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An Era Of Precision Medicine And Rapid Learning


February 20th, 2015

At a recent White House event, President Obama presented his proposals for a Precision Medicine Initiative. The key elements include a national research system where 1 million or more volunteers can share their (privacy protected) electronic health records, genetics, and other data, and a national cancer initiative. The proposals will be developed in more detail based on meetings led by the National Institutes of Health (NIH) Director Francis Collins.

If national health policy adopts these proposals, much about today’s medical care system—including biomedical science, medical education, diagnostics, treatment options, comparative effectiveness research, quality metrics, payment systems, the role of patients, the personalization of medical care and prevention, and an understanding of the roles of environment, nutrition, culture, and many other factors—may greatly change.

The Obama administration proposes a highly collaborative, non-partisan public-private process. These proposals bring the era of “big data” to the center of the heath policy arena (see the July 2014 Health Affairs theme issue, “Using Big Data To Transform Care”). Many in the health system may want to take part in developing the proposals and being part of the implementation.

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The Challenges Of Developing A Sustainable Network For The Care Of The Chronically Ill


February 11th, 2015

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, held in Berlin, Germany on January 29 and 30, 2015. For updates on the Forum’s results please check the Center for Healthcare Management’s website or follow on Twitter @HCMatColumbia.

Health care systems the world over are searching for new organizational models to deliver better clinical outcomes, improved customer satisfaction, and lower costs. In any such systems, quality will no longer be the sole province of clinicians and the responsibility for cost containment will no longer fall solely on payors. Increasingly, clinical care and social service providers, patients, and payors alike have a role to play in achieving the best clinical outcomes for patients and the best economic outcomes for the system as a whole, signifying a value based health delivery system.

As primary and acute care networks embark on this move from volume to value, the special needs of chronic populations, those that comprise 45 percent of domestic health care spending — or $1.2 trillion annually, can easily be lost and, with them, the ability to address a very significant gap between quality outcomes and cost controls.

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How Hepatitis C Is Shining A Light On Critical Gaps In Payment Reform


February 3rd, 2015

Since December 2013, regulatory approval of new treatments for hepatitis C have brought long simmering debates on drug pricing and value to full boil. The drugs—Gilead’s Sovaldi and successor combination treatment Harvoni, AbbVie’s Viekira Pak—represent significant steps forward for treatment in hepatitis C, demonstrating cure rates well above 90 percent in the clinical trial setting as well as greater tolerability for patients.

This unprecedented effectiveness, however, has come at a high cost, with treatment ranging from $63,000 for an eight-week course of Harvoni on the low end to above $150,000 for Sovaldi in combination with other products on the high end. This is likely to be representative of a wave of similar products coming through the drug development pipeline: highly targeted, highly effective, and highly priced.

Also indicative of things to come are the steps some groups are taking to blunt the impact of increased spending on hepatitis C treatments, such as formulary adjustments or prioritized coverage for particular subsets of the hepatitis C patient community. Days after the U.S. Food and Drug Administration (FDA) approved AbbVie’s Viekira Pak in December 2014, for example, the largest pharmacy benefit management company in the United States, Express Scripts, announced that the drug regimen would be the only hepatitis C treatment on its preferred list of covered drugs.

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Is Bias A Source Of Unmet Needs For Medically Complex Kids?


February 2nd, 2015

A study on the “Inequities In Health Care Needs For Children With Medical Complexity,” published in the December 2014 issue of Health Affairs on children’s health, supports a suspicion I have had for some time. Children with medical complexity face the possibility of unmet health care needs simply because of who they are.

Dennis Kuo and colleagues found that children with medical complexity had higher unmet needs than children without medical complexity. The authors describe medical complexity as “children who require medical services beyond what is typically required by children with special health care needs.”

This inequity holds regardless of race, ethnicity, insurance coverage, and household income in relation to poverty level. In other words, unmet needs remain high even among those who have favorable social determinants of health care. The authors conclude that medical complexity itself may be an independent determinant of health care inequity for children.

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New On GrantWatch Blog


January 27th, 2015

Health Affairs GrantWatch Blog brings you news and views of what foundations are funding in health policy and health care.

Here are the most recent posts:

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How Policy Makers In Emerging Health Systems Can Advance Innovative Care For The Chronically Ill


January 15th, 2015

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 info@centerforhealthcaremanagement.org or follow @HCMatColumbia.

Discussions of innovation in health care often focus on new technologies, big data, and refined population health strategies within the context of mature Western health care systems. But innovation is just as important, with perhaps greater impact, in evolving systems where more foundational opportunities exist to deliver affordable, quality care to the most expensive and challenging patients: those with chronic illnesses. In that context, public policy and regulation can spur innovation.

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CMS Spending Report Leads Health Affairs 2014 Top-Ten List


January 13th, 2015

A report on 2012 health spending by analysts at the Centers for Medicare and Medicaid Services Office of the Actuary was the most-read Health Affairs article in 2014. To celebrate the New Year, Health Affairs is making this piece and all the articles on the journal’s 2014 top-ten list freely available to all readers for two weeks.

Health Affairs publishes annual retrospective analyses of National Health Expenditures by the CMS analysts, as well as their health spending projections for the coming decade. In the latest installment in this series — which also made our 2014 top ten — the analysts reported on 2013 health spending and discussed their findings at a Washington DC briefing. The two reports documented continued slow growth in health spending; the 2013 report featured the slowest rate of health spending growth since CMS began tracking NHE in 1960.

Next on the 2014 Health Affairs most-read list was an article on PepsiCo’s workplace wellnesss program. John Caloyeras and coauthors at RAND and PepsiCo found that the diseases management component of the program saved money, but the lifestyle management component did not. This was followed by two Narrative Matters essays by Charlotte Yeh and Diane Meier; another Narrative Matters piece, by Janice Lynn Schuster, rounded out the list at number ten.

The full top-ten list is below. And check out the 2014 most-read Health Affairs Blog posts and GrantWatch Blog posts.

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Medicaid Expansion Post Leads Health Affairs Blog 2014 Top-Fifteen List


January 8th, 2015

As we begin 2015, we present the fifteen most-read Health Affairs Blog posts from 2014. Topping the list is “Opting Out Of Medicaid Expansion: The Health And Financial Impacts,” by Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhander. “Low-income adults in states that have opted out of Medicaid expansion will forego gains in access to care, financial well-being, physical and mental health, and longevity that would be expected with expanded Medicaid coverage,” the authors write, and they offer a state-by-state projection of these consequences.

Next on the list is Susan DeVore‘s overview of health care trends to watch in 2014, followed by David Muhlestein‘s look at the likely growth of accountable care and an examination of declining inpatient hospital utilization by Robert York, Kenneth Kaufman, and Mark Grube. The list also includes two posts from Tim Jost’s comprehensive series on implementing the Affordable Care Act, on waiting periods for employer-sponsored health insurance and Medicaid asset rules.

Stay tuned for the 2014 most-read lists for Health Affairs journal and GrantWatch Blog.

The full top-fifteen list is below:

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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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CMS Proposes Coverage For Lung Cancer Screening With Low Dose CT


December 9th, 2014

On November 11, the Centers for Medicare and Medicaid Services (CMS) released its Proposed Decision Memo for Screening Lung Cancer with Low Dose Computed Tomography (LDCT), which is expected to be finalized in mid-December. Despite a negative assessment by its own advisory committee, CMS has proposed coverage with evidence development (CED) for an annual “lung cancer screening counseling and shared-decision-making visit” and, for appropriate beneficiaries, additional screening with LDCT.

Under CED, Medicare provides conditional coverage for a new treatment or technology while additional data is collected to confirm its effectiveness and make a final determination. Through this proposed decision, CMS has followed the lead of numerous other expert and advisory groups, which have concluded that the overall benefits of such screening for at-risk individuals outweigh concerns regarding gaps in evidence, generalizability and potential harms.

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Evolving Medicaid To Better Serve Children With Medically Complex Conditions


December 8th, 2014

The fragmented Medicaid system must evolve to better meet the needs of children with medically complex conditions, a growing population responsible for a high proportion of health care spending. Regional care networks and national data support are two viable tools for containing costs while improving care for our nation’s most vulnerable children.

The Case for Change

Medicaid has evolved into an essential health care payor for the nation’s children, supporting health care coverage for more than 30 million children.

The program has become particularly vital to families of children with complex medical conditions. Care for this population was not widespread when Medicaid was created nearly 50 years ago. In the early 1960s very few infants born with extreme prematurity and/or congenital conditions survived. Thanks to advances in pediatric subspecialty training and technology, the life prospects for these children have greatly improved, and Medicaid now supports an estimated 2 million children with medical complexity. This population is projected to double over the coming decade.

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Adverse Events In Older Adults: The Need For Better Long-Term Care Financing And Delivery Innovation


November 20th, 2014

Evidence mounts that a major disconnect exists between the services most frail older adults need and what they get. The vast majority of frail older adults (around 75 percent) who face challenges in taking care of themselves live at home. According to new research from Vicki Freedman and Brenda Stillman, published in the most recent issue of The Milbank Quarterly, almost a third of these older adults report having an adverse consequence as a result of not getting the help they need. These consequences are pretty grim – the most frequently reported event being wet clothes associated with an unmet need around toileting.

But the most shocking statistic from this research is that hiring a paid helper appears to do little to protect against these consequences. Among those who hired help, nearly 60 percent reported adverse consequences. No doubt this reflects a higher level of need: paid helpers are brought in when the risk is quite high. But, it also reflects an inadequacy in support — an analogous group living in supportive housing (i.e., residential care or assisted living facilities) reported these events at a much lower rate (36 percent).

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Health Affairs Web First: In 11-Country Survey Of Older Adults, Americans Are Sickest But Have Quickest Access To Specialists


November 20th, 2014

A new survey of the health and care experiences of older adults in eleven different countries, released recently as a Web First by Health Affairs, found that Americans were sicker than their counterparts abroad, with 68 percent of respondents living with two or more chronic conditions and 53 percent taking four or more medications. Also, Americans were most likely to report cost-related expenses for care (19 percent of respondents) than residents in any of the other countries surveyed.

On the other hand, the United States compared favorably in some aspects: For example, 83 percent of US respondents had a treatment plan they could carry out in their daily life, one of the highest rates across the surveyed countries.

A few other key findings:

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Continuity Of Care For Chronic Conditions: Threats, Opportunities, And Policy


November 18th, 2014

Continuity of care is a bedrock principle of the patient-doctor relationship and is believed to be a fundamental attribute of high-quality medical care. Mounting evidence suggests that continuity of care for patients with chronic conditions prevents hospitalizations, reduces health care costs, and may prolong life in some populations.

Because patients are most likely to have longitudinal relationships with their pediatricians, family physicians, and internists, taken together, these primary care doctors are integral to translating continuity into meaningful care coordination. However, within the rapidly shifting landscape of health care delivery in the United States, continuity of care is simultaneously threatened and promoted by emerging care models.

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Health Affairs Web First: For Global Health Programs Aiding Developing Countries, Analyzing A New Funding Model


November 13th, 2014

Development assistance for health in low-and-middle-income countries nearly tripled from 2001 to 2010, with much of that growth directed toward the response to HIV. Donor agencies struggle to determine how much assistance a country should receive. A new study, recently released as a Health Affairs Web First, presents three allocation methodologies to align funding with priorities.

The study authors Victoria Fan, Amanda Glassman, and Rachel Silverman then select a model—one with enough flexibility to solve mismatches between disease burdens and allocations—to evaluate the progress that could be made by one organization—the Global Fund to Fight AIDS, Tuberculosis, and Malaria—in fighting HIV. The authors found that under the new funding model, substantial shifts in the Global Fund’s portfolio are likely to result from concentrating resources in countries with more HIV cases and lower per capita income.

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Examining State Prison Health Care Spending: Cost Drivers And Policy Approaches


November 4th, 2014

Health care and corrections have emerged as fiscal pressure points for states in recent years as rapid spending growth in each area has competed for finite revenue. Not surprisingly, health care spending for prison inmates—the intersection of these two spheres—also has risen swiftly.

Yet this trend of rising health care costs for prisoners may have been reversed in many states, according to a new report by the State Health Care Spending Project, a collaboration between The Pew Charitable Trusts and the John D. and Catherine T. MacArthur Foundation. Total correctional health care expenditures and per-inmate spending increased in nearly all states from fiscal years 2007 to 2011, but in most states it began declining after peaking in 2009 and 2010. Nationwide, prison health care spending totaled $7.7 billion in 2011, down from a high of $8.2 billion in 2009, after adjusting for inflation. The downturn in spending stemmed in part from a reduction in state prison populations.

As states work to manage prison health care expenditures, a decrease in spending was a positive development as long as it did not come at the expense of access to good quality care. Yet states continue to face a variety of challenges that threaten to drive costs back up. Chief among these is a steadily aging prison population.

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Bringing Health, Wellness, And Opportunity To Coal Country


October 31st, 2014

Editor’s Note: This post is part of an ongoing series written for Health Affairs Blog by local leaders from communities honored with the annual Robert Wood Johnson Foundation Culture of Health Prize. In 2014, six winning communities were selected by RWJF from more than 250 applicants and celebrated for placing a priority on health and creating powerful partnerships to drive change.

A small Appalachian coal mining town might seem like an unlikely place for a contemporary community health revolution, but Williamson, WV can proudly claim that achievement. As a city of 3,098 people along the banks of the Tug Fork River, Williamson has a long history of defying expectations. In the late 19th and early 20th century, it became the center of a cultural renaissance that began when the Norfolk and Western Railway brought people from all over the United States to Mingo County (Williamson is the county seat).

This diverse group of entrepreneurs and miners turned Williamson into a sophisticated urban center that became the “heart” of America’s billion-dollar-coal-field. They created an infrastructure that survived three great floods and today is part of a network of facilities that are being used for renewed development through the Sustainable Williamson project — a six-part initiative designed to bring better health and economic opportunity to a region faced with daunting financial and public health challenges.

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Poverty’s Association With Poor Health Outcomes and Health Disparities


October 30th, 2014

A recent ecological study by Carl Stevens, David Schriger, Brian Raffetto, Anna Davis, David Zingmond, and Dylan H. Roby, published in the August issue of Health Affairs, showed significant associations between neighborhood poverty and diabetes-related lower extremity amputations (LEA) in the state of California, which adds to the growing evidence that where you live (not just how you live) may directly impact your health.

The authors linked data from multiple sources (i.e. California Health Information Survey, Census Bureau’s American Community Survey, health facility discharge data) and used geographic information system (GIS) analyses and regression analyses to identify amputation “hot spots” and uncovered a 10-fold variation in LEA rates between low-income and high-income neighborhoods.

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Adult Conversation On High-Priced Drugs? Don’t Hold Your Breath (But Hang In There) …


October 27th, 2014

The benevolent identity of the health care enterprise tends to moderate disagreements and keep them under a big tent of shared goals. In the case of very high prices for powerful new drugs, however, the commons gets stretched painfully thin. Drug companies which see themselves as pioneers are accused of being merely greedy. Cost-conscious payers and regulators are impugned for depriving patients of life-conserving treatment breakthroughs. A divisive political undercurrent often threatens to obtrude. Altogether, a tough environment for rational policy assessment.

Credit is due, accordingly, to the Brookings Institution, for putting a wide array of views on display at its October 1 forum on “the cost and value of biomedical innovation,” which was jointly sponsored by the Schaeffer Center at the University of Southern California. With the head of Gilead Sciences at one pole of the discussion and a leading generics industry attorney at the other, the discussion didn’t lack for strongly-held views, strongly stated.

But the tone was civil, a lot of useful information was exchanged, and the audience went away carrying a meta-message about the importance of maintaining an “adult conversation” on a subject of such obvious importance and difficulty.

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Is A Study Of HIV Treatment For Mothers In Africa Unethical?


October 1st, 2014

A global health controversy erupted this summer when the prominent scientific journal Nature ran an article entitled “HIV trial attacked.” Within, commentators squared off over whether a huge ongoing study provides suboptimal and thus unethical treatment options to mothers with HIV in the developing world.

The multinational PROMISE study (for Promoting Maternal and Infant Survival Everywhere) is enrolling thousands of pregnant women with HIV in hopes of comparing mortality and other clinical outcomes between mothers who receive lifelong HIV therapy to mothers who receive shorter treatment durations if they have less advanced HIV disease.

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