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For High-Risk Medicare Beneficiaries: Targeting CMMI Demonstrations On Promising Delivery Models

April 22nd, 2014

Medicare beneficiaries with multiple chronic conditions, certain types of serious conditions (e.g. heart disease, pulmonary disorders, mental disorders, cancer), and functional limitations have higher health and long-term care costs and more adverse outcomes than other beneficiaries.

One of the biggest opportunities for savings for Medicare, Medicaid, and beneficiaries themselves, is through reducing hospitalizations, readmissions, and institutional care, especially for these high-risk beneficiaries. Achieving these savings and serving this population will require innovative delivery models and a clear business case to convince organizations to implement those new models.

The Affordable Care Act set aside $10 billion for experiments in innovative care delivery and payment systems.  With these funds, the Centers for Medicare and Medicaid Innovation (CMMI) is launching and evaluating several initiatives, primarily Accountable Care Organizations (ACOs), bundled payment for care innovation, and primary care transformation.  These initiatives change financial incentives for health care providers so that while they bear some financial risk for the costs of providing care, they also stand to benefit from any savings produced.

Historically, it has taken additional legislative action to apply successful delivery models more broadly across the Medicare program. Now, the health care law has removed this barrier, giving the Secretary of Health and Human Services the ability to expand successful innovations that improve quality or lower costs.  While early results show improvements in quality and modest savings, most CMMI pilots and demonstrations to date are not specifically targeted on high-risk beneficiaries, where the biggest gains can be expected.

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Payment and Delivery Reform Case Study: Congestive Heart Failure

April 15th, 2014
by Darshak Sanghavi

Editor’s note: In addition to Darshak Sanghavi (photo and bio above), this post is coauthored by Meaghan George, a project manager at the Engelberg Center for Health Care Reform at the Brookings Institution. The post is adapted from a full-length case study, the first in a series of case studies made possible through the Engelberg Center’s Merkin Initiative on Physician Payment Reform and Clinical Leadership, a special project to develop clinician leadership of health care delivery, payment and financing reform. The case studies will be presented using a “MEDTalk” format featuring live story-telling and knowledge-sharing from patients, providers, and policymakers. The event series will kickoff on Wednesday, April 16 from 10 a.m. – Noon EST.


Clinicians and hospitals across the nation struggle with providing and paying for optimal care for their congestive health failure (CHF) patients. However, there are opportunities to make care better. In fact, of the more than 10,000 pages in the Affordable Care Act (ACA) implementing regulations, the least talked about are the dozens of small experiments led by the Center for Medicare and Medicaid Innovation (CMMI) that test new ways to pay for medical services.

We use a case study approach to investigate and tell the story of what two academic medical centers, Duke University Health System (“Duke”) and University of Colorado Hospital (“Colorado”), are doing to innovate and improve CHF care while implementing alternative payment models offered by CMMI.

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New Health Affairs: Implications Of Alzheimer’s And The State Of Research

April 7th, 2014
by Chris Fleming

Health Affairs’ April issue addresses the litany of public and personal ramifications of Alzheimer’s disease—the most expensive condition in the United States both in terms of real costs and the immeasurable toll on loved ones. Articles examine best practices and models of care; a global view of the disease; the effects on caregivers; and what may lie ahead for a disproportionately underfunded research community.

Unnecessary hospital and emergency department (ED) visits are particularly difficult on people with Alzheimer’s—and costly to the health care system—but they experience them more often than their counterparts without dementia. Zhanlian Feng of RTI International and colleagues examined Medicare claims data linked to the Health and Retirement Study to determine hospital and ED use among older people with and without dementia across community and institutional settings. They found that in the community older people with dementia were more likely to have a hospitalization or ED visit than those without dementia, and that both groups had a marked increase in health care usage near the end of life.

Specifically, they found significant differences in hospitalizations and ED visits among community-dwelling residents, with 26.7 percent of dementia patients versus 18.7 percent of non-dementia residents experiencing hospitalization, and 34.5 percent versus 25.4 percent experiencing an ED visit. Differences were less pronounced among nursing home residents and tended to even out among all groups in the last year of life. The researchers suggest that policy makers consider promoting the use of alternative end-of-life options such as hospice care and providing supportive services and advance care planning to Medicare beneficiaries that can help reduce avoidable hospital-based care.

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Embarking On A New Journey With Health Affairs

March 31st, 2014
by Alan Weil

I am delighted to be taking on the role of editor-in-chief of Health Affairs. This is a dynamic time in all aspects of health and health care: insurance coverage expansions, delivery system changes, and growing attention to population health.  Building upon thirty-three years of peer-reviewed scholarship, Health Affairs will continue to serve as the nation’s primary resource for the health policy community.

My goals for Health Affairs coalesce around a single theme: broadening the reach of the journal.

Health Affairs is strong in the core health policy community, but our scholarship is relevant to myriad actors in the one-sixth of the United States economy represented by health care.  My goal is to broaden our engagement with the worlds of law, finance, design, and many others.

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Health Affairs Briefing: Long Reach Of Alzheimer’s Disease

March 26th, 2014
by Chris Fleming

Despite decades of effort, finding breakthrough treatments or a cure for Alzheimer’s has eluded researchers. In the April 2014 issue of Health Affairs, The Long Reach Of Alzheimer’s Disease, we explore the many subjects raised by the disease: the optimal care patients receive and the testing of new models, international comparisons of how the disease is treated, families’ end-of-life dilemmas, a new public-private research collaboration designed to produce improved treatments, and others.

Please join us on Wednesday, April 9, at W Hotel in Washington, DC, for a Health Affairs briefing where we will unveil the issue. We are delighted to welcome Dr. Richard Hodes, director of the National Institute on Aging at the National Institutes of Health to deliver the Keynote.

Wednesday, April 9, 2014
8:30 a.m. – 12:30 p.m.

W Hotel Washington
515 15th Street NW, Washington, DC (Metro Center)
Great Room, Lower Level


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

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PCORI’s Research Will Answer Patients’ Real-World Questions

March 25th, 2014
by Joe Selby

As a physician, I know the challenge of helping patients determine which health care options might work best for them given their personal situation and preferences. Too often they — and their clinicians — must make choices about preventing, diagnosing and treating diseases and health conditions without adequate information. The Patient-Centered Outcomes Research Institute (PCORI) was created to help solve this problem — to help patients and those who care for them make better-informed health decisions.

Established by Congress through the Patient Protection and Affordable Care Act as an independent research institute, PCORI is designed to answer real-world questions about what works best for patients based on their particular circumstances and concerns. We do this primarily by funding comparative clinical effectiveness research (CER), studies that compare multiple care options. But more research by itself won’t improve clinical decision-making. Patients and those who care for them must be able to easily find relevant evidence they can trust. That’s why our mandate is not just to fund high-quality CER and evidence synthesis but to share the results in ways that are meaningful to patients, clinicians and others. We’re also charged with improving the methods used in conducting those studies and enhancing our nation’s capacity to do such research.

We will be evaluated ultimately on whether the research we fund can change clinical practice and help reduce the variations and disparities that stand between patients and better outcomes. We’re confident that the work we’re funding brings us and the audiences we serve closer to that goal.

Recently, some questions have been raised in health policy circles about our holistic approach to PCORI’s work. That view holds that direct comparisons of health care options — especially those involving high-priced interventions — should be the dominant if not sole focus of PCORI’s research funding approach as a path to limiting the use of expensive, less-effective options.

We agree that discovering new knowledge on how therapies compare with one another is a critical mandate of PCORI and is essential to improving the quality and effectiveness of care. However, ensuring that patients and those who care for them have timely access to and can use this knowledge, so that they can effectively apply it to improve their decisions, is also very important. That is the reasoning behind our integrated approach path that addresses the gaps in available evidence, and also studies how best to make the evidence available and usable.

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Countering Cancer: The New Foreign Policy Issue

March 21st, 2014
by Tara Sonenshine

For years internationalists have being trying to make the argument to ordinary Americans that foreign policy matters — that we must contend with complex issues overseas like countering terrorism while also focusing resources and energies on economic issues at home. We have posed it as a trade-off.

We are making the foreign affairs case the wrong way. Rather than argue the positive merits of trade or the negative repercussions of unchecked global terrorism, we (all of us in the international arena) should be talking more about cancer — something every citizen understands. Countering cancer is akin to countering terrorism and, like most global issues, demands international cooperation.

Cancer is a war and peace issue. The enemy– a foreign mutated cell– spreads destruction with no regard to human life. Cancer does not discriminate against religions or ideology. It invades lungs, livers, breasts, colons, bowels and every conceivable organ. The warriors are good cells and good doctors, reliant on the best research and medicine available—wherever in the world we can find it.

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Health Information Exchange In NYC Jails: Early Policy Challenges

March 20th, 2014
by Michelle Martelle

Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health. For more on jails and health information technology in particular, see here, here, and here.

New York City has the second largest jail system in the United States, with an average daily census of approximately 12,000 and 80,000 annual admissions. It is well documented that the population that cycles in and out of US jails each year is statistically sicker than the general population and therefore would benefit from greater care coordination between correctional and community settings. The Department of Health and Mental Hygiene’s Bureau of Correctional Health Services (CHS) is responsible for the care delivered in all 12 NYC jail facilities. The mission of CHS is to provide a community standard of care based on three core frameworks; patient safety, population health and human rights.

As part of this mission, CHS implemented a full electronic health record (EHR) system starting in 2008, completing the implementation of the final facility in 2011. One of the most promising features of EHRs is the ability to share information electronically to facilitate care coordination, referred to as Health Information Exchange (HIE).  Preliminary research of the use of HIE in community based settings is encouraging, with the use of HIE in the Emergency Department resulting in 30 percent fewer admissions and use in ambulatory settings resulting in 56 percent fewer readmissions within 30 days of hospital discharge. (Results pending review; presented 11/14/13 at NYeC Digital Health Conference by Center for Healthcare Informatics and Policy (CHiP).) In the hopes of realizing the full benefits of its EHR system, CHS recently launched an HIE pilot in its women’s facility.

The goals of integrating HIE into jail-based health care are to inform the care patients receive while incarcerated and to coordinate care upon release.  Currently, CHS has access to two external sources of information: BHIX, a Regional Health Information Organization (RHIO) that recently merged with Healthix and now includes patient data from some major hospital systems and community providers in parts of Brooklyn, Queens and Long Island; and PSYCKES, a Medicaid claims-based data warehouse that includes claims information (both medical and mental health) on patients who have had a substance abuse or mental health diagnosis and/or substance abuse or mental health treatment within the last five years.

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A Lifetime Value-Based Proposal For Medicare Payment Reform

March 14th, 2014
by Zhou Yang

urrent Medicare reform policy proposals mainly focus on lowering annual cost or cost increase per capita, but they fail to recognize Medicare as a lifetime plan that covers each beneficiary from age 65 to death. I propose a Lifetime Value-Based Payment Plan (LVBPP) for Medicare reform. LVBPP aims to achieve efficient use of the government contribution to Medicare for each beneficiary from age 65 to death and features shared responsibility among beneficiaries, providers, and federal government.

LVBPP includes six major components to create incentives for chronic disease prevention and efficient use of medical care resources by promoting market-based competition on quality of care and innovations in medical technology and care delivery models. Preliminary results indicate that LVBPP could lead to better health in terms of longer longevity and lower disability rate, save up to $70 billion over 10 years, and save up to $164 billion for the federal government over the lifetime of the cohort of upcoming beneficiaries age 55 to 59, as of the 2010 census. (The bases for these savings estimates, as well as suggested values for the expenditure thresholds and copayment rates involved in LVBPP, are provided in the Simulation Appendix below.)

The challenge. There is wide consensus that chronic disease is the leading cause of mortality and rapidly increasing health care costs in the US. Lifestyle choices have been found to be a major factor behind the increasing prevalence of chronic disease. It is estimated that 60 percent of deaths and 70 percent of health care spending in the US are related to lifestyle choices. However, despite volumes of science-based clinical trial results demonstrating positive effects of behavioral change on patients’ long-term well-being, and continuous public media campaigns promoting lifestyle change, there is no sign of reduction in the prevalence rate of chronic disease in the US population.

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Howard Koh To Keynote Health Affairs Briefing Tomorrow On ACA And HIV/AIDS

March 10th, 2014
by Chris Fleming

One of the least explored yet most important parts of the Affordable Care Act (ACA) are provisions that hold promise for addressing serious health care challenges facing the 1.1 million Americans who are living with HIV/AIDS — and others like them — most of whom are impoverished and uninsured.

Please join Health Affairs Founding Editor John Iglehart on Tuesday, March 11, in Washington, DC, for a Health Affairs briefing on our March issue where we will spotlight topics related to the ACA and people with HIV/AIDS. The briefing will be keynoted by Howard K. Koh, Assistant Secretary for Health, U.S. Department of Health and Human Services.

Tuesday, March 11, 2014
9:00 a.m. – Noon

National Press Club
529 14th Street NW, Washington, DC, 13th Floor (Metro Center)


Follow live Tweets from the briefing @HA_Events, and join in the conversation with the hashtag #HA_HIVAIDS

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How Will California’s Penal System Respond To The ‘Perfect Storm’?

March 7th, 2014
by Jonathan Simon

Editor’s note: In addition to Jonathan Simon (photo and bio above), this post is coauthored by Daniel Mistak, a graduate student in Jurisprudence and Social Policy at the University of California, Berkeley. He previously earned his juris doctorate from University of California, Berkeley, School of Law. Prior to law school he attained a master’s degree in philosophy, with a focus in bio-ethics, and a master’s degree in genetics and cell biology. This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health.

California’s system of incarceration is in the midst of sweeping changes. Recent shifts in state and federal law, motivated and bolstered by Supreme Court decisions, have created a perfect storm for institutional change. But as with any storm, it can be difficult to predict what can be done to prepare and what will be left when the clouds clear.

What caused this perfect storm in California? In 2011, the Supreme Court found in Brown v. Plata that California’s prisons could not meet the mental and physical health needs of the inmates because of prison overcrowding. To avoid violating the VIII Amendment’s prohibition on cruel and unusual punishment, the Court mandated that California prisons decrease their over-crowded prison populations to 137.5 percent of their design capacity within two years. Governor Jerry Brown signed into law Assembly Bill 109 (‘Realignment’) to facilitate this transition.

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Financial Orphan Therapies Looking For Adoption

March 6th, 2014

There exist scientifically promising treatments not being tested further because of insufficient financial incentives. Many of these therapies involve off-label uses of drugs approved by the Food and Drug Administration that are readily available and often inexpensive. Pharmaceutical companies—largely responsible for clinical drug development—cannot justify investing in such clinical trials because they cannot recoup the costs of these studies.  However, without prospective data demonstrating efficacy, such treatments will never be adopted as standard of care.

In an era of increasing health care costs and the need for effective therapies in many diseases, it is essential that society finds ways to adopt these “financial orphans.” We propose several potential solutions for the non-profit sector, pharmaceutical companies, health insurers, patient driven research and others to accomplish this goal.

Drug Development Today

Under today’s drug development model, the vast majority of clinical trials are sponsored by pharmaceutical companies, and the process is lengthy, expensive, and, some have argued, inefficient. The cost of developing a new FDA approved drug is estimated to exceed $1.2 billion, the average time from lead to market is typically over 10 years, and only 1 in 10 drugs entering a phase I study is finally approved. Thus pharmaceutical companies, seeking to recoup this investment, conduct a return on investment (ROI) calculation with attention to both scientific and financial considerations such as the chances of success and whether the therapy will be sufficiently profitable to justify the high cost of clinical development.

These considerations sometimes lead to inefficient outcomes from society’s perspective in which promising and potentially transformative therapies are not pursued because of improperly designed financial incentives. We call such therapies “financial orphans.”

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The PRIDE Initiative: Building The Capacity And Scalability Of Integrated Managed Care Plans

February 13th, 2014

As health care costs have increased, the challenges of managing complex chronic conditions, compounded by frailty, disability, mental illness, poverty, or limited education, have become more pressing. Correspondingly, individuals, families, and government entities alike are increasingly frustrated with the current health care system. Even people like me – a seasoned health services researcher working in a large integrated delivery system – find it difficult to assemble and coordinate an array of medical and long-term services and supports (LTSS) to meet our family members’ preferences and needs.

Coordinating services for my own mother – an upbeat 94-year old with considerable financial resources but advancing dementia, frailty, blindness, and a variety of health and LTSS needs – requires more of my time and that of other family members.  People with similar needs but fewer resources often face far more daunting problems in trying to understand diverse Medicare and Medicaid benefits, access appropriate services, and navigate among multiple health and LTSS providers that rarely communicate with each other.

Below I describe the early work of the PRIDE consortium, a small group of seven high potential health care organizations (CareSource, OH; Commonwealth Care Alliance, MA; iCare, WI; Health Plan of San Mateo, CA; Together4Health, IL; UCare, MN; and VNSNY CHOICE , NY) that aim to provide access to genuinely integrated medical and behavioral health and LTSS for people dually eligible for Medicare and Medicaid. The backdrop for PRIDE (Promoting Integrated Care for Dual Eligibles) is the new federal-state effort to align the Medicare and Medicaid programs and enroll high-needs, high-cost dually eligible beneficiaries in integrated health care entities that will offer better coordinated, more consumer-centric and lower-cost care. At the federal level, the Centers for Medicare & Medicaid Services (CMS) is the chief honcho for efforts to harmonize the workings of Medicare and Medicaid, test innovative payment and service delivery models, and reduce expenditures.

In 2011, CMS awarded contracts of up to $1 million to each of fifteen states to design coordinated care demonstrations involving capitation arrangements or fee for service entities.  Additionally, eleven states (plus those that received the $1 million planning awards) submitted proposals to participate in CMS’s “financial alignment initiative,” intended to improve alignment between Medicare and Medicaid policies affecting care for dual eligibles.  By September 2013, CMS had signed Memorandums of Understanding (MOU’s) with seven states to pursue coordinated care demonstrations, while others’ MOU’s were in the pipeline.

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The Changing Health Care World: Trends To Watch In 2014

February 10th, 2014
by Susan DeVore

While today’s news is bombarding us with headlines about, the Affordable Care Act isn’t just about insurance coverage. The legislation is also about transforming the way health care is provided. Consequently, it has ushered in new competitors, services and business practices, which are in turn generating substantial industry shifts that affect all players along healthcare’s value chain. Following are some of the top trends that our alliance is preparing for in 2014:

Chronic Care, Everywhere. It’s no secret that providers are moving quickly to implement accountable care organizations (ACOs). Recently, the Premier healthcare alliance released a survey of hospital executives projecting that ACO participation will nearly double in 2014. As providers work to improve their way to shared savings payments, look for a more intensive focus on the biggest health care consumers: those with multiple chronic conditions.

Since each chronic condition increases costs by a factor of three, managing this population is the sweet spot for the ACO, and the deepest pool from which to pull savings. To do it, an increasing number of providers will deploy Ambulatory Intensive Care Units (A-ICUs) or patient centered medical homes as part of their ACO, which will be charged with better managing chronic conditions exclusively within a clinically integrated, financially accountable primary care practice. As part of the approach, providers will develop care pathways for better managing chronic conditions and behavioral health needs, with an eye toward lowering hospital utilization, including inpatient bed days, length of stay, admissions, readmissions, and ED visits.

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New Health Affairs Issue: Successes And Missing Links In Connected Health

February 3rd, 2014
by Chris Fleming

Health Affairs’ February issue focuses on the current evidence and future potential of connected health — encompassing telemedicine, telehealth, and mHealth. The importance of connected health is sure to grow as more Americans gain access to health care and new, team-based models seek to provide better quality care in more efficient ways. The issue offers a variety of articles that explore what can entice hospitals, health systems, and individual providers to embrace telehealth, as well as the policy solutions that can better facilitate adoption across the health care system:

Want to increase telehealth adoption among U.S. hospitals? Look to state legislatures. Julia Adler-Milstein of the University of Michigan School of Information and co-authors emphasize that state policies are influential. According to their findings, states that wish to encourage the use of telehealth should promote private payer reimbursement and relax licensure requirements.

Overall, Adler-Milstein and coauthors found that 42 percent of US hospitals had adopted telehealth by late 2012, with significant variation across the country: Alaska was the highest with 75 percent, and Rhode Island had minimal adoption.

Market forces and individual hospital features also influence telehealth adoption rates. Factors that positively influence adoption rates include serving as a teaching hospital, being part of a larger system, having greater technological capacity, and higher rurality. Factors negatively affecting adoption include high population density, being for-profit, and operating in a less competitive market.

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Accountable Care Growth In 2014: A Look Ahead

January 29th, 2014
by David Muhlestein

On December 23, 2014, the Centers for Medicare and Medicaid Services announced 123 new Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs).  This represents the fourth round of MSSP participants, which, coupled with the Pioneer ACOs, brings the number of Medicare ACOs to 366.  Some of these organizations were already known to be ACOs, including those that transferred from the Pioneer ACO program, but many were new to accountable care, bringing the total number of public and private ACOs to 606.

With continued government support of ACOs and considerable growth in the number of organizations becoming ACOs, the prospect of ACOs becoming a dominant model in care delivery seems very real.  In this post I will evaluate how the accountable care movement has grown and suggest what industry observers should look for in 2014.

Overview of Accountable Care Organizations

An accountable care organization, at its most basic level, is a group of health care providers that accept responsibility to care for the health needs of a defined population while meeting predetermined quality benchmarks.  The specific goals of ACOs are to improve quality outcomes, improve the experience of care, and lower costs.  Without conveying all the details of what that definition includes, it is important to recognize that the definition is relatively broad; it includes multiple types of organizations operating under many different payment arrangements.  While the MSSP is the most publicized incarnation of ACOs, many other public and private models exist, with many different approaches to achieving the common goals.

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Broadening the ACA Story: A Totally Accountable Care Organization

January 23rd, 2014
by Stephen Somers and Tricia McGinnis

Note: This post is coauthored by Stephen Somers and Tricia McGinnis of the Center for Health Care Strategies.

Amid the bumpiness of Obamacare’s widely publicized technical launch, some in the media started taking the opportunity to laud the Affordable Care Act’s (ACA) largely untold story in reforming our “overpriced, underperforming health care system.”  The New York Times’ Bill Keller and Harvard health economist David Cutler, writing in the Washington Post, reported that progress was being made on multiple fronts in re-orienting the system to pay “for the value, not the volume, of medical care.” They pointed to penalties for hospital readmissions; the use of bundled payments; the development of Medicare and commercial accountable care organizations (ACOs); and a slowdown in health care cost growth at least partially attributable to these changes.

Within state-run Medicaid programs, a parallel phenomenon has been taking shape—the creation of ACOs tailored to the care needs of Medicaid’s beneficiaries, many of whom have multiple chronic health and social challenges. While ACOs for the broad range of Medicaid beneficiaries will be similar to the ACOs that already exist in the Medicare and commercial insurance sector, a new breed of Totally Accountable Care OrganizationsTACOs – offer the potential to push accountability for Medicaid populations, including those with complex needs, to a new level. “Totally” refers to the expectation that these organizations will be responsible for services beyond just medical care (for example, mental health, substance abuse treatment and other social supports), as well as the aspiration that these organizations will assume accountability for all associated costs of care, ultimately, through global payment mechanisms.

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Advanced Care Model Honors Dignity, Integrates Health System For Seriously Ill People And Loved Ones

December 23rd, 2013

Editor’s Note: This post is the second in a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on an upcoming volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value. This post describes the Advanced Care model, a delivery system approach that includes palliative care and coordinates services for people with serious chronic illness across hospitals, medical groups, homes, and the community.

Like other initiatives to reform American health care, the movement to improve care for patients with advanced illness does not suffer from a lack of new ideas. The real barriers to improvement lie in replicating innovative models that have already addressed the problem and found scalable and sustainable solutions. Fortunately, promising initiatives are now prepared to transform care on a national scale. These developments are timely because reform is badly needed.

Our fragmented approach to advanced illness exacts a terrible toll from our sickest and most vulnerable citizens and their families. It also places a growing burden on our health care system. Hospital treatment of advanced illness absorbs a large fraction of the Medicare budget. Over one quarter of all Medicare expenditures pay for care in the last year of life, a proportion that has not changed in 35 years.  CMS research shows that about 30 percent of this final-year spending is concentrated in the month prior to death, and 80 percent of Medicare dollars spent during that final month go toward hospital treatment.

People suffering from advanced illness – multiple chronic conditions with declining function and poor prospects for full recovery – often fall through the cracks between current programs and providers.  Like patients under disease management, people with advanced illness have multiple chronic conditions, but their decline in health and function is more pronounced, faster, and in many cases, irreversible. In short, a person with advanced illness has entered the “gray zone” between treatable and terminal illness.

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The Untold Story Of 2013: Governors Lead In Health Care Transformation

December 17th, 2013
by Dan Crippen and Frederick Isasi

As 2013 winds to a close, it is a good time for the health policy community to reflect on a historic year for our nation. The most talked about health care issues have centered on the rollout of new health insurance and Medicaid coverage as part of the Affordable Care Act. However, another watershed reform of our health care system has been taking root across the country, relatively unnoticed and with many governors at the helm.

These efforts are focused on broad, statewide reforms designed to dramatically alter the way we think about, deliver and pay for health care. The reforms move away from a siloed and fractured delivery system and are focused on two key objectives: improving the health of the nation, and reducing the financial burden of health care on the government, employers and individuals.

The drive for these reforms results from several key pressures. Perhaps most urgent is the fiscal pressure bearing down on states. Governors have acutely experienced the effect of decades of rapidly escalating health care costs, and almost all states are under a requirement to balance their budgets. Governors must, therefore, account for growth in spending in Medicaid and CHIP, state employee and retiree health insurance, and indigent health care. Often these increases must be funded by increased tax revenue or reductions in other areas of state spending, for example education or transportation.

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HELP Committee Explores Life Expectancy And Health Disparities Through Health Affairs Lens

December 12th, 2013
by Amir Al-Kourainy

On November 20th, the Health, Education, Labor, and Pensions Committee subcommittee on Primary Health and Aging held a hearing, “Dying Young, Why Your Social and Economic Status May Be a Death Sentence in America,” which explored the troubling link between poverty, decreased life expectancy, and increased rates of chronic disease. The hearing featured testimony from authors who have recently published related work in Health Affairs.

The committee heard testimony from David Kindig, Emeritus Professor of Population Health Sciences, University of Wisconsin School of Medicine, and Linda Berkman, Director of the Harvard Center for Population and Development Studies and Thomas D. Cabot Professor of Public Policy and Epidemiology. Their testimony highlighted a chart (see Exhibit 2) from Kindig’s Health Affairs research. Also testifying was Steven Woolf, Director of the Center on Society and Health and Professor of Family Medicine and Population Health, Virginia Commonwealth University. Others who testified at the hearing included Nicholas Eberstadt of the American Enterprise Institute, Michael Reisch of the University of Maryland School of Social Work, and Sabrina Schrader, a constituent from West Virginia who provided a heartfelt and compelling personal story detailing the impacts of poverty on health.

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