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New On GrantWatch Blog


November 21st, 2014

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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Shifting From Depression Screening Alone To Evidence-Based Depression Treatment In ACOs


November 19th, 2014

In their October 2014 Health Affairs article, “Few ACOs Pursue Innovative Models That Integrate Care for Mental Illness And Substance Abuse With Primary Care,” Valerie Lewis et al. identified that the quality measures in an Accountable Care Organization’s (ACO) contract affect how well that ACO integrates behavioral and physical health integration.

The authors note that depression screening is a common measure among the ACO contracts that include behavioral health measures and suggest that additional measures could lead to further improvement. In this blog, we propose some additional measures and consider whether effective measures alone will be sufficient or just necessary to promote integrated care models that reduce costs and improve health for the ACO’s defined population.

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Exhibit Of The Month: Mental Health Spending On A Global Scale


September 29th, 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 exhibit, published in the September global health issue of Health Affairs, looks at budget allocation for mental health services by country income level.

In the article, “Policy Actions To Achieve Integrated Community-Based Mental Health Services,” authors Mary DeSilva, Chiara Samele, Shekhar Saxena, Vikram Patel, and Ara Darzi write that “most low-income countries allocate about 0.5 percent of their already small health budgets to the treatment and prevention of mental health problems.”

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Implementing Health Reform: Excepted Benefits Final Rule


September 29th, 2014

Congress adopted Title I of the Affordable Care Act to increase access to health coverage for individuals by reforming employer group health coverage and health insurance offered to individuals and groups, requiring large employers to offer their employees affordable minimum health coverage or pay a penalty, imposing a penalty on individuals who can afford health coverage but fail to obtain it, and offering advance premium tax credits through the exchanges to individuals who cannot otherwise afford to purchase health coverage.

Coverage has long been available both through groups and for individuals that provides some health-related benefits but is neither a group health plan nor insured health coverage, as those terms are defined in the ACA.  These benefits were originally labeled by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 as “excepted benefits,” because they are excepted from the forms of benefits regulated initially by HIPAA and now by the ACA.

On September 26, 2014 the Internal Revenue Service, Department of Labor, and the Centers for Medicare and Medicaid Services (“the agencies”) issued regulations expanding access to excepted benefits through insured and self-insured groups.

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Mental Health Reform: Treating Before Stage 4


August 11th, 2014

When I talk about mental illnesses, I often point out that as a matter of public policy they are the only chronic conditions we wait until Stage 4 – the final stage in a chronic disease process – to treat, and then often only through incarceration.

To me, it is clear why this is the case. We have adopted a behavioral standard – danger to self or others – as a trigger to treatment.

But waiting until injury or death is imminent is no way to treat a chronic health condition. David Mechanic’s thoughtful Health Affairs article, “More People Than Ever Before Are Receiving Behavioral Health Care in the United States, But Gaps and Challenges Remain,” published in the recent August issue, examines the result of this Stage 4 thinking.

Beginning with “the devastating effects on the well-being of individuals, families, and communities,” Mechanic lays out the current state of mental health care in America. Mental illnesses rob individuals of both dignity and decades of life expectancy.

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Issues Of Overuse In Health Care Tops Health Affairs Blog Most-Read List For April


May 7th, 2014

Shannon Brownlee, Vikas Saini, and Christine Cassel’s look at issues of overuse in health care is the most-read Health Affairs Blog post for April. Brownlee et al.’s post was followed by Dean Aufderheide’s post on mental illness in America’s jails and prisons, published in conjunction with the March issue of Health Affairs.

Next on the list was Glenn Melnick and Lois Green’s report on costs savings and other impacts four years into a commercial accountable care organization serving the California Public Employees Retirement System, followed by Rachel Davis’ discussion of connected health opportunities for low-income patients.

The full list appears below.

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Implementing Health Reform: The Latest Affordable Care Act Coverage Numbers (Updated)


April 18th, 2014

On February 17, 2014, the White House announced that 8 million Americans have signed up for private health insurance coverage through the health insurance marketplaces, or exchanges. This significantly exceeds the White House’s original goal of 7 million enrollees. It is far more than the Congressional Budget Office’s recent projections of 6 million.

The number of actual enrollees will be smaller than this number. The CBO’s projections are for the average number of those actually enrolled in coverage over the course of a calendar year. To calculate the average number of enrollees, one must subtract from the 8 million the number of individuals who fail to pay their premiums and thus are never actually enrolled in coverage, as well as those who will drop coverage at some later point during the year. To that reduced number, then, must be added back the number who become newly covered through special enrollment periods during the remainder of the year. In the end, 6 to 7 million average enrollees is probably a reasonable estimate.

This does not, however, exhaust the number of Americans who are now covered under the Affordable Care Act. The fact sheet states that 3 million young adults are covered under their parents’ plans because of the ACA. This number is probably high, but it is clear that the ACA has dramatically increased coverage of Americans between the age of 19 and 25 — the age group most likely to lack health insurance prior to the ACA (and still).

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Families Under Stress: Reflections On April’s Narrative Matters Essay On Dementia


April 16th, 2014

Editor’s note: This post responds to the April Narrative Matters essay by Gary Epstein-Lubow, a geriatric psychiatrist, which recounts the life-changing stress experienced by relatives who care for loved ones with dementia. Epstein-Lubow’s essay is freely available to all readers, or you can listen to him read it. You can also read an abridged version of the essay published April 15 in the Washington Post.

When my daughters were five and six years old, I took them to visit my grandmother in the Rosa Coplon Home in Buffalo, New York.

“Bubbie,” I said, “These are my little girls. Do you remember when I was this age?”

She looked at me and at them and finally held out her arms to embrace us and said (in Yiddish), “I don’t know who you are, but I know you belong to me.”

That experience so affected my elder daughter that when she was a teenager she undertook a project interviewing older people and creating a radio program from the tapes.

I thought of this moment when I read Gary Epstein-Lubow’s Narrative Matters essay, “A Family Disease: Witnessing Firsthand The Toll That Dementia Takes on Caregivers,” published in the April issue of Health Affairs.

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The Latest Health Wonk Review


April 11th, 2014

Billy Wynne at Healthcare Lighthouse offers this week’s April Fool’s edition of the Health Wonk Review. All of the posts in Billy’s “April Fool’s” edition are an excellent read, including the Health Affairs Blog post by Dean Aufderheide on mental illness in America’s jails and prisons.

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Recent Health Policy Briefs: Mental Health Parity And ICD-10 Update


April 3rd, 2014

The latest Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation examines the issue of mental health parity. The push to make coverage for mental health treatment equal to that of physical health has been on legislative to-do lists for some time, both in Congress and in state houses. This brief looks […]

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Mental Illness In America’s Jails And Prisons: Toward A Public Safety/Public Health Model


April 1st, 2014

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. 

Mental Illness in America’s Jails and Prisons

The United States continues to have one of the highest incarceration rates in the world, with 5 percent of the world population, but nearly 25 percent of the world’s prisoners.  Inmates are spending more time behind bars as states adopt “truth in sentencing laws,” which requires inmates to serve 85 percent of their sentence behind bars.

In 2012, about 1 in every 35 adults in the United States, or 2.9 percent of adult residents, was on probation or parole or incarcerated in prison or jail, the same rate observed in 1997.  If recent incarceration rates remain unchanged, an estimated 1 out of every 20 persons will spend time behind bars during their lifetime; and many of those caught in the net that is cast to catch the criminal offender will be suffering with mental illness.

Nearly a decade ago, I wrote an article with Patrick Brown titled “Crisis in Corrections: The Mentally Ill in America’s Prisons.”  It was about the alarming growth in the number of mentally ill individuals behind bars.  Since then, it has been shown that about 20 percent of prison inmates have a serious mental illness, 30 to 60 percent have substance abuse problems and, when including broad-based mental illnesses, the percentages increase significantly. For example, 50 percent of males and 75 percent of female inmates in state prisons, and 75 percent of females and 63 percent of male inmates in jails, will experience a mental health problem requiring mental health services in any given year.

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HA Web First: New Medicaid Recipients Healthier Than Pre-ACA Enrollees


March 26th, 2014

The Affordable Care Act (ACA) gives states the option of expanding Medicaid coverage to individuals and families with incomes of up to 138 percent of the federal poverty level. A new study, being released today as a Web First by Health Affairs, used simulation methods to compare nondisabled adults enrolled in Medicaid before the ACA with newly eligible adults and those previously eligible but not enrolled in the program.

According to the study’s analysis, both the newly eligible and those not previously enrolled were healthier than the pre-ACA Medicaid enrollees. Authors Steven Hill, Salam Abdus, Julie Hudson, and Thomas Selden found that the pattern of results was similar for physical and mental health. They also determined that in states not expanding Medicaid under the ACA, adults in the income range for the law’s Medicaid expansion were healthier than pre-ACA enrollees.

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


March 25th, 2014

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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Incarceration And Release From Jail: Improving Re-integration Into Society Using A Health Information Exchange


March 17th, 2014

Editor’s note: This post is coauthored by Mary Darby, vice president for health policy at Burness Communications, working on issues related to health care and jails.

In the Narrative Matters essay, “To Improve Public Health And Safety, One Sheriff Looks Beyond The Jail Walls,” published in the March issue of Health Affairs, Michael Ashe, sheriff of Hampden County in Massachusetts, describes the county’s efforts to help break the cycle of reincarceration by ensuring inmates get quality health care in and out of jail. Here, Jeffrey Brenner reflects on efforts to bring jails in Camden, N.J., into a health information exchange.   

Camden, N.J., is one of the nation’s poorest cities, with 38.6 percent of the population below the poverty line in 2010, according to Census Data.  With profound poverty comes a host of other problems, including high levels of crime, violence, pollution, and illness.  People here struggle to maintain decent health, and often it is a losing battle.

One day in 2002, at the family medicine practice in Camden where I worked, I opened an envelope from the Camden County jail.  It contained a letter from a patient, “James,” who told me he’d wound up in jail, a result of some bad choices on his part.  I knew James and his family quite well.  I’d seen his wife for prenatal care when she was pregnant and given his kids their routine well-child checkups.  James himself was a poorly controlled asthmatic with seizure disorder, so I had seen him pretty regularly in the clinic.

James’ letter distressed me.  He said that his asthma and allergies, already severe, were getting worse.  In addition to being sick, he felt overwhelmed, depressed, and afraid.  After reading his letter, I called the jail to find out what was happening.

Although the staff people with whom I spoke were very nice, I found it difficult to get the information I needed – and to share the important information I had concerning James’ medical history with the appropriate personnel.  After all, James had two potentially serious chronic conditions, and he took several medications.  The health care providers in the jail didn’t know James’ medical history and they didn’t know what medications he was taking.  They also had no connection to the primary care provider who knew him best: me.

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Implementing Health Reform: Ryan White Third-Party Payments, 2015 Letter To Issuers, And Other ACA Developments


March 15th, 2014

On March 14, 2014, the Department of Health and Human Services released a flood of regulations, proposed regulations, and guidance addressing a host of Affordable Care Act implementation issues. From all indications, HHS has cleared the decks of all the regulatory issuances it had under consideration– nothing involving ACA implementation remains pending at the Office of Management and Budget. Perhaps someone made a promise that all would be completed by the end of the winter (or by Saint Patrick’s Day). More likely the necessity of having the ground rules for 2015 in place so that insurers could proceed with their 2015 forms and rates, and states with approving them, drove the deluge. In any event, it will take several posts to cover it all.

Yesterday’s post covered a notice on extending the federal preexisting condition high risk pool and a frequently asked questions document on coverage of same-sex spouses. The Internal Revenue Service also released a set of general Tax Tips for Same-Sex Couples (which covers general tax information and will not be discussed here), while HHS issued a blog post summarizing its frequently asked questions document.

This post will cover several other issuances released late in the day on March 14, 2014. These include an interim final rule (with comment period) dealing with third party payments for qualified health plans (QHPs) and stand-alone dental plans (SADPs); the 2015 final annual letter to issuers in the federally facilitated marketplace; a set of frequently asked questions on retroactive coverage, and a set of frequently asked questions on the use of exchange grants and no-cost extensions.

A final post will examine a proposed rule on exchange and insurance standards for 2015 and beyond and an accompanying bulletin on product discontinuance.

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Ethical Dilemmas In Prison And Jail Health Care


March 10th, 2014

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.

Prison and jail health care, despite occasional pockets of inspiration, provided by programs affiliated with academic institutions, is an arena of endless ethical conflict in which health care providers must negotiate relentlessly with prison officials to provide necessary and decent care.  The “right to health care” articulated by the Supreme Court pre-ordained these ongoing tensions.  The court reasoned that to place persons in prison or jail, where they could not secure their own care, and then to fail to provide that care, could result in precisely the pain and suffering prohibited by the Eighth Amendment to the Constitution.

Good reasoning was followed by a deeply flawed articulation of the “right” that defines the medical care entitlement as care provided to inmates without “deliberate indifference to their serious medical needs.” By forging a standard which was, and remains, unique in medicine and health care delivery — designed to avoid intruding on state malpractice litigation regarding adequacy of practice and standards of care — the court guaranteed that dispute would surround delivery.  That first framing, which did not establish a right to “standard of care” or to care delivered according to a “community standard,” set the stage for endless ethical and legal conflict.

The Eighth Amendment’s deliberate indifference standard, forbidding cruel and unusual punishment, presents a relatively demanding standard for proving liabil­ity.  The Eighth Amendment, as interpreted by the federal courts, does not render prison officials or staff liable in federal cases for malpractice or accidents, nor does it resolve inter-professional disputes — or patient-professional disputes — about the best choice of treatment. It does require, however, that sufficient resources be made available to implement three basic rights: the right to access to care, the right to care that is ordered, and the right to a professional medical judgment.

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New Health Affairs: ACA’s Impact On Americans With HIV/AIDS And Jail-Involved Individuals


March 3rd, 2014

Health Affairs’ March issue, released today, explores how the Affordable Care Act (ACA) could affect two key sectors of the population with unique public health needs—those living with HIV/AIDS and people who have recently cycled through local jails.

When it comes to HIV treatment, timing is everything. Dana Goldman of the University of Southern California and coauthors modeled HIV transmission and prevention based on when HIV-positive individuals started combination antiretroviral treatment (cART). They estimate that from 1996-2009, early treatment initiation in the US prevented 188,700 HIV cases and avoided $128 billion in life expectancy losses.

The authors highlight treatment at “very early” stages (when CD4 white blood cell counts are greater than 500, consistent with current treatment guidelines in the US) as responsible for four-fifths of prevented cases. Early treatment both reduces morbidity and mortality in people living with HIV/AIDS, and decreases the transmission of the disease to the uninfected. Goldman and coauthors conclude that early treatment has clear value for both HIV-positive and HIV-negative populations in the US.

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Broadening the ACA Story: A Totally Accountable Care Organization


January 23rd, 2014

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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Implementing Health Reform: New Affordable Care Act Guidance; Church Plans And Contraceptive Coverage


January 10th, 2014

The pace of Affordable Care Act regulatory activity has slowed dramatically with the new year, particularly in comparison with the frenetic pace late in 2013 leading up to the January 1, 2014 implementation date for major ACA reforms. On January 9, 2014, however, the Departments of Labor, Treasury, and Health and Human Services issued a series of Frequently Asked Questions (FAQs) regarding implementation of the ACA, as well as the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). This post discusses these FAQs and summarizes other recent regulatory and legal developments.

Coverage of breast cancer risk-reducing drugs. The first FAQ provides that, pursuant to a September, 2013 recommendation from the United States Preventive Services Task Force, non-grandfathered group health plans and health insurers must cover without cost sharing breast cancer risk-reducing medications, such as tamoxifen or raloxifene, for women who are prescribed such medications by their clinicians because they are at increased risk for breast cancer and are at low-risk for adverse medication effects.

Cost-sharing guidance. FAQs two through five address issues that have arisen with respect to ACA limits on cost sharing for essential health benefits (EHB). An earlier guidance provided that group health plans and insurers that use more than one service provider to administer EHBs would be permitted for 2014 to apply out-of-pocket maximums up to the statutory limit ($6350 for self-only and $12,700 for family coverage for 2014) for each form of coverage they offered (for example pediatric dental or prescription drug coverage), as long as the out-of-pocket limit for major medical coverage (including mental health coverage) or for any other single form of coverage did not individually exceed the statutory out-of-pocket limit. FAQ two clarifies that this exception only applies for 2014, and plans and insurers will be expected to be in full compliance with the out-of-pocket limits requirement by 2014.

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Slowed ACO Growth Leads Health Affairs Blog November Top Ten


December 24th, 2013

With the success or failure of Accountable Care Organizations (ACOs) having significant implications for the U.S. health care system, David Muhlestein‘s post on the slowed growth of ACOs was the most-read post on Health Affairs Blog in November. Next on the list is James Rickert‘s discussion of patient-centered care, followed by two posts by Timothy Jost on health insurance policy terminations and events in the individual market, including mental health and substance abuse parity.

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