Mental Hygiene with the Primary Care Information Project (PCIP) demonstrates that with the proper support, EHRs can be a powerful tool for improving clinical care and managing population health. Now we are about to turn another corner on our journey, to see if we can use the data we collect from New York City EHRs to paint an accurate picture of the population at large.

Since 2005, PCIP has helped more than 3,200 providers implement EHRs, and we currently provide assistance to more than 7,700 providers in New York City. Our staff members help with everything from choosing an EHR to billing, coding, and documenting workflows, to assisting providers with navigating the federal EHR incentive program, to reviewing their clinical quality measures and helping them with numerous quality improvement (QI) activities. We are the home of New York City’s Regional Extension Center (REC), one of 62 such centers nationwide that are funded to support primary care providers through the transition to an EHR and help them achieve the federal Meaningful Use standards.

Use rates for inpatient and certain hospital outpatient services are declining in many areas of the country, reflecting fundamental change brought by the new business model. Importantly, as evidenced by trends in Chicago and Minnesota, there also appears to be a correlation between the level and pace of a market’s shift toward value-based care and the level and pace of utilization decline.

We believe this trend is here to stay and that it has significant strategic and financial implications for health care providers. Specifically, providers that embrace the migration to value-based care will need to work aggressively to eliminate unnecessary and/or ineffective activities in order to thrive under risk contracts. This requires a fundamental change in mindset, culture, and attitude about volume and activity. It also requires providers to rethink the organization and structure of their delivery networks to avoid supporting unnecessary capacity, and to drive patients into the lowest-possible cost setting in which quality care can be delivered.

The goal will be to manage a population’s health across the care continuum, keeping patients healthy through preventive and primary care services, and out of acute care facilities whenever possible. The right place to provide the right care at the right time with the right quality, cost, and access increasingly will be a setting other than a hospital. By eliminating waste and redirecting patients to ambulatory centers, physician offices, clinics, and online and/or telephonic interactions, less work will be done in the hospital. To reduce well-documented overutilization, tests and services deemed inappropriate or unnecessary based on medical evidence will be eliminated in all settings. (See Note 1) Acute care will be one, and only one, component of the population-centric health management services continuum.

The loud cries warning that rising health care costs are going to destroy the nation’s economy have been shouted so often that the will to move firmly in any one direction has almost halted. We’ve all heard them: health care costs are unsustainable, excessive spending is fueling our nation’s debt, and despite high costs, health outcomes are behind much of the world and aren’t improving.

The way doctors are paid is one of the most significant drivers of escalating health care costs. The National Commission on Physician Payment Reform, which we chair, was formed by the Society of General Internal Medicine to provide the public and private sector with recommendations for transforming the way we pay doctors in order to rein in spending and improve quality.

On Monday, after a year of intensive study, the 14-member Commission issued a blueprint for exactly how to move the nation toward a physician payment system that will yield better results for payers and patients.

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.

Currently, most hospitals and health systems focus on patient engagement because of their mission to deliver patient-centric care. These efforts are pursued despite the neutral or even negative economic consequences to these organizations, which operate within the fragmented, fee-for-service payment system. For example, care coordination attendant to patient engagement efforts will, at times, reduce demand for services and, thereby, reduce fee-for-service payments to providers.

As public and private sector health care purchasers shift payment models towards value and as demographic changes result in more chronically ill patients entering the health care system, patient engagement efforts will become increasingly important to the financial sustainability and clinical success of these hospitals and health systems.

New patient engagement efforts shift focus from the inpatient core of hospitals to ambulatory care settings and to the integration of care into the homes and communities of patients. To succeed at these efforts, organizations must build longitudinal partnerships with patients to drive ongoing management of chronic conditions and utilization of preventive care services to drive long-term quality and cost outcomes.

The mistake policymakers have long made in debating Medicare (and Medicaid, though that’s a topic for another day) is that they talk about Medicare the same way they talk about Social Security. It’s understandable at some level, since these two programs are the country’s largest entitlement programs and serve similar populations. However, the two programs could not be more different.

Social Security is a relatively simple program of transfer payments. The fundamental issue for Social Security is how to manage the inflow and outflow of funds.

Medicare is an entirely different animal.

Historically, legislative changes to the program have attempted to mimic the Social Security focus on budgetary inflows and outflows by adjustments to benefits and provider reimbursements. While expanding coverage has largely been an attempt to be more inclusive of vulnerable populations and allow access to needed services to improve overall health (while simultaneously lowering beneficiaries’ cost burden), it has always come at a price, literally. Similarly, while provider payment cuts — and in some cases increases — have often been critical to increasing access or controlling spending in the near-term, they have done nothing to address the structural reforms desperately needed to sustain the program over the long-term.

Unfortunately, while there remain budgetary questions to consider, the opportunities and demands inherent in future structural changes to Medicare are an order of magnitude more challenging.

The pharmaceutical drugs developed over the past two decades have helped us more effectively manage, and in some cases dramatically change, the outcomes of patients with hypertension, high cholesterol, diabetes, and even some cancers. Increasingly, though, the stroke of a prescription pen doesn’t solve all patient problems. Nor does it solve the problems in our health systems.

To really fulfill the potential of health care, we need patients who are engaged, patients who take “actions (as) individuals … to obtain the greatest benefit from the health care services available to them.” (See Exhibit one below, click to enlarge)

Leonard Kish recently called patient engagement “the blockbuster drug” of the century. It’s an exciting idea and an apt label that raises an interesting question: what would an “engagement pill” actually look like?

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.

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.

Structural reforms to the Medicare and Medicaid programs will be on the table as the debate over entitlement reform intensifies. There are three areas of opportunity for changing our entitlement programs: adding prevention initiatives that truly slow or reduce the growth in chronic disease prevalence; introducing care coordination into the original Medicare program; and reforming how we pay health care providers.

On November 30^th, the Centers for Medicare and Medicaid Services (CMS) provided additional information regarding the implementation of the Bundled Payment for Care Improvement (BPCI) initiative. The CMS released a preliminary list of 48 “episodes of care” where providers would be paid a targeted rate lower than actual fee for service payments. The extent of the episodes is notable since they would cover approximately 70 percent of all Medicare expenditures if applied to all providers and to all 48 episodes. Under the initiative, participating providers could identify which of the 48 conditions they were interested in testing.

These reforms could replace the clearly flawed sustainable growth rate formula and provide strong financial incentives to integrate inpatient and post-acute health care services. Over 75 percent of spending in the Medicare program is associated with patients under treatment for 5 or more medical conditions and virtually all the growth in Medicare spending since 1987 has come from patients with multiple chronic health care conditions. Despite these fiscal facts, original Medicare does not provide coordinated care for chronically ill patients. Such care requires “team-based care” that includes transitional care, comprehensive medication management, health coaching, and a care coordinator among other elements.

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.

Time travel, both backward and forward, continues to be a favorite theme in popular culture. If we could travel back just 60 years or so, we would see a vastly different health care system, one geared to provide acute care, not chronic care, and one offering what today would be seen as rudimentary treatments. No one in 2012 would expect a surgeon to use techniques from that era or a doctor to prescribe medications long surpassed by more effective drugs. Yet one important area of health care and long-term care services and supports clings to outmoded terms and measures.

Welcome to the hidden world of family caregivers — broadly defined as the spouses, adult children, other family members, partners, friends and neighbors who provide or manage most of the care of the growing number of noninstitutionalized people with chronic illnesses and disabilities. As our recently released AARP Public Policy Institute and United Hospital Fund report (available here and here) puts it:

Family caregivers have traditionally provided assistance with bathing, dressing, eating, and household tasks such as shopping and managing finances. While these remain critically important to the well-being of care recipients, the role of family caregivers has dramatically expanded to include performing medical/nursing tasks of the kind and complexity once provided only in hospitals.

These tasks include managing multiple medications, not just pills but injections and infusions; wound care; operating medical equipment like feeding tubes, dialysis machines, and mechanical ventilators; and using electronic monitors and other devices.