Blog Home

Archive for the 'Policy' Category




The Time Is Now To Fix Medicare ACOs


March 27th, 2015

This past January 20th, the Department of Health And Human Services established national Medicare pay-for-value goals. By 2016, the Department intends to tie 30 percent of Medicare payments, and by 2018 50 percent of payments, to quality or value through alternative payment models. Medicare Accountable Care Organizations (ACOs) are expected to make a significant contribution toward meeting these goals. With current ACOs accounting for 7.8 million beneficiaries and 15 percent of Medicare spending, it will be essential for the current 405 ACOs to stay in the Medicare Shared Savings Program (MSSP) through 2016, and for a substantial number of new ACOs to join the program.

However, common concerns about the MSSP became apparent a year ago when stakeholders submitted comment letters in response to the Centers for Medicare and Medicaid Services’ “Evolution of ACO Initiatives at CMS” RFI (Request for Information). These concerns were reinforced last July after CMS announced proposed changes to ACO quality measure set and quality performance benchmarking, and again in November when the National Association of ACOs reported survey data showing nearly two-thirds of member ACOs would leave the program unless substantial improvements were made.

Recognizing these concerns, this past December CMS published a proposed rule offering many possible improvements to the Shared Savings Program. Public comments were due February 6th. CMS now has the opportunity to use stakeholder input to redesign the program in a way that will allow ACO providers to drive payment and delivery reform and thereby enable DHHS to meet its newly established pay-for-value goals.

Read the rest of this entry »

Paying For The ‘Doc Fix’


March 26th, 2015

For years now it has become apparent that the Sustainable Growth Rate (SGR) system is not sustainable.  However, fixing the SGR will require increases in budgeted costs, and so one of the major barriers to replacing the SGR is figuring out how to pay for the fix. Towards this end, it is important to understand the appropriate cost-comparison.

Federal scorekeepers (appropriately) assess the cost of the SGR fix relative to current law, which assumes that fees will follow a trajectory defined by current policy. But as near as I can tell, few advocate for that path or believe it will occur; rather the current system will continue to require regular “patches”.  Therefore, the appropriate measure of the cost of the doc fix is spending with the fix relative to spending without it.  The latter includes the costs of future “patches” necessary to ensure continued operation (as well as any savings that can be achieved because of continued SGR related negotiations).  Substituting this realistic alternative into the cost calculus likely substantially lowers the incremental cost of any SGR fix.

Read the rest of this entry »

Health Affairs Web First: Without CHIP, Sharply Higher Insurance Costs For Many Low-Income Families


March 26th, 2015

Funding for the Children’s Health Insurance Program (CHIP) is now set to expire after September 2015. A new study, being released by Health Affairs as a Web First, and also appearing in its April issue, examines the availability and cost of dependent coverage for children through employer-sponsored plans. Such plans would be the primary pathway to affordable coverage for more than half of all children losing CHIP eligibility, insofar as access to employer-sponsored coverage through their parents can bar children from receiving Marketplace subsidies.

According to the study, 96.9 percent of enrollees in employer-sponsored plans had access to dependent coverage. The additional cost would vary — as much as $7,252 per year for workers with one dependent child and $11,829 for those with two or more dependent children. The study also found that adding dependent coverage could cost many families more than 8.05 percent of their income, qualifying them for hardship exemptions from buying coverage.

As a result, many children once covered by CHIP would no longer be insured. This study is thought to provide the first estimates documenting variations across employers in the marginal costs to families adding children to employer-sponsored plans.

Read the rest of this entry »

Executions, Doctors, The U.S. Supreme Court, And The Breath Of Kings


March 26th, 2015

Editor’s note: This post is part of a series stemming from the Third Annual Health Law Year in P/Review event held at Harvard Law School on Friday, January 30, 2015. The conference brought together leading experts to review major developments in health law over the previous year, and preview what is to come. A full agenda and links to video recordings of the panels are here.

The relationship between medicine and capital punishment has been a persistent feature of this past year in health law, both at the level of medical ethics and Supreme Court review.

Our story starts in Oklahoma, where the execution of Clayton Lockett was botched on April 28, 2014. NIH bioethicist Seema Shah described the events in question:

Oklahoma was administering a new execution protocol that used the drug midazolam, a sedative that is often used in combination with other anesthetic agents. Oklahoma had never used this drug in executions before; in fact, only a few states had experience with using the drug in lethal injection. Florida had previously used this drug in lethal injections, but with a dose five times higher than what was indicated in Oklahoma’s protocol. If the execution had gone as planned, Clayton Lockett would have first received midazolam; been declared unconscious, then received vecuronium bromide (a paralytic/neuromuscular blocking agent that would restrict his movements), and finally received potassium chloride (the drug likely to end his life). A few minutes after officially being declared unconscious, Lockett mumbled statements including the word, “Man.” He “began breathing heavily, writhing, clenching his teeth and straining to lift his head off the pillow.” Prison officials prevented the witnesses from seeing the rest of the proceedings by closing the curtains. The Department of Corrections then called off the execution and unsuccessfully tried to resuscitate Lockett, and Lockett eventually died of a heart attack more than 45 minutes after the execution began. Although a Department of Corrections official stated that Lockett’s veins “exploded,” an autopsy examination performed by a forensic pathologist hired by death row inmates appears to contradict official reports. This report concluded that even though prison officials decided to inject the drugs into Lockett’s femoral vein (which is a more difficult and risky procedure), Lockett’s surface and deep veins had “excellent integrity.” Another execution that was scheduled to occur that same night has now been stayed for six months, pending an investigation into Mr. Lockett’s execution.

On July 23, 2014, Arizona encountered a problem with the same drug in the execution of Joseph Wood, wherein the condemned inmate allegedly gasped for almost two hours before dying.

The executions have prompted two important but different kinds of responses. In this post I write about the role of medical ethics and the U.S. Supreme Court’s response.

Read the rest of this entry »

The Final Stage Of Meaningful Use Rules: Will EHRs Finally Pay Off?


March 25th, 2015

Six years ago, President Obama signed into law the HITECH Act, which spelled out a path to a nationwide health information technology infrastructure.  The goal was simple:  every doctor, nurse, and hospital in America should use electronic health records — and do it in a way that leads to better care delivered more efficiently.  The Act provided $30 billion in incentives for providers and hospitals who met the criteria for “Meaningful Use”, which the Obama administration was given the authority to define.  The rules were set up to be rolled out in three stages, and while the first two stages have been out for a while, the criteria for the third and final stage of Meaningful Use (MU) were finally released on March 20.

David Blumenthal, the first national coordinator under HITECH, used the analogy of the Meaningful Use program as an escalator — with the first stage focused on just getting people on board and each stage requiring a higher level of use — which would focus on demonstrating better care through advanced EHR use.  Put more simply, the goal of the three stages was to first get providers to just start using EHRs, and then over time to get them to use the systems more frequently, more robustly, and ultimately, in ways that lead to better, more efficient care.

The new stage 3 rule reflects both the successes and the failures of the first two stages.  It moves toward making the EHR market more open and competitive, and providing more choices, in ways that I think are helpful — but possibly not helpful enough.

Read the rest of this entry »

Health Affairs Briefing: The Cost And Quality Of Cancer Care


March 25th, 2015

Cancer is the second leading cause of death among US adults, and cancer care now costs in excess of $125 billion each year in the United States alone. Cancer has also become the second leading cause of death worldwide, making it an increasing priority in low- and middle-income countries. The April 2015 issue of Health Affairs, “The Cost and Quality of Cancer Care,” includes a collection of papers on the cost and quality of cancer care.

You are invited to join us on Tuesday, April 7, 2015, at a forum featuring authors from the new issue at the National Press Club in Washington, DC. Panels will cover valuing cancer care innovation, paying for care, and quality of cancer care.

WHEN:
Tuesday, April 7, 2015
9:00 a.m. – 11:40 a.m.

WHERE:
National Press Club
529 14th Street NW
Washington, DC, 13th Floor

Register Now!

Follow live Tweets from the briefing @Health_Affairsand join in the conversation with #HA_CancerCare.

Read the rest of this entry »

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.

Read the rest of this entry »

Unpacking The Burr-Hatch-Upton Plan


March 24th, 2015

Anticipating the upcoming Supreme Court decision on King v. Burwell, which could halt health insurance subsidies available through the federal exchange, Republican Senators Richard Burr and Orrin Hatch joined with Representative Fred Upton to propose a comprehensive replacement for the Affordable Care Act (ACA). The Patient Choice, Affordability, Responsibility, and Empowerment Act, or Patient CARE Act, is modeled on a proposal of the same name offered last year by Senators Burr, Hatch, and Tom Coburn, who has retired from the Senate. The Burr-Hatch-Upton plan, like its predecessor, adopts consumer-based reforms of the insurance market, modernizes the Medicaid program, and makes other changes intended to lower cost and increase choices.

In an earlier post, we described in detail the provisions of the Burr-Coburn-Hatch bill. In this post, we discuss how the Burr-Hatch-Upton plan differs from the earlier proposal. We also discuss the impact of the new proposal on health insurance coverage, premiums, and the federal budget based on a new analysis from the Center for Health and Economy (H&E), a non-partisan think tank focused on producing informative analyses of trends in U.S. health care policy and reform ideas. We conclude by commenting on the direction Republicans are likely to take in reforming the health system in the aftermath of a Supreme Court decision in the King v. Burwell case.

Read the rest of this entry »

Ensuring Timely Approval Of Generic Drugs


March 24th, 2015

Having saved US consumers over $1.5 trillion in the past decade, generic drugs are one of the most cost-effective interventions in our entire health care system. Using generic drugs instead of brand-name drugs, when a generic is available, has been shown to increase medication adherence and improve health outcomes for chronic conditions.

Importantly, generic drugs offer these advantages without sacrificing quality; the Food and Drug Administration’s bioequivalency standards are met and often exceeded by generic-name manufacturers, and no randomized controlled trials—the gold standard of medical evidence—have identified clinically significant variations in outcomes between brand-name and FDA-approved interchangeable generic drugs.

Read the rest of this entry »

A Check-Up On Dental Coverage And The ACA


March 24th, 2015

Oral health is an important but often overlooked part of health and insurance coverage. State Medicaid and the Children’s Health Insurance Program (CHIP) are required to cover children’s dental services (and children’s access to care has been improving over the last ten years), but coverage for adults is optional. As noted in a recent Health Affairs GrantWatch Blog post, only about 15 states offer extensive coverage for adult dental services in Medicaid.

Medicare does not cover most dental services. And most private dental coverage is offered through stand-alone dental products that are separate from medical plans. Overall, this has resulted in more than 2.5 times as many Americans going without dental coverage as medical coverage.

Inadequate access to dental care is costly. Many low-income individuals turn to the emergency department as their primary and only source of care for oral health needs. The American Dental Association estimates that emergency room visits for avoidable oral health-related visits cost the U.S. health care system as much as two billion dollars per year. A recent Narrative Matters feature in Health Affairs (“Navigating Veronika”) highlighted the steep barriers that low-income individuals can face in navigating the dental safety net and finding a provider who will treat them, even when Medicaid covers the costs of care.

Read the rest of this entry »

Implementing Health Reform: Medicaid & CHIP Enrollment; Tax Forms; And Special Enrollment Period (March 27 Update)


March 22nd, 2015

The Centers for Medicare and Medicaid Services released a number of items to close out the week on March 20, 2015.  First, CMS released the January 2015 Medicaid and CHIP Monthly Applications, Eligibility Determinations, and Enrollment Report.  (CMS blog post,  one pager)  The 50 states and the District of Columbia reported nearly 70 million enrollees in comprehensive Medicaid and CHIP programs as of the last day of the month.

Second, CMS and the Internal Revenue Service released updates regarding the issuance of corrected 1095-A forms.  The 1095-As are the forms that exchanges are providing to individuals who received premium tax credits for 2014; they are supposed to help individuals reconcile the advance premium tax credits they received for 2014 with the tax credits they should have received.

Finally, CMS has further clarified eligibility requirements for the special enrollment period (SEP) for people who owe an individual responsibility fee for 2014.

Read the rest of this entry »

What Kind Of Advance Care Planning Should CMS Pay For?


March 19th, 2015

Currently, Medicare does not offer a paid benefit for advance care planning (ACP). As a result, health care providers who want to assist Medicare enrollees with ACP do so voluntarily and neither they, nor their institutions, are compensated for their time and efforts. This is not only an unfair expectation on individual practitioners or health institutions, it is also medically and ethically unsound. Fortunately, two recent events have the potential to reshape the landscape of advance care planning in the U.S.

Cultural And Policy Evolution In Advance Care Planning

On September 17, 2014, the Institute of Medicine (IOM) published Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. The report is built on two basic premises:

Read the rest of this entry »

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.

Read the rest of this entry »

Moving In Reverse? Potential Coverage Impacts For Children Of King v. Burwell, Medicaid And CHIP Eligibility Changes


March 17th, 2015

Over the last three decades, the US has taken important steps to reduce financial barriers to health insurance coverage for low and moderate-income children. These steps began with the Medicaid expansions for children in the 1980s and early 1990s, which were followed by the creation of the Children’s Health Insurance Program (CHIP) in 1997. Most recently, Congress reauthorized CHIP in 2009 and enacted the Affordable Care Act (ACA) in 2010.

This commitment to children has resulted in substantial increases in coverage. The uninsured rate among children decreased from 15.0 percent in 1989 to 6.6 percent in 2012 (Exhibit 1).

Read the rest of this entry »

Implementing Health Reform: Wraparound Benefits Final Rule; Coverage Report (Revised)


March 17th, 2015

With open enrollment closed for 2015 and the Departments having finalized the Benefit and Payment Parameters Rule and Letter to Issuers for 2016, we have entered the Spring Affordable Care Act regulatory doldrums.  Reports, minor regulations, guidances, and court decisions continue to appear, however.  Two appeared on March 16.  This post addresses the final wraparound coverage excepted benefits rule, and a report on health insurance coverage and the ACA (technical appendix here), both released on March 16, 2015.

The wraparound coverage rule creates a new category of excepted benefits.  The concept of excepted benefits was created by the Health Insurance Portability and Accountability Act of 1996 and is carried forward in the ACA.  Excepted benefits plans provide benefits that resemble in some way the health benefits that have been regulated by HIPAA and are now regulated by the ACA, but are more limited or are more tangential to medical care.  These include benefits that are not generally medical benefits but do afford some medical coverage (auto liability, workers’ compensation); health coverage that is not medical coverage (dental, vision, long-term care); benefits that are not coordinated with medical benefits (specific disease coverage, fixed dollar indemnity coverage); and coverage that is supplemental to medical coverage (such as Medicare supplement policies).  Additional specific conditions must be met for some of these benefits to qualify as excepted benefits.

Excepted benefits are generally not subject to Affordable Care Act requirements, such as the ban on dollar coverage limits or preexisting conditions clauses.  But excepted benefit coverage explicitly does not qualify as minimum essential coverage.  An individual who has only excepted benefit coverage and does not qualify for a shared responsibility requirement exception must still pay the individual mandate penalty.  Large employers that offer only excepted benefits may have to pay the employer responsibility penalty, but individuals offered only excepted benefits by their employers are not disqualified from receiving premium tax credits to purchase individual coverage through the marketplaces.

Read the rest of this entry »

Can Safety-Net Hospital Systems Redesign Themselves To Achieve Financial Viability?


March 16th, 2015

Safety-net hospital systems have long played a special role in the nation’s health care system by serving low-income, medically, and socially vulnerable patients regardless of their ability to pay. Beyond caring for people regardless of insurance coverage, safety-net systems provide comprehensive care to meet the needs of their diverse, complex patient populations, including culturally-responsive health and social services that other hospital systems do not.

As providers of last resort, some safety-net systems, especially public hospitals, are expected by their communities and by state and local governments to offer needed but unprofitable services, regardless of whether adequate revenue streams exist to support these services.

 In recognition of that role, national, state, and local government agencies historically have provided supplemental funding to these systems to offset unreimbursed and under-reimbursed care. Under the Affordable Care Act, however, that is changing. With the expectation that most people will be insured under the new law, policy makers have planned to reduce much of this supplemental funding. In this view, safety-net systems will either become financially independent or close.

Read the rest of this entry »

Should Health Lawyers Pay Attention To The Administration’s Privacy Bill?


March 13th, 2015

Health care lawyers justifiably ignored the 2012 Obama administration consumer privacy framework because it expressly and broadly exempted entities subject to HIPAA, stating “To avoid creating duplicative regulatory burdens, the Administration supports exempting companies from consumer data privacy legislation to the extent that their activities are subject to existing Federal data privacy laws.”

In contrast, the administration’s 2015 draft bill, the Consumer Privacy Bill of Rights Act, though based on that framework, substantially affects health care entities, including those subject to HIPAA, and so demands more attention in the health law community.

The “HIPAA clause” in the draft bill is subtly different (and noticeably narrower than its preemption of state law clause): “If a covered entity is subject to a provision of this Act and a comparable provision of a Federal privacy or security law [the list includes HIPAA] such provision of this Act shall not apply to such person to the extent that such provision of Federal privacy or security law applies to such person.”

The “provision” wording is key; most of the key substantive provisions in the draft bill—those going to consent, withdrawal of consent, context, and data minimization—do not crosswalk to any comparable provisions in HIPAA. For HIPAA mavens this has the potential of “more stringent than” all over again, but at a higher stakes table. (For nonmavens, this refers to questions raised by HIPAA’s language leaving intact state laws “more stringent than” HIPAA’s privacy protections.)

Read the rest of this entry »

Physician Aid In Dying: Whither Legalization After Brittany Maynard?


March 12th, 2015

Editor’s note: This post is part of a series stemming from the Third Annual Health Law Year in P/Review event held at Harvard Law School on Friday, January 30, 2015. The conference brought together leading experts to review major developments in health law over the previous year, and preview what is to come. A full agenda and links to video recordings of the panels are here.

Brittany Maynard’s highly publicized decision to end her life under Oregon’s Death With Dignity law has given a new face to the American right to die movement. It is that of a young, attractive, athletic newlywed, who would not have considered herself as having a stake in the movement until the day she learned a brain tumor was the cause of her severe headaches. She was terminally ill and faced a future of six months of increasing pain, debilitation, and severe seizures before dying.

A video of Maynard’s story produced by the non-profit advocacy organization Compassion and Choices has reached many millions of viewers. Extended coverage of her decision-making process by People Magazine resulted in record numbers of hits to the publication’s website. During her illness, Maynard moved from California to Oregon and on November 1, 2014 took barbiturates to end her life. In her memory, her husband and mother have become prominent activists in the effort to legalize physician aid-in-dying (PAD).

Is all of this likely to advance the PAD movement and, if so, through what legal processes?

Read the rest of this entry »

Reconciling Prevention And Value In The Health Care System


March 11th, 2015

The term ‘value’ (commonly defined as health improvements attained per dollar spent) has become ubiquitous in discussions around improving the health care system. Increasingly, payers are adopting value-based purchasing programs (paying more for higher value care) and providing benefits that follow the principles of value-based insurance design (aligning patient cost-sharing with the value of the service). These programs typically focus on services widely regarded as relatively low-cost and clinically effective, such as beta-blockers prescribed for patients following a myocardial infarction (i.e. heart attack).

Simultaneously, there is widespread enthusiasm for the increased use of preventive services. The Patient Protection and Affordable Act (ACA) mandates the elimination of consumer cost sharing for selected preventive services in marketplace plans and many other individual health plans. A particular subset of plans, High-Deductible Health Plans with Health Savings Accounts (HSA-HDHPs) can cover certain preventive services—but not other services—before the deductible, a minimum of $1,250 for an individual and $2,500 for a family, is met.

Generally, policies supporting prevention and value are consistent. Many (not all) preventive services do provide considerable value. Yet as with value, there are nuances in the definition of prevention that can lead to suboptimal policy choices. Specifically, most policy related to prevention defines preventive services as those delivered to asymptomatic individuals.

Read the rest of this entry »

Health Affairs Web First: Assessing Efforts To ‘Solve The Sustainable Growth Rate Formula Conundrum’


March 11th, 2015

On April 1, unless Congress acts to prevent it, the current Sustainable Growth Rate (SGR) fee cut will take effect, dictating a 21.2 percent reduction in Medicare physician fees. A new commentary, released today by Health Affairs as a Web First, assesses last year’s bipartisan and bicameral legislative model for how to repeal the SGR, a model likely to be used in similar efforts this year.

The 2014 legislation contained many useful steps to replace the SGR but had a major omission, authors James Reschovsky, Larisa Converse, and Eugene Rich of Mathematica Policy Research argue: It did not adequately address overhauling the current Medicare fee schedule.

Read the rest of this entry »

Click here to email us a new post.