http://healthaffairs.org/blog The Policy Journal of the Health Sphere Fri, 24 May 2013 19:29:45 +0000 en-US hourly 1 http://healthaffairs.org/blog/2013/05/24/the-latest-health-wonk-review-20/?utm_source=rss&utm_medium=rss&utm_campaign=the-latest-health-wonk-review-20 http://healthaffairs.org/blog/2013/05/24/the-latest-health-wonk-review-20/#comments Fri, 24 May 2013 15:51:48 +0000 Chris Fleming http://healthaffairs.org/blog/?p=31585 latest edition of the Health Wonk Review. Brad includes a Health Affairs Blog post by Al Adelman and Lew Morris reacting to an earlier Health Affairs Narrative Matters essay by Jonathan Welch. Welch's mother received "indifferent" hospital care and eventually died; Adelman and Morris believe that this substandard care reflected systemic deficiencies, and they urge hospital leaders to ask hard questions about their institutions that address those factors.]]> http://healthaffairs.org/blog/2013/05/24/the-latest-health-wonk-review-20/feed/ 0 http://healthaffairs.org/blog/2013/05/21/where-was-the-leadership-the-questions-raised-by-jonathan-welchs-narrative-matters-essay/?utm_source=rss&utm_medium=rss&utm_campaign=where-was-the-leadership-the-questions-raised-by-jonathan-welchs-narrative-matters-essay http://healthaffairs.org/blog/2013/05/21/where-was-the-leadership-the-questions-raised-by-jonathan-welchs-narrative-matters-essay/#comments Tue, 21 May 2013 19:38:38 +0000 S. Allan Adelman http://healthaffairs.org/blog/?p=31455 Dr. Jonathan Welch's Narrative Matters essay in the December, 2012 edition of Health Affairs, regarding the cascade of errors and omissions he witnessed in connection with the care provided to his mother, should raise profound questions about how the hospital allowed those failures of care to happen. Dr. Welch, an emergency medicine physician, watched helplessly as his mother received indifferent care from various nurses and doctors and ultimately died. Despite having classic signs of evolving sepsis, she was not closely monitored by the nursing staff which ignored alarming signs, was not put on a sepsis treatment protocol by her oncologist, and was not put in an intensive care unit where she could receive more intense monitoring and aggressive treatment from specialists.

While it is tempting to blame the nurse (for not taking vital signs frequently enough and not reacting to abnormal vital signs) and the oncologist (for not following the patient closely enough, not initiating appropriate treatment, and not involving other specialists), Dr. Welch’s story suggests that there were more deeply rooted systemic problems at the hospital that went beyond the shortcomings of the individuals involved in his mother’s care.

As health care attorneys who represent hospitals and physicians, we believe there are some fundamental questions which should be asked by this hospital’s administration, medical staff leadership and governing body to ensure Dr. Welch’s experience is not repeated. Those questions, which the leaders in all hospitals should consider, include the following:]]> http://healthaffairs.org/blog/2013/05/21/where-was-the-leadership-the-questions-raised-by-jonathan-welchs-narrative-matters-essay/feed/ 0 http://healthaffairs.org/blog/2013/05/16/hospital-charges-and-the-need-for-a-maximum-price-obligation-rule-for-emergency-department-out-of-network-care/?utm_source=rss&utm_medium=rss&utm_campaign=hospital-charges-and-the-need-for-a-maximum-price-obligation-rule-for-emergency-department-out-of-network-care http://healthaffairs.org/blog/2013/05/16/hospital-charges-and-the-need-for-a-maximum-price-obligation-rule-for-emergency-department-out-of-network-care/#comments Thu, 16 May 2013 19:12:45 +0000 Robert Murray http://healthaffairs.org/blog/?p=31255 release of average charges for common procedures in more than 3,000 U. S. hospitals last week by the Centers for Medicare and Medicaid Services (CMS) elicited divergent reactions – not surprisingly. On one hand, it was front-page news for most of the major newspapers: “Hospital Billing Varies Wildly, Government Billing Data Shows,” was the headline in the New York Times. The article went on to speculate that these new data would likely “intensify a long debate over the methods that hospitals use to determine their charges.”

On the other hand the data were “old hat” to most health policy analysts. Several colleagues mentioned to me that “this is old news” and “it isn’t meaningful at all because we all know that charges don’t mean anything.”

“No one pays charges” is the common refrain. “Charges are merely an accounting fiction.”

Charges Do Matter -- They Matter A Great Deal

Counter to the belief of both hospital industry representatives and many of my colleagues, hospital charge levels and rapidly escalating charges matter a great deal. While individual states and the Affordable Care Act (ACA) have instituted limits on the amounts low-income uninsured patients pay hospitals, insured patients that receive care at hospitals that are “Non-Par” or “out-of-network” are still victims of hospital’s exorbitant charging practices. When patients receive emergency services at an out-of-network hospital, the patient and/or insurance company (depending on insurer cost sharing for out-of-network care) pay full charges.

High and increasing hospital charges, combined with increasing proportions of cases admitted through the hospital Emergency Department (ED), are major factors behind the ever-declining negotiating leverage of private health insurers. This situation, coupled with the increased pricing power of the ever-more-concentrated provider industry, will be a major contributor to the almost certain rapid escalation in total U.S. health care costs in coming years.]]> http://healthaffairs.org/blog/2013/05/16/hospital-charges-and-the-need-for-a-maximum-price-obligation-rule-for-emergency-department-out-of-network-care/feed/ 3 http://healthaffairs.org/blog/2013/05/13/implementing-health-reform-medicaid-dsh-payments-utah-exchanges-and-more/?utm_source=rss&utm_medium=rss&utm_campaign=implementing-health-reform-medicaid-dsh-payments-utah-exchanges-and-more http://healthaffairs.org/blog/2013/05/13/implementing-health-reform-medicaid-dsh-payments-utah-exchanges-and-more/#comments Mon, 13 May 2013 22:06:29 +0000 Timothy Jost http://healthaffairs.org/blog/?p=31150 HHS proposed rule on Medicaid disproportionate share hospital payment reductions; an IRS notice of proposed rulemaking on medical loss ratios for Blue Cross and Blue Shield plans that receive certain tax preferences; and a set of frequently asked questions on the Utah SHOP exchange.

Medicaid DSH payments. The Department of Health and Human Services issued a proposed rule for cuts in disproportionate share hospital payments on May 13, 2013. The DSH program has since 1981 provided federal funding to state Medicaid programs to allow those programs to offer additional support to hospitals that serve a disproportionate share of low-income patients with special needs. The Medicaid DSH program, together with a similar Medicare program, has provided essential support to hospitals that have often borne the brunt of providing services to the uninsured.

With the Affordable Care Act’s expansion of coverage of the uninsured through the expanded Medicaid program and premium tax credits and cost-reduction payments, Congress concluded that DSH payments would be less necessary and cut both the Medicaid and Medicare programs. Since 1998, Medicaid DSH payments to each state have been limited to an annual allotment. The ACA requires reductions in these allotments, beginning with $500,000 for 2014 and increasing to $5.6 million for 2019, before dropping to $4 million of 2020. It also lists five factors that HHS must consider in reducing the state allotments. It does not specify, however, how those factors should be applied or weighted. The proposed rule addresses this question.]]> http://healthaffairs.org/blog/2013/05/13/implementing-health-reform-medicaid-dsh-payments-utah-exchanges-and-more/feed/ 2 http://healthaffairs.org/blog/2013/05/13/watch-health-affairs-briefing-on-health-spending/?utm_source=rss&utm_medium=rss&utm_campaign=watch-health-affairs-briefing-on-health-spending http://healthaffairs.org/blog/2013/05/13/watch-health-affairs-briefing-on-health-spending/#comments Mon, 13 May 2013 19:37:05 +0000 Chris Fleming http://healthaffairs.org/blog/?p=31141 Health Affairs briefing on our May issue, "Tackling The Cost Conundrum," or if you just want to see it again, video and speaker materials are now available on the Health Affairs website. You can watch the whole briefing or select particular panels or speakers.]]> http://healthaffairs.org/blog/2013/05/13/watch-health-affairs-briefing-on-health-spending/feed/ 0 http://healthaffairs.org/blog/2013/05/07/is-the-recent-health-care-spending-growth-slowdown-sustainable-over-the-long-term/?utm_source=rss&utm_medium=rss&utm_campaign=is-the-recent-health-care-spending-growth-slowdown-sustainable-over-the-long-term http://healthaffairs.org/blog/2013/05/07/is-the-recent-health-care-spending-growth-slowdown-sustainable-over-the-long-term/#comments Tue, 07 May 2013 12:10:20 +0000 John Holahan http://healthaffairs.org/blog/?p=30803 Centers for Medicare and Medicaid Services estimated the growth in national health expenditures to be a record-low 3.9 percent, considerable speculation on the causes of slower spending growth has come from a variety of sources. There seems to be a consensus among actuaries, academics, and other analysts that the recession and the associated increase in unemployment and decline in insurance coverage led individuals to cut back on their use of health care services. (See here, here, But, while the recession is clearly associated with the dramatic slowdown in spending growth from 2007-2009, there is also evidence that the slowdown in spending preceded the recent recession and seems to be continuing during the modest economic recovery.

Observers of this more general trend have begun to suggest that fundamental structural changes in the health system are playing a role in recent spending trends. The ability of some high profile providers and health systems to achieve high quality outcomes with greater efficiency has garnered a lot of attention and some suggest that more salaried employment of physicians could be altering the practice patterns that developed under a fee-for-service system. Others have pointed to patient-centered medical homes, accountable care organizations, and other payment and delivery system reforms as potential contributors to the slowdown in spending growth. The Obama administration has also argued that the Affordable Care Act has started to have a moderating effect on spending growth.

The extent to which the economy versus broader systemic changes has been driving slower spending growth has enormous implications for forecasting future spending trends. If the economy has been the primary driver of recent trends, we should expect spending growth to return to historically high levels as the economy recovers. The Congressional Budget Office (CBO) and the CMS actuaries have revised their Medicare and Medicaid forecasts downward to reflect the latest trends, but both entities seem to suggest that spending growth over the long term will return to historical levels. If, however, more structural changes are at work, then perhaps there is reason to be hopeful that health care spending growth will continue at a rate much closer to the rate of growth in the economy.]]> http://healthaffairs.org/blog/2013/05/07/is-the-recent-health-care-spending-growth-slowdown-sustainable-over-the-long-term/feed/ 1 http://healthaffairs.org/blog/2013/04/24/reforming-the-research-regulatory-system/?utm_source=rss&utm_medium=rss&utm_campaign=reforming-the-research-regulatory-system http://healthaffairs.org/blog/2013/04/24/reforming-the-research-regulatory-system/#comments Wed, 24 Apr 2013 18:26:28 +0000 Joel Kupersmith http://healthaffairs.org/blog/?p=30361 in need of reform. Established 21 years ago by the Common Rule, it has functioned via a rigorous environment to assure that risk in research is dealt with and transparency maintained.

The trigger for these regulations is a definition of research as a “systematic investigation…designed to develop or contribute to "generalizable knowledge." When this definition is satisfied, an intensive set of requirements ensues including review, approval, and continued oversight by an Institutional Review Board (IRB); reporting requirements;, the necessity for informed consent (often highly complex); and other administrative components. If projects are not “generalizable,” (e.g., local hospital programmatic or quality review), they fall strictly under healthcare system purview rather than under Common Rule regulatory oversight.

The current system has a strong moral imperative and has been critical to mitigating risk for research subjects and providing transparency. However, it is burdensome and fails to take into account the considerable progress made in both the research and clinical enterprises over the last few decades: in research, technological advances in generating data on routine care, and in healthcare, much more stringent oversight.]]> http://healthaffairs.org/blog/2013/04/24/reforming-the-research-regulatory-system/feed/ 1 http://healthaffairs.org/blog/2013/04/10/a-misleading-suggestion-of-increased-utilization-from-mental-health-parity/?utm_source=rss&utm_medium=rss&utm_campaign=a-misleading-suggestion-of-increased-utilization-from-mental-health-parity http://healthaffairs.org/blog/2013/04/10/a-misleading-suggestion-of-increased-utilization-from-mental-health-parity/#comments Wed, 10 Apr 2013 14:08:58 +0000 Howard Goldman http://healthaffairs.org/blog/?p=29992 Oregon and the Federal Employees Health Benefits Program have not found that similar parity requirements resulted in increased costs.

A recent report from the Health Care Cost Institute (HCCI) has been widely interpreted as suggesting that the MHPAEA and an interim final rule (IFR) implementing the statute caused an increase in hospital inpatient admissions for psychiatric conditions. However, the report does not support this interpretation.

The HCCI released its report on trends in inpatient psychiatric admissions as if it evaluated the impact of the MHPAEA. But the report simply juxtaposes a longstanding trend of increasing hospitalization for psychiatric conditions between 2007 and 2011 with the observation that the MHPAEA and its Interim Final Rule (IFR) were implemented at the end of 2010 and in 2011. This tells us nothing useful about the impact of the MHPAEA. In contrast, the FEHB Program and Oregon studies, which did not find cost increases attributable to parity, analyzed time periods just prior to policy implementation and just following implementation, and they controlled for the secular trend of increasing psychiatric admissions, using a difference-in-differences analytic strategy.]]> http://healthaffairs.org/blog/2013/04/10/a-misleading-suggestion-of-increased-utilization-from-mental-health-parity/feed/ 2 http://healthaffairs.org/blog/2013/04/09/analysis-of-utilization-rate-declines-leads-ha-blog-march-top-ten/?utm_source=rss&utm_medium=rss&utm_campaign=analysis-of-utilization-rate-declines-leads-ha-blog-march-top-ten http://healthaffairs.org/blog/2013/04/09/analysis-of-utilization-rate-declines-leads-ha-blog-march-top-ten/#comments Tue, 09 Apr 2013 19:46:13 +0000 Stephen Langel http://healthaffairs.org/blog/?p=29952 Mark Grube, Kenneth Kaufman and Robert York’s analysis of the decline in hospital utilization rates leads the Health Affairs Blog most-read list for March. Also on the top-ten list are articles on: the human face of hospital readmissions by Risa Lavizzo-Mourey; the impact of the Affordable Care Act by Kathleen Sebelius; the health care workforce by Thomas Daschle; and physician payment reform by Bill Frist and Steven Schroeder.

The most-read list also includes David Muhlestein’s survey of the accountable care organization landscape; Diane Archer's discussion of the effects of concentration in the health care market, and Jesse Singer's look at the use of electronic health records by the New York City Primary Care Information Project. Also among the top ten are Tim Jost’s article about the role of federally facilitated and partnership exchanges; and an article by Sara Rosenbaum and Joel Teitelbaum on the impact of the Essential Health Benefits rule on persons with disabilities.]]> http://healthaffairs.org/blog/2013/04/09/analysis-of-utilization-rate-declines-leads-ha-blog-march-top-ten/feed/ 0 http://healthaffairs.org/blog/2013/04/08/the-april-issue-of-health-affairs-the-triple-aim-goes-global/?utm_source=rss&utm_medium=rss&utm_campaign=the-april-issue-of-health-affairs-the-triple-aim-goes-global http://healthaffairs.org/blog/2013/04/08/the-april-issue-of-health-affairs-the-triple-aim-goes-global/#comments Mon, 08 Apr 2013 20:20:27 +0000 Stephen Langel http://healthaffairs.org/blog/?p=29909 April issue of Health Affairs, released today, examines how all high-income countries are struggling to achieve the “Triple Aim” -- better health and better health care at lower cost. The articles in this issue find that the United States and other high-income countries have much to learn, with the “trade” in strategies and tactics likely to flow both ways.

Join us on Thursday, April 11, for a briefing on the April issue. Support for the new Health Affairs volume was provided by The Commonwealth Fund, Britain’s Nuffield Trust, and the Institute of Global Health Innovation at Imperial College London.

Drug Payment And Pricing -- How Do US Practices Compare With Other Countries?

A featured study by Panos Kanavos of the London School of Economics and Political Science and coauthors compared prescription drug prices among selected countries that are members of the Organization for Economic Cooperation and Development in 2005, 2007, and 2010. Depending on how prices were adjusted for the volume of drugs consumed in the various countries, drug prices in the United States were between 5 percent and nearly 200 percent higher than in the other nations studied. A key contributing factor is that the United States takes up new and more expensive prescription drugs faster than other countries. The authors recommend that the United States require pharmaceutical manufacturers to provide more evidence about the value of new drugs in relation to cost before use of such drugs is reimbursed.]]> http://healthaffairs.org/blog/2013/04/08/the-april-issue-of-health-affairs-the-triple-aim-goes-global/feed/ 0