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Payment and Delivery Reform Case Study: Congestive Heart Failure


April 15th, 2014
by Darshak Sanghavi

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

Introduction

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

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

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Look At Consequences Of Rejecting Medicaid Expansion Leads First Quarter Health Affairs Blog Most-Read List


April 14th, 2014
by Tracy Gnadinger

Given their recent mention in Paul Krugman’s New York Times‘ column, it’s not surprising that Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhandler‘s discussion of the health and financial impacts of opting out of Medicaid expansion was the most-read Health Affairs Blog post from January 1 to March 31, 2014.

Next on the list was Robert York, Kenneth Kaufman, and Mark Grube‘s discussion of a regional study on the transformation from inpatient-centered care to an outpatient model focused on community-based care. This was followed by Susan Devore‘s commentary on changing health care trends and David Muhlestein‘s evaluation of accountable care organization growth.

Tim Jost is also listed four times for contributions to his Implementing Health Reform series on Medicaid asset rules, CMS letter to issuers, contraceptive coverage, and exchange and insurance market standards.

The full list appears below.

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The Case For Global Health Diplomacy


April 14th, 2014
by Bill Frist

At the end of February, I had the pleasure of speaking about global health diplomacy at the Nursing Leadership in Global Health Symposium at Vanderbilt University. Nurses are one of the specialties that we support in the Frist Global Health Leaders program facilitated by Hope Through Healing Hands, a nonprofit dedicated to advancing peace by supporting health care services and education in some of the world’s most vulnerable communities. Nurses, including the men and women I met at Vanderbilt, have an enormous opportunity to affect health and global health diplomacy. Indeed, everyone in the medical profession can play a crucial role in health diplomacy.

Global Health Diplomacy And Foreign Policy

For several years now I’ve been thinking about—and speaking about—global health diplomacy. The term started appearing around 2000 and has many definitions, representing the complexity of the issue itself. Diplomacy, at the simplest level, is a tool used in negotiating foreign policy. Health diplomacy is different, though. As a physician, the overall goal of health is clear: improve quality of life by improving health and meeting overall patient goals of care. As a diplomat and policymaker, the goal is more complicated.

Foreign policy, in general, is a dance—a negotiation of shared goals and identification of conflicts between nations, always with inherent tension. For example, what we want for the government of Afghanistan may not align with their complex political and cultural ideologies.

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Implementing Health Reform: Changing Focus, And Changing Leadership, At HHS (Updated)


April 11th, 2014
by Timothy Jost

With the March 31, 2014 deadline for applying for qualified health plan coverage through the health insurance exchanges behind us, and the April 15, 2014 deadline for completing those applications upon us, Affordable Care Act implementation has quieted considerably. The Centers for Medicare and Medicaid Services have been very active on the Medicare front, releasing in recent days their 2015 Medicare Advantage Rate Announcement and Call Letter and publishing data on Medicare payments to 880,000 Medicare providers. But on the exchange and insurance market reform side, CMS has only one major proposed rule pending at this time, the Exchange and Insurance Market Standards Rule proposed in March, and nothing pending for regulatory review at the Office of Management and Budget.

I am unaware of any major regulatory issuances expected in the immediate future from the Departments of Treasury or Labor, although Treasury does have a number of proposed rules on the table that have yet to be finalized dealing with issues such as minimum value of employer coverage or premium tax credit reporting requirements for exchanges.

On April 10, the media reported two major Health and Human Services developments. First, Secretary of Health and Human Services Kathleen Sebelius announced at a Senate Hearing that 7.5 million Americans have now signed up for health plans through the exchanges. Although opponents of the ACA continue to quibble about how many of these individuals have actually paid their premiums and how many were uninsured previously, the number far exceeds earlier estimates of how many would enroll in health insurance through the exchanges. A recently released Rand survey, which does not fully take into account the late surge that increased exchange enrollment by over 70 percent in the last month, indicates that in fact the ACA has made a significant dent in the number of uninsured in the United States.

The second announcement was of the resignation of Secretary Sebelius herself, and of the nomination of Sylvia Mathews Burwell as her replacement.

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Medicare Advantage Rolls On


April 11th, 2014
by Billy Wynne

Monday afternoon, the Centers for Medicare and Medicaid Services (CMS) released the final rates and other reimbursement policies for Medicare Advantage (MA) plans, referred to as the Final Call Letter. Once again, the Administration took pains to ameliorate planned cuts to MA, demonstrating the program’s increasing popularity with seniors and, by extension, its robust political strength.

For my money, we’ll look back at this year as the final hurdle the program jumped on its path to dominating the Medicare benefit for a generation to come. It’s already well on its way, covering 30 percent of Medicare beneficiaries and growing. So let’s take a quick tour of the MA program’s initially volatile history and the winning streak it’s been on of late, culminating with the breaks the Administration cut it this go round.

The history. First there was the growth and then precipitous decline of managed care in the 90s, a wave that the program – then called Medicare+Choice – rode alongside the commercial sector.

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Takeaways From The Aspen Institute’s Care Innovation Summit


April 10th, 2014
by Matthew Richardson

Back in February, The Aspen Institute and The Advisory Board Company sponsored the Care Innovation Summit in Washington, DC. With a keynote address from Secretary of Health and Human Services Kathleen Sebelius, the daylong summit featured some of the newest data and research on the rapidly evolving U.S. health care landscape.

Featured speakers such as Jeffrey Brenner of the Camden Coalition of Healthcare Providers and Claudia Grossmann of the Institute of Medicine in addition to others from State and Federal government, insurers, hospitals, and research institutions offered insights on higher-value care and improved health for individuals and populations.

Here are five most memorable takeaways:

1. Health Care Cost Inflation Has Slowed

Perhaps the most eye-catching data trend presented was the dramatic slowing of Medicare spending showcased by Patrick Conway, Director of CMMI (presentation available here). The collapse of annual per capita spending growth is important not only because it implies significant value changes are underway in the provision of ever more services by Medicare, but also because it can further mean many things to many people.

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What’s Past Is Prologue: Making The Case For PET Beta-Amyloid Imaging Coverage


April 9th, 2014
by Dora Hughes

Editor’s note: This post is published in conjunction with the April issue of Health Affairs, which features a series of articles on Alzheimer’s disease.

In September of 2013, CMS issued its final decision memo that concluded positron emission tomography- amyloid beta (PET Aβ) imaging is “not reasonable or necessary”, finding “insufficient evidence” that use of this diagnostic tool would improve health outcomes for patients with dementia or neurodegenerative disease. As such, PET Aβ imaging to help diagnose Alzheimer’s disease (AD) is not a covered service for Medicare beneficiaries except for those enrolled in CMS-approved clinical trials.

CMS’ final decision underscores the emerging new paradigm for coverage decision-making, requiring innovators not only to demonstrate to FDA’s satisfaction that their products are effective, but also to prove to CMS and other payors that their use will improve clinical outcomes. This paradigm will increase confidence in the value and health benefit of new technologies, although it will make the path to coverage more difficult and uncertain for diagnostic developers.

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Health Affairs Web First: Global Health Funding In 2013 Five Times Greater Than 1990


April 8th, 2014
by Tracy Gnadinger

Development assistance for health (DAH) to low- and middle-income countries provided by donors and international agencies are given in the form of grants, low-cost loans, and goods and services. Without this assistance, some of the poorest countries would be less able to supply basic health care.

A new study, being released today as a Web First by Health Affairs, tracked the flow of development assistance for health and estimated that in 2013 it reached $31.3 billion.

Looking at past growth patterns of these international transfers of funds for health, authors Joseph Dieleman, Casey Graves, Tara Templin, Elizabeth Johnson, Ranju Baral, Katherine Leach-Kemon, Anne Haakenstad, and Christopher Murray identified a steady 6.5 percent annualized growth rate between 1990 and 2000, which nearly doubled to 11.3 percent between 2001 and 2010 with the burgeoning of many public-private partnerships. Since 2011, however, annualized growth has dramatically dropped, to 1.1 percent, due, in part, to the effect of the global economic crisis.

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What The Affordable Care Act Means For Pregnant Inmates


April 4th, 2014
 
by Katy Kozhimannil and Rebecca Shlafer

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.

The Affordable Care Act (ACA) is anticipated to expand coverage to 44 million Americans. As John Iglehart noted in his introduction to the March issue of Health Affairs, expansion of Medicaid through the ACA will open an important door for a particularly vulnerable population – those who are cycling in and out of the criminal justice system.

Although Medicaid does not cover standard health care for inmates during incarceration, expansion of Medicaid to single and childless adults has meant that prisons and jails can start enrolling inmates (a substantial portion whom meet these criteria) so they are covered upon release.

The ACA also allows Medicaid to pay for inmates’ care for hospital stays longer than 24 hours. Such changes have important implications for a group of inmates that is not often the focus of health policy dialogue – incarcerated pregnant women.

A Particularly Vulnerable and Costly Group: Pregnant Prisoners

Nationwide, 75 percent of incarcerated women are of reproductive age, and about 6-10 percent of female prisoners are pregnant during their incarceration. Incarcerated women fare worse than incarcerated men, and their reproductive health care needs, including access to contraception and abortion services, often go unmet. Inmates who are pregnant face additional risks. Compared with similar women that are not incarcerated, pregnant inmates have more risk factors and worse birth outcomes, for both mothers and babies.

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Health Affairs Briefing Reminder: Long Reach Of Alzheimer’s Disease


April 4th, 2014
by Chris Fleming

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

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

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

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

 REGISTER ONLINE

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

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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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Responding To ‘The Hidden Curriculum’: Don’t Forget About The Patient


April 3rd, 2014
by Rob Lott

Narrative Matters readers might remember Joshua Liao’s moving essay about the dangers of the Hidden Curriculum. Liao, a resident physician at Brigham and Women’s Hospital, wrote about the consequences of making a serious mistake as a medical student on an obstetrics rotation. He read the essay for the Narrative Matters podcast and it’s a great listen.

Liao’s essay, penned with Eric Thomas and Sigall Bell, also generated some compelling responses. It inspired Tim Lahey to write about his experience leading the curriculum redesign at Dartmouth’s Geisel School of Medicine. And when the Washington Post ran an excerpt of Liao’s essay last week, it led Franca Posner to remind readers about “one missing piece of this puzzle”: the patient’s perspective.

Posner was once in a similar situation, but it was she on the hospital bed: “I was that woman 20 years ago, only I was almost 40 and had a 5-year-old child and five miscarriages in my reproductive history,” Posner wrote in a letter to the editor published in the Post’s Health and Science section on March 31.

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The Payment Reform Landscape: Price Transparency


April 2nd, 2014
by Suzanne Delbanco

Editor’s note: This is the third post in a Health Affairs Blog series on payment reform by Catalyst for Payment Reform Executive Director Suzanne Delbanco. The first two posts are available here and here.

Last week Catalyst for Payment Reform (CPR) and our partners at the Healthcare Incentives Improvement Institute (HCI3) released our second annual Report Card on State Price Transparency Laws. This year, we decided not to grade states on a curve and to place greater emphasis on the price information actually available to consumers—not just what is written in the law.

Forty-five states received an F in this year’s Report Card, but there were a couple of notable exceptions: Massachusetts and Maine. Each month in this blog, I’ve been sharing insights about payment reform and which models are proving to work, so this naturally raises the question: what is the relationship between payment reform and the success of state price transparency efforts?

At CPR, we like to say price transparency is one of the core building blocks of payment reform and a higher-value health care system. Purchasers and consumers need transparency for three primary reasons: (1) to help contain health care costs; (2) to inform consumers’ health care decisions as they assume greater financial responsibility; and, (3) to reduce unknown and unwarranted price variation in the system.

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Implementing Health Reform: First Marketplace Open Enrollment Ends With More Than Seven Million Enrollees


April 2nd, 2014
by Timothy Jost

The White House announced on Tuesday April 1, 2014 that as of the end of open enrollment, 11:59 p.m. on March 31, 2014, 7.1 million Americans had signed up for health plans under the Affordable Care Act. Tens of thousands more will be added from individuals who attempted to apply during the open enrollment period but were unable to complete their applications. And many more will be enrolled through special enrollment periods as they undergo life changes over the coming year.

Of course, arguments will continue as to how many of those who selected a plan will pay their premiums (which they must do before they are covered); how many were previously uninsured; and whether those who enrolled are young, healthy, and male enough to offer insurers a risk pool like that they anticipated when they set their rates. There is ample evidence that many have not yet paid, but it is reasonable to expect that the payment rate will pick up as enrollees figure out how to pay their insurers and insurers figure out who their enrollees are. There is also evidence that many of those who signed up were previously covered. Of course, one of the purposes of the ACA was to make insurance affordable, so if someone who was struggling to afford coverage (and might have had to drop it in the near future) can now afford it, that is also a success. Moreover, millions of the uninsured have also signed up for Medicaid and some have also obtained coverage in the individual market outside the exchange or from their employer. Finally, the size of the risk pool suggests that it is reasonably balanced demographically.

In any event, 7 million enrollees was the number that has constantly been held up as the unobtainable goal for the exchanges, and it has been reached–indeed surpassed. Pictures all over the web today of long lines and full waiting rooms of people eager to enroll in coverage demonstrate that in fact people want health care coverage and the ACA is allowing them to get covered.

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Embarking On A New Journey With Health Affairs


March 31st, 2014
by Alan Weil

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

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

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

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Health Policy Leader Alan Weil To Become New Health Affairs Editor-in-Chief


March 31st, 2014
by Chris Fleming

Health Affairs and its publisher Project HOPE are pleased to announce that Alan Weil will become the journal’s new editor-in-chief on June 2, 2014.

Weil, a highly respected expert in health policy and current member of Health Affairs’ editorial board, will lead the journal after serving as the executive director of the National Academy for State Health Policy (NASHP) since 2004. His work with state policymakers of both political parties put Weil at the forefront of health reform policy, implementation, innovation, and practice. Prior to his leadership of NASHP, he served in both the public and private sectors. He directed the Urban Institute’s “Assessing New Federalism” project; served as the executive director of the Colorado Department of Health Care Policy and Financing and a health policy advisor to Colorado’s then-governor, Roy Romer; and was the assistant general counsel in the Massachusetts Department of Medical Security.

“We’re delighted to welcome Alan to the Project HOPE family,” said John P. Howe III, M.D., President and CEO of Project HOPE. “He comes to Health Affairs with more than 24 years of experience in health policy development and a stellar record of leadership and innovation in this field. I’m confident he will lead the journal’s talented staff on a new and successful path forward. I am extremely grateful to John Iglehart, the Founding Editor of Health Affairs for his stewardship of the journal for more than 25 years, ensuring its coveted rank as the leading health policy journal of our time.”

“Alan Weil’s extensive background in health and health care policy will serve him well in his new role as Health Affairs’ editor-in-chief,” noted John Iglehart, who currently leads the journal. “With his position on the front lines of health system change, he is an experienced leader who has deep familiarity with and longstanding connections to the health policy, research, and health care leadership communities. In particular, in his role as NASHP’s executive director, Alan worked on complex issues of critical importance to leaders in state and federal government and the private sector. This background will serve Health Affairs well as it continues to grow in influence both in the US and globally.”

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Should Provider Performance Measures Be Risk-Adjusted For Sociodemographic Factors?


March 27th, 2014
by Christine Cassel

The National Quality Forum released draft recommendations on March 18 to change the way we assess the care that doctors and hospitals provide, and they are sure to cause a buzz in and beyond the health care community. That’s a good thing, because reflection and conversation are vital pieces of ‘getting it right’ when determining how measures can be used to gauge healthcare performance.

The recommendations come from a panel of 26 national experts convened by NQF at the request of the federal government. The question before them: Should the measures we use to assess providers’ performance be risk-adjusted to account for patients who are poor, homeless, illiterate, uneducated, or have other indicators of lower socioeconomic status? The panel’s recommendations are discussed below, and we encourage you to register your views by commenting on the report by April 16 and on this post.

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A March Madness Health Wonk Review


March 27th, 2014
by Chris Fleming

Welcome to the “March Madness” edition of the Health Wonk Review. The NCAA college basketball tournament seemed like a natural theme for a health care policy blog post: huge amounts of money floating around in ways that only sometimes correlate with performance, and head-to-head match-ups that can yield results no one expected (though in the tournament those unexpected results produce quicker and more certain changes than is often the case in health care).

We considered illustrating each blog post with pictures of a college basketball team from the author’s home state celebrating a championship, but we thought better of that after seeing this cautionary tale. So let’s get to the great collection of posts from our Wonkers.

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Implementing Health Reform: Additional Enrollment Opportunities And ACA Litigation (Updated)


March 26th, 2014
by Timothy Jost

On March 26, 2014, the Centers for Medicare and Medicaid Services drew the 2014 open enrollment period toward a close with a flourish, releasing a series of guidance documents regarding opportunities that remain to enroll in coverage after the open enrollment period. The Department of the Treasury also released a guidance, a fact sheet, and letter addressing the situation of domestic violence victims who apply for premium tax credits but are unable to file taxes jointly, as generally required by the ACA.

Extended Enrollment Opportunities

The first CMS Guidance addresses the situation of people waiting “in line” for enrollment in the federally facilitated marketplace or exchange (FFM) on the final day of the 2014 open enrollment period, March 31. CMS anticipates that application traffic will be very high during the last week of open enrollment—over a million individuals visited healthcare.gov on Monday, March 24. Individuals who applied by March 31, but did not complete their application, will be allowed to complete it—effectively given a special enrollment period to finish enrolling. CMS does not specify how long consumers may continue to do so beyond saying that they will have a “limited amount of additional time.” If applicants pay their first month’s premium by the time required by their insurer, they will be able to being coverage on May 1.

Paper applications that are received by April 7, or that were filed by March 31 but uncompleted because they were pending submission or review of documents, can also be approved for coverage beginning May 1 for consumers who choose a plan by April 30. Consumers who take advantage of this special enrollment period may also apply for a hardship exemption to avoid paying the individual responsibility tax for the additional month they are uninsured. The guidance applies only to the FFM, but it clarifies that state based marketplaces can apply similar policies.

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Health Affairs Briefing: Long Reach Of Alzheimer’s Disease


March 26th, 2014
by Chris Fleming

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

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

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

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

REGISTER ONLINE

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

Read the rest of this entry »

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