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Good And Bad News For Diabetes Prevention In The Community


March 25th, 2015

The findings from a recent synthesis of the literature about the effectiveness of prevention initiatives focused on reducing the risk of Type 2 diabetes among high-risk populations (people already obese or inactive or diagnosed as having prediabetes) are largely encouraging.

The synthesis includes a comprehensive and systematic review of the medical, diabetes, and public health literature for evaluation studies of interventions published between 2002 and 2013. The search was undertaken using medical subject headings and keywords related to diabetes and its risk factors.

A number of interventions—such as the National Institutes for Health’s Diabetes Prevention Program and the Group Lifestyle Balance Program—focused on helping people eat better and become more physically active are effective in reducing the risk of diabetes onset. Robust studies show that these interventions work even better than medication to prevent diabetes.

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When It Comes To The Value Of Wellness, Ask About Fairness Not Just About Effectiveness


March 18th, 2015

After a short truce, the wellness wars are raging again on this blog, with some voices hailing workplace wellness programs as cost effective means to better public health and others questioning their value.

Our own data show that both have a point. We have found that program participation is associated with statistically significant improvements in biometric markers, like BMI, and health-related behavior, like smoking and exercise. But we also find that those changes are not large enough, and the relationship between health risks and spending too weak, to result in reduction of health care cost, let alone in return of investment.

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How Menu Labeling Could Spark Change Beyond The Menu Board


February 24th, 2015

If there’s one thing we’ve learned about catalyzing changes that prevent illness in the first place, it’s that passage of a single policy can be like lighting a match — illuminating the way towards strategies with greater impact and igniting the energy of leaders. The success of a menu labeling might be the match needed to inspire further policy change to shift the trend of increased diet-related chronic disease in the United States.

In November, the Food and Drug Administration released the final rule guiding calorie labeling of menu items at chain food service establishments with 20 or more outlets nationally. The rule will apply to fast-food and sit-down restaurants, supermarkets, convenience stores and movie theaters, and will take effect on December 1, 2015.

Once implemented, calorie counts will be posted for all items (including alcoholic drinks) on menus and menu-boards, and on display tags for salad bars, bakery items, and soda dispensers. A companion rule requiring calorie labeling for vending machines will take effect one year later.

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Oregon Bridges The Gap Between Health Care And Community-Based Health


February 12th, 2015

It is now commonly accepted that to achieve health, the U.S. health system must address the social determinants of health. While the integration of health care with social services and public health is happening relatively infrequently across the country, one bright spot can be found in Oregon, where an innovative Medicaid health system model, referred to as the coordinated care model, is showing early signs of success in bridging the gap between the community and the health care system.

Under Oregon Governor John Kitzhaber’s leadership, newly created coordinated care organizations (CCOs)—partnerships between physical, behavioral, and oral health providers—have over the past two years adopted Oregon’s coordinated care model, which was created as the foundation for Oregon’s health system reform efforts to ensure care is coordinated, performance is measured, positive outcomes are rewarded, and that there is a shared responsibility for health, sustainable rate of growth, and transparency in price and quality—all with the goal of promoting positive health outcomes.

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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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Finding And Supporting A Workforce With The Right Skill Mix


January 27th, 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.

Many health systems are experiencing shortages of health care workers. Policymakers and practitioners have tried for a long time to figure out how to assess workforce productivity, skills and roles, in order to achieve the best mix of professionals needed to deliver high quality care while preserving sustainability.

Unfortunately, many obstacles have slowed progress toward this goal. Open questions still concern not only how many doctors or nurses are needed in any given system or organization level, but also over what roles and responsibilities fall to different health professionals and specialists.

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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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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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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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The Payment Reform Landscape: Benefit And Network Design Strategies To Complement Payment Reform


November 4th, 2014

For the past ten months on Health Affairs Blog, we’ve been discussing the evidence for different models of payment reform, examining everything from pay for performance to nonpayment. But no discussion of payment reform is complete without addressing benefit and network designs and how they can help or hinder various payment reforms.  When the right payment method is paired with the right benefit and/or network design, they can work together to help reduce costs and improve care.  There are a number of payment approaches that pair well with specific benefit and network design strategies to yield higher-quality, lower-cost care. Below we discuss a few of these effective pairings.

But before we get into the specifics, why it is important to motivate providers to deliver and patients to seek higher-value care?  Health care providers may not only respond to direct financial incentives, but they are also likely to respond to knowing information about their performance is being put in front of prospective and current patients.  They also may be more willing to accept new forms of payment if acceptance means payers will encourage more patients to seek their care.

On the flip side, patients are unlikely to know how their providers are paid.  But if motivated (financially and otherwise), patients may act on meaningful distinctions in price and quality by choosing higher-value providers, saving money for themselves and whoever else is footing the bill for their care.

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Exhibit Of The Month: Comparing The Cost And Value Of Specialty And Traditional Drugs


October 27th, 2014

Editor’s note: This post is part of an ongoing “Exhibit of the Month” series. Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

This month’s exhibits, from the article, “Despite High Costs, Specialty Drugs May Offer Value For Money Comparable To That Of Traditional Drugs,” published in the October issue of Health Affairs, compare the value and costs of specialty and traditional drugs approved by the Food and Drug Administration from 1999-2011.

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Relative Value Health Insurance And Pay For Performance For Insurers: Complements, Not Substitutes


September 19th, 2014

Background

The quest for value dominates contemporary health policy.  Value, properly defined, is not about cost-savings but about the balance of costs and health benefits — improving the average cost-effectiveness of health interventions.  In choosing which care is funded, insurers are a crucial but commonly neglected driver of health system value.

Insurers can increase health system value by covering fewer cost-ineffective interventions or covering more cost-effective interventions.  Perhaps the earliest attempt to reform insurance, managed care, attempted to pursue both goals, but by the time it was implemented it widely focused (or was perceived to focus) on cost-containment.

A recent insurance reform proposal, known as Relative Value Health Insurance (RVHI), received considerable attention, for instance, in The Upshot, The Incidental Economist, and Forbes.  RVHI enables insurers to reduce their contractual obligation to cover “usual and customary” care.  This and similar earlier proposals rely on the insurers’ natural incentive to cut costs.  Less well-covered, however, are proposals to alter the very incentives of insurers to improve health, which we will call “pay-for-performance-for-insurers” (P4P4I).

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The Payment Reform Landscape: Accountable Care Organizations


August 5th, 2014

“The accountable care organization is like a unicorn, a fantastic creature that is vested with mythical powers. But no one has actually seen one,” said former California HealthCare Foundation CEO, Mark Smith, MD, in 2010. Over the last four years, we’ve certainly seen a proliferation of unicorns and we’re now reaching the point where fantasy—at least in a handful of cases—is becoming a reality.

A growing number of large employers are piloting accountable care organizations (ACOs), working through their health plan; in some cases they are doing so directly with provider systems, such as the new Boeing arrangement with Providence Health and Services, Swedish Health Services, and University of Washington Medicine and Intel’s contracting efforts in Albuquerque, New Mexico and Portland, Oregon. The large employers and other health care purchasers with whom we work — eager, if not desperate, for solutions to contain the costs of health care and improve its quality — are watching these first movers carefully to see if ACOs prove to be a viable strategy for improving population health and bending the cost trend.

These leading purchasers intend to set the bar high. They cannot make the investment to pursue these ACO relationships if they are not assured that their populations will see meaningful, measurable gains in their health care and its affordability, as well as their health. That often means contractual commitments to lowering total costs of care and showing improved patient outcomes for targeted populations — like high risk, medically complex patients. Our purchaser colleagues who have been among the early adopters of ACO arrangements have begun to identify the features critical to successful ACOs; these are the elements other purchasers will look for when deciding if it’s worth proceeding.

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Individual Patient Expanded Access: Developing Principles For A Structural And Regulatory Framework


July 31st, 2014

Individual patient expanded access, sometimes termed “compassionate use,” refers to situations where access to a drug still in the development process is granted to patients on a case-by-case basis outside of a clinical trial, prior to completion of mandated clinical trials and approval by the Food and Drug Administration (FDA). This typically involves filing a single patient or emergency investigational new drug (IND) request with the Food and Drug Administration and voluntary release of the drug by the manufacturer.

Generally, the following criteria must be met: there is reasonable expectation of meaningful benefit despite the absence of definitive clinical trial data, the patient has a serious or life-threatening condition, there are no comparable or satisfactory treatment alternatives, and there are no suitable clinical trials for the drug available to the patient. This form of expanded access, which is the focus of this paper, is different from the situation in which a drug is discharged to a large group of needy patients in the interval between successful phase 3 trials and presumed FDA approval, a strategy often termed a “treatment” IND or protocol, which was initially used in the 1980s for releasing zidovudine to patients with acquired immune deficiency syndrome.

A Call to Action: The Importance of Expanded Access Programs

The Engelberg Center for Health Care Reform at the Brookings Institution recently invited senior leaders from several pharmaceutical companies, two bioethicists, a senior FDA representative, and a patient advocate to share experiences and discuss organizational strategies related to expanded access (see acknowledgements). A driving factor for this meeting was a recent flurry of highly public cases of desperate patients seeking access to experimental drugs, which lead to social media campaigns and media coverage.

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New Drug And Device Approval: What Is Sufficient Evidence?


July 1st, 2014

Editor’s note: In addition to Jonathan Darrow, this post is also coauthored by Aaron Kesselheim. 

The federal Food, Drug, and Cosmetic Act gives the Food and Drug Administration (FDA) the authority to evaluate all prescription drugs and high-risk medical devices before they can be marketed to physicians and patients to ensure that they are safe and effective.

However, there is growing pressure to lessen the traditional standards for defining “safe and effective” for particularly promising therapies and accelerate patient access to these products.

A recent national health policy conference in Washington, D.C., explored the nature of the evidence needed for the regulatory approval of new therapeutics and the implications for patient care. The conference was organized by the Program On Regulation, Therapeutics, And Law (PORTAL) at Brigham and Women’s Hospital/Harvard Medical School, the National Center for Health Research, and the American Academy for the Advancement of Science (AAAS).

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Request For Abstracts: Health Affairs Health Care And Medical Innovation Theme Issue


June 5th, 2014

Health Affairs is planning a theme issue on health care and medical innovation in early-2015. The issue will span the fields of medical technology and also cover public policy and private sector innovations that promote improvements in the delivery of care, lower costs, increase efficiency, etc. 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.

We invite interested authors to submit abstracts for consideration for this issue. To be considered, abstracts must be submitted by June 25, 2014. We regret that we will not be able to consider any abstracts submitted after that date. Editors will review the abstracts and, for those that best fit our vision and goals, invite authors to submit papers for consideration for the issue. Invited papers will be due at the journal by September 2, 2014.

More information on topics and themes for this issue, as well as process guidelines and timetables, is available below and on the Health Affairs website.

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Measuring Patient Satisfaction: A Bridge Between Patient And Physician Perceptions Of Care


May 9th, 2014

Patient satisfaction is at the core of patient centered medicine. Improved patient satisfaction not only leads to an enhanced patient experience—something every sick or injured patient deserves—it is also associated with improved treatment outcomes. In 2008, researchers demonstrated that improved patient satisfaction was correlated with higher quality hospital care “for all…conditions measured.” More recent work has begun to identify exactly how this correlation works. For example, higher patient satisfaction has been associated with reduced readmission rates. Furthermore, improved patient satisfaction has even been correlated with reduced inpatient mortality, “suggesting that patients are good discriminators of the type of care they receive.”

Despite the correlation between higher patient satisfaction rates and improved outcomes, measurement of patient satisfaction remains controversial among many health care providers. Physicians, in particular, often chafe when organizations, such as The Commonwealth Fund through their site WhyNotTheBest, or the Centers for Medicare and Medicaid Services though their Physician Compare website, begin to publicly report doctors’ patient satisfaction data. Additionally, employed physicians often fret when patient satisfaction is included in their reimbursement metrics.

Certainly there are instances in which sound medicine may lead to a lower rate of patient satisfaction; infrequently, satisfaction can correlate, not with high quality care, but with the fulfillment of patients’ a priori wishes for their treatment. A good example of this problem is the difficulty in refusing to fill narcotics prescriptions and steering a patient toward alternative pain relief modalities when the physician has good evidence that a patient has a problem with narcotics abuse. While the doctor in this example is practicing good medicine, it is highly unlikely that the patient will leave the office anything other than deeply disappointed.

Despite these relatively rare cases, many studies show a deep chasm between how patients and doctors view medical care, and thus demonstrate the need to measure patient satisfaction rates. Patients and their doctors can view the same episodes of care quite differently so, without patient satisfaction measures, we are left with an incomplete or even misleading picture of patient care.

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The Payment Reform Landscape: Payment For Non-Visit Functions And The Medical Home


May 6th, 2014

As I’ve been discussing in Health Affairs Blog each month, payment reforms can pose a spectrum of financial risk for providers, with financial upside only — such as pay-for-performance programs — on one end, and downside-only models — such as nonpayment for care that shouldn’t happen — on the other. In March, we examined pay-for-performance, an upside-only model.  This month, we look at another upside-only model, typically used to support care coordination and patient centered medical homes (PCMH). The technical term Catalyst for Payment Reform (CPR) has coined for this payment model is “payment for non-visit” functions.

In its simplest form, this model is a per member per month (PMPM) payment, layered on top of another form of payment like fee-for-service. Providers typically receive this PMPM payment to help them manage their patients’ care and to support their coordination with other providers in the “medical home.” A lot has been written about care coordination and patient-centered medical homes and their ability to improve care outcomes; however, like their pay-for-performance “cousin,” the ability of these models to contain costs remains to be seen.

How common is this payment model?

According to CPR’s 2013 National Scorecard on Payment Reform, based on responses to eValue8, a nationwide survey of commercial health plans, 0.6 percent of commercial insurance payments to doctors and hospitals are payments for non-visit functions, such as care coordination fees for patient-centered medical homes. This percentage represents about 5 percent of all value-oriented payment as measured by CPR. (Approximately 11 percent of all commercial payments are value-oriented—designed to improve quality and reduce waste.)

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When Less Is More: Issues Of Overuse In Health Care


April 25th, 2014

Editor’s Note: This post is part of an ongoing 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.

About 18 months ago, Daniel Wolfson, president of the American Board of Internal Medicine (ABIM) Foundation began asking audiences of clinicians if any of them had ever seen a patient subjected to unnecessary medical care. As one of the architects of the Choosing Wisely campaign, an initiative of the ABIM Foundation intended to reduce overuse of medical services, Wolfson had a particular interest in the answer to this question. He was surprised to find that in some of his audiences, a majority of clinicians have personal experience with overuse.

Clinicians’ newfound willingness to concede that overuse is a problem comes as good news for people who have long labored to increase awareness of this aspect of medicine in America, including the authors of this blog and many of the readers of Health Affairs.

Overuse is costly, pervasive, and causes harm to patients, yet it has been remarkably difficult to get the medical profession, health care industry, and general public to take note of it, much less take steps to reduce it. Today, however, there are multiple efforts underway that offer hope for real change, including Choosing Wisely, the growth of palliative care, and the Lown Institute’s Right Care Alliance; but until now, the most difficult step has been the first: for patients, payers, physicians and policymakers to acknowledge the scope of the problem.

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Clinical Nuance: Benefit Design Meets Behavioral Economics


April 3rd, 2014

On Capitol Hill, there’s a growing chorus of support from both sides of the aisle to move the focus of health care payment incentives from volume to value. Earlier this month, legislators introduced proposals that would have fixed the sustainable growth rate in Medicare, as well as made other changes, including allowing for clinical nuance in Medicare benefit designs. The Centers for Medicare and Medicaid Services, too, is embracing this trend, recently asking for partners in a demonstration project to used value-based arrangements in benefit design. These efforts of policymakers and agencies to innovate Medicare’s benefit design are crucial both for the health of seniors and to ensure value in the Medicare program.

The concept of clinical nuance, implemented using value-based insurance design (V-BID), is a key innovation already widely implemented in the private and public payers. It recognizes two important facts about the provision of medical care: 1) medical services differ in the amount of health produced, and 2) the clinical benefit derived from a medical service depends on who is using it, who is delivering the service, and where it is being delivered.

Today’s Medicare beneficiaries face little clinical nuance in their benefit structure. Medicare largely uses a “one-size-fits-all” structure that does not recognize that some treatments, drugs or tests are more important to health than others. Not only does it create inefficiencies in the health system, it can actually harm the health of beneficiaries.

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