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The United States’ Misguided Self-Interest On Ebola


October 31st, 2014

The Ebola epidemic in West Africa is spiraling out of control. The international community allowed a manageable outbreak to mushroom into a health and humanitarian crisis. The World Health Organization (WHO) has been enfeebled and largely sidelined. Belatedly, the United States sent military troops into Liberia and spearheaded a United Nations Security Council resolution. Yet since isolated Ebola cases have appeared on our shores, the US has begun to look inward, at risk of falling into a trap that I will call “misguided self-interest.”

While the West African epidemic rages, the US delayed significant action until long after the unprecedented nature of the Ebola epidemic became clear, and even now the response is incommensurate with the massive need. Now we are transferring our gaze from the real crisis and headed on an insular journey.

I grant the premise that a country’s first responsibility is to protect its inhabitants. But calls for a travel ban from the region and newly announced state quarantine policies that would ensnare travelers from affected countries appear selfish. To put it in perspective, the US has experienced only a few domestically diagnosed cases, with an exceedingly low risk of an outbreak.

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North Carolina Dental Board v. FTC: A Bright Line On Whiter Teeth?


October 30th, 2014

On October 14, 2014, the United States Supreme Court heard oral arguments in North Carolina Board of Dental Examiners vs. Federal Trade Commission.  The case does not involve the Affordable Care Act, but it goes to the heart of the professional self-regulatory paradigm that has governed the U.S. health care system for more than a century.  The specific legal question under review is the standard for determining when a state professional licensing board’s activities are subject to scrutiny for anticompetitive effect under the federal antitrust laws.

Antitrust law applies to private anticompetitive conduct.  Congress did not intend to interfere with state regulation that limits or even eliminates competitions.  As long as states do so using public agencies and officials, they are on safe ground.  If a state empowers private parties to administer such regulation, however, it not only must “clearly articulate” its intent to diminish competition, but also must “actively supervise” the conduct of the private parties.  In previous cases, the Supreme Court developed and elaborated this two-part test, which is called the “state action doctrine.”

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Implementing Health Reform: The Qualified Health Plan Federal Exchange Participation Agreement And More


October 21st, 2014

CMS continues to put the pieces into place that are needed for the launch of the 2015 coverage year.  On October 16, 2014, the Centers for Medicare and Medicaid Services released at its REGTAP.info website the certification agreement and privacy and security agreement that qualified health plan (QHP) insurers must sign with CMS to access the federally facilitated exchange (FFE), the federally facilitated SHOP (FF-SHOP), and CMS Data Services Hub.  The agreement focuses primarily on obligations that the QHP insurer undertakes to protect personally identifiable information and to ensure secure communications with CMS, although it also addresses the effective date and termination of the agreement and a few other issues.  Most of the terms of the agreement are unremarkable, and this post will only comment on a few.

QHP insurers undertake under the agreement to protect personally identifiable information and to ensure secure communications with CMS in conformity with applicable laws, regulations, and standards.  They must also ensure that their contractors and downstream entities comply with these requirements.  QHP insurers agree to report any personally identifiable information incidents or breaches to CMS within 72 to 96 hours.  This is a far cry from the one-hour breach reporting requirement proposed by CMS last year but never finalized, but perhaps recognizes the difficult of identifying and assessing a security breach.

The agreement expressly recognizes that QHP insurers have developed their products based on the assumption that advance premium tax credits and cost-sharing reduction payments will be available through the marketplace and that QHP insurers could have cause to terminate the agreement if this assumption ceases to be valid.  This could be interpreted as a reference to the Halbig/King litigation which currently threatens the availability of tax credits and cost-sharing reduction payments through the FFE, but could also have been included in recognition of the likely Republican takeover of the Senate and the possibility that the Republicans may accomplish through budget reconciliation or otherwise their longstanding goal of repealing the ACA.  As the agreement is renewable from year to year, this clause may contemplate contingencies in the indefinite as well as the near future

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Thomas Frieden And The U.S. Ebola Response


October 20th, 2014

On Friday, October 17, the White House named Ron Klain the new Ebola czar. This move followed a storm of criticism in the media, on Capitol Hill, and elsewhere. The criticism focused on the multiple mistakes made by the U.S. agencies and Texas Health Presbyterian Hospital in Dallas in the weeks since Thomas Eric Duncan, infected with Ebola, arrived in the United States on September 19. Duncan set off a disturbing train of events that included secondary infections of two nurses, Nina Pham and Amber Vinson, along with the lingering threat of additional infections.

That threat widened rapidly over the course of this past week. Dozens of health workers in Dallas remain under some form of quarantine or very close monitoring. Contact tracing revealed 300 persons who had possibly come in contact with Vinson during her Columbus Day weekend travel from Dallas to Cleveland and back. Schools were subsequently shuttered in Ohio and Texas.

Most remarkable, within a month the controversy surrounding the threat of Ebola to Americans had mushroomed into a political emergency for the Obama presidency itself, only a few tense weeks before the November 4 elections. Calls escalated for the appointment of an Ebola czar and a travel ban on persons originating in Liberia, Sierra Leone, and Guinea, the root sources of the Ebola emergency. A special measure of criticism was reserved for the Obama administration’s lead face in the U.S. response, Dr. Thomas Frieden, head of the U.S. Centers for Disease Control and Prevention (CDC). In the words of one observer, this week became full of “recriminations, political showboating… and panicked overreactions.”

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Teaching Health Centers: An Attainable, Near-Term Pathway To Expand Graduate Medical Education


October 17th, 2014

Stakeholders in Graduate Medical Education (GME) and members of Congress eagerly anticipated the long delayed but recently released Institute of Medicine (IOM) GME report. While perceptively characterizing the defects in our GME system, recommendations of the report generated substantial controversy among participants at a recent GME forum hosted by Health Affairs. The IOM proposed limited and gradual changes in Medicare GME financing, but the lack of support for GME expansion was not well received by some.

At present there are multiple legislative GME proposals, but none has gained broad support among the various stakeholders. Congressional committees responsible for GME funding view this lack of consensus among GME stakeholders as a major obstacle.

We describe a near-term and attainable pathway to expand GME that could gain consensus among these stakeholders. This approach would sustain and expand Teaching Health Centers (THCs), a recent initiative that directly funds community-based GME sponsoring institutions to train residents in primary care specialties, dentistry and psychiatry. We further propose selectively expanding GME to meet primary care and other demonstrable specialty needs within communities, and building in evaluations to measure effectiveness of innovative training models.

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Rethinking Graduate Medical Education Funding: An Interview With Gail Wilensky


September 9th, 2014

A recent Institute of Medicine report has stirred controversy by proposing to significantly reshape the way Medicare graduate medical education funding is distributed. However, before the panel that wrote the report grappled with how the federal government should fund GME, it had to decide whether the federal government should be involved in the area at all.

“We struggled with the rationale [for a federal role] from the first meeting to the last time we convened,” Gail Wilenksy, who co-chaired the panel with Don Berwick, said in a recent interview with Health Affairs Blog.  After all, she said, the federal government “is not in the business of funding undergraduate medical education or other health care professions in any similar way, or funding other professions that are believed to be important to society and in shortage,” such as engineers, mathematicians, or scientists.

GME funding has been discussed at length in the pages of Health Affairs and will be the subject of a briefing sponsored by the journal tomorrow, Wednesday September 10. (Live and archived webcasts will be available for those who cannot attend in person.) Wilensky will offer opening remarks at the briefing. A summary of the GME report is provided in an earlier Health Affairs Blog post by Edward Salsberg, who will also participate in the briefing.

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Transcending Obamacare? Analyzing Avik Roy’s ACA Replacement Plan


September 2nd, 2014

Avik Roy’s proposal, “Transcending Obamacare,” is the latest and most thoroughly developed conservative alternative for reforming the American health care system in the wake of the Affordable Care Act. It is a serious proposal, and it deserves to be taken seriously.

Roy’s proposal is a curious combination of conservative nostrums (limiting recoveries for victims of malpractice), progressive goals (eliminating health status underwriting, providing subsidies for low-income Americans), and common sense proposals (enacting a uniform annual deductible for Medicare).

Most importantly, however, Roy proposes that conservatives move on from a single-minded focus on repealing the ACA toward building upon the ACA to accomplish their policy goals. He supports repealing certain features of the ACA—including the individual and employer mandate—but would retain others, such as community rating and exchanges. As polling repeatedly shows that many Americans are not happy with the ACA, but that a strong majority would rather amend than repeal it, and as it is very possible that we will have a Congress next year less supportive of the ACA than the current one, Roy’s proposal is important.

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Whither CHIP?


August 19th, 2014

In a day all but lost to Affordable Care Act prehistory, on November 7, 2009, the House of Representatives passed the Affordable Health Care for America Act. Among the bill’s many differences with its Senate counterpart, it would have allowed the Children’s Health Insurance Program (CHIP) to expire at the end of 2013, with children covered under that program enrolled in either Medicaid or commercial Exchange plans.

On December 24, the Senate passed the Patient Protection and Affordable Care Act (ACA). Their bill extended CHIP through fiscal year 2015 while, curiously, enhancing the Federal match rate for the program beyond that date and instituting a maintenance of effort (MOE) requirement for states to keep CHIP kids covered through 2019.

At the time, drafters of the respective chamber’s versions of health reform anticipated heading to conference to negotiate and resolve their differences, with the disposition of CHIP one of the top considerations.

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IOM Graduate Medical Education Report: Better Aligning GME Funding With Health Workforce Needs


July 31st, 2014

After nearly two years of deliberation, the Institute of Medicine (IOM) Committee on the Governance and Financing of Graduate Medical Education (GME) has issued its report. It presents a strong case for the need for change and a strong case for its recommendations.

The members of the Committee and the IOM are to be commended for their hard work, vision, and a high quality report. The report presents a clear path to a system that would help produce a physician workforce better aligned with the nation’s needs and a framework for a rational and defensible expenditure of nearly 15 billion dollars in public funds each year on GME.

Issues related to GME financing have been contentious for many years. In 1965, Congress included GME financing under Medicare reimbursement in what was intended to be a temporary arrangement. Nearly 50 years later, we are still trying to find a permanent and more rational way to finance and pay for the training of physicians as an alternative to the current complex, arcane formula built on Medicare inpatient days. Despite the well-documented shortcomings of the current system and numerous studies, attempts to find agreement on how to change and improve GME financing have been unsuccessful.

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Income Verification On The Exchanges: The Broader Policy Picture


July 14th, 2014

The Affordable Care Act scandal de jour (or at least one of them) is the difficulty the exchanges have faced in verifying the eligibility of many premium tax credit applicants. Two Department of Health and Human Services Office of Inspector General Reports in early July documented the existence of these problems. One reported that as of the first quarter of 2014, the federal exchange alone had been unable to resolve 2.6 or 2.9 million data inconsistencies. Another reported that internal controls at the federal and two state exchanges were not fully effective in ensuring that individuals enrolled in exchanges were in fact eligible.

House Republicans claim that in fact there are 4 million data inconsistencies affecting half of all enrollments. In House Energy and Commerce hearings on June 10, 2014, Republican Representative Charles Bustany Jr. claimed that $44 billion in improper payments would be made over the next 10 years. Douglas Holtz-Eakin, a former Bush Administration official, who testified at the hearings claims that improper payments may equal $152 billion. The House Energy and Commerce Health Subcommittee is holding further hearings on data inconsistencies on July 16.

The seriousness of verification issues should not be overestimated. The administration has been put in place procedures to verify carefully premium tax credit applications. Many of the discrepancies CMS is attempting to resolve do not relate to income eligibility, and those that do may result ultimately in a finding of eligibility for increased, rather than decreased, premium tax credits. A discrepancy that could result in the need for additional documentation may be as trivial as a hyphen left out of a name or a digit transposed on a Social Security number.

Unfortunately, programs proposed by Republicans and other ACA opponents that in fact make a serious attempt to cover the uninsured will require income reporting and face similar difficulties. Current reform proposals that avoid coverage eligibility determinations will not in fact cover the uninsured. While the administration could have perhaps done a better job in making eligibility determinations, any means-tested program faces a similar challenge. It is possible to design a system that does not rely on means testing and could cover low-income and high-cost uninsured Americans, as I describe below. But it would be a very different system than the ACA or alternatives currently being proposed.

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A Health Reform Framework: Breaking Out Of The Medicaid Model


July 10th, 2014

Editor’s note: This post is coauthored by Joseph Antos and James Capretta.

A primary aim of the Patient Protection and Affordable Care Act (ACA) is to expand insurance coverage, especially among households with lower incomes. The Congressional Budget Office (CBO) projects that about one-third of the additional insurance coverage expected to occur because of the law will come from expansion of the existing, unreformed Medicaid program. The rest of the coverage expansion will come from enrolling millions of people into subsidized insurance offerings on the ACA exchanges — offerings that have strong similarities to Medicaid insurance.

Unfortunately, ample evidence demonstrates that this kind of insurance model leaves the poor and lower-income households with inadequate access to health care. The networks of physicians and hospitals willing to serve large numbers of Medicaid patients have been very constrained for many years, meaning access problems will only worsen when more people enroll and begin using the same overburdened networks of clinics and physician practices.

It does not have to be this way. It is possible to expand insurance coverage for the poor and lower-income households without reliance on the flawed Medicaid insurance model. Opponents of the ACA should embrace plans to replace the current law with reforms that would give the poor real choices among a variety of competing insurance offerings, including the same insurance plans that middle-class families enroll in today. Specifically, we propose a three-part plan that includes a flexible, uniform tax credit for all those who lack employer-based coverage; deregulation of Medicaid; and improved safety-net primary and preventive care.

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The Supreme Court And The Contraception Mandate: A Temporary Setback For Contraception Coverage


June 30th, 2014

Editor’s note: See Health Affairs Blog for more coverage of the Supreme Court’s Hobby Lobby decision.

Today, the United States Supreme Court ruled that for-profit companies may avoid providing contraception coverage to employees if the companies sincerely object on religious grounds. At its narrowest interpretation, this decision is a significant but remediable setback for women’s reproductive health. At its broadest (but least likely interpretation), the decision has the potential to wreak havoc on public health regulation.

The legal challenges to the Affordable Care Act’s (ACA’s) contraception mandate have been well described in three previous Health Affairs Blog posts. To briefly recap, though, the ACA requires preventive services to be covered without copayments or other cost sharing in most employer-supported health plans. To implement this requirement, the Department of Health and Human Services (HHS) issued regulations that include all FDA-approved contraceptives, and a company that does not provide no-cost coverage of contraception is subject to substantial penalties.

Three groups of employers are exempt from the mandate: small businesses with less than 50 employees, purely religious employers, and “grandfathered” plans that have not changed meaningfully since the ACA was passed. Additionally, religiously affiliated non-profits (such as universities and hospitals) received a special accommodation from HHS by which women can receive contraception from third-party insurers at no extra cost to employees or the organization if the organization objects to covering contraception and identifies an alternate insurer.

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Repeal, And Replace, The Employer Mandate


June 4th, 2014

As it enters its fifth year, the Affordable Care Act has chalked up an impressive list of accomplishments. More than 8 million Americans have chosen a health plan through the ACA exchanges. At least another five million have likely enrolled in Medicaid. The minimum medical loss ratio requirement has saved privately insured Americans billions of dollars, while the closing of the doughnut hole has saved Medicare beneficiaries billions more. The percentage of Americans who are uninsured is dropping precipitously and is already at the lowest level it has been for years.

Recent polling, however, seems to show that Americans are not yet impressed — a majority still oppose the Affordable Care Act. Significantly, however, polling also consistently shows that Americans are not giving up on the law–a substantial majority of Americans are against repealing the ACA and would rather that problems with the ACA be fixed. Support for amending the law should create an opening for lawmakers who can identify real problems with the ACA and propose practical solutions.

One provision of the ACA that cries out for repair is the employer mandate. The Urban Institute has recently raised the question, “Why Not Just Eliminate the Employer Mandate?Conservative advocacy groups have called for its repeal for some time. Repeal of the employer mandate might, in fact, not be such a bad idea, as long as the current mandate was replaced with a better alternative.

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The Latest Health Wonk Review


May 28th, 2014

Hank Stern offers the latest edition of the Health Wonk Review at InsureBlog. His “Life’s a Beach” edition features many interesting reads on health care polity and policy.

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Is Public Policy Changing The Practice of Medicine?


May 21st, 2014

The quick answer to the title question is yes, but not in the way the architects of the Affordable Care Act (ACA) intended. Indeed, the most significant unintended consequence of the ACA may be the way poorly designed regulations are inadvertently opening the door to improved medical practice.

But first things, first. At the time the ACA was enacted, the belief that health care delivery in the United States was about to be radically transformed was widespread. “We’re going to find out what works and then go do it,” said Barrack Obama. Doctors will learn to practice medicine like engineers, predicted Atul Gawande. The profession will be dominated by Accountable Care Organizations (ACOs), said Karen Davis, and doctors will be rewarded for lowering costs and raising the quality of care. Only through ACOs can we achieve low-cost, high-quality care, said Elliott Fisher. Fee-for-service medicine is the problem, we were told, and the solution is bundled care. The idea that we should buy on value, not on volume, was a sentiment often heard.

Four years on, these predictions have been far from the mark — to put it charitably. We have spent tens of millions of dollars on demonstration programs and pilot projects investigating coordinated care, integrated care, managed care, pay-for-performance medicine, electronic medical records systems, etc. The result? Three separate Congressional Budget office reports have concluded that none of this is working, or at least not working very well. (See here, here and here.) The experience of the pilot ACO projects has been dismal. A total of 5.3 million Medicare beneficiaries are now in Medicare ACOs. Yet in their first year, only 29 percent of the physician-led ACOs and only 20 percent of the hospital-sponsored ACOs turned a “profit.” And among those that did so, the results were fairly mediocre.

The response of the advocates: double down and do more of the same. But before we throw good money after bad, perhaps we should stop and take stock.

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Managed Competition 2014: Rescued By The Private Sector?


May 12th, 2014

Managed Competition (MC) among health care financing and delivery systems was first conceived as a proposed public policy to drive delivery system change in the private sector by assuring consumers that they have choices, as well as rewards for choosing high-value providers. Many legislative proposals have used MC ideas in whole or in part. The Affordable Care Act’s (ACA) exchanges reflect the MC idea, but the three percent of the population they cover is too small to drive large scale change.

The new private corporate exchanges are also based on MC. While they cover few people now, private exchanges have the potential to change the incentives for tens of millions of consumers, and — if done right — to drive large scale delivery system reform. The combination of both kinds of exchanges could be powerful.

This post puts the idea of managed competition in a historical context, then describes how private exchanges are operationalizing the concept. I conclude with a brief look at how managed competition may develop going forward, and how MC may change the health care system.

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Lessons From Abroad And At Home: How PCORI Can Improve Quality Of Care (And Prove It) By 2019


May 2nd, 2014

The Patient-Centered Outcomes Research Institute (PCORI) was established with the passing of the Affordable Care Act in 2010 to oversee and set guidelines for comparative effectiveness research (CER). PCORI was also designed with a sustainable funding model, having received $210 million from 2010 to 2012 and expected appropriations of $150 million annually via fees imposed on Medicare and private health insurance companies. The international comparative effectiveness research community has recognized PCORI as the most funded CER initiative in existence, far surpassing the annual budgets of comparable international programs such as U.K.’s National Institute for Health and Clinical Excellence (NICE).

Despite the considerable resources designated to PCORI, its future remains tenuous. For one, the ACA legislation also created a “sunset date” of September 2019, giving PCORI seven years to convince Congress to reauthorize funding for the institute. Further, legislative efforts have already been made to repeal PCORI; H.R. 3827 was introduced by Rep. Brett Guthrie (R-KY) in January 2012, asking for immediate elimination of PCORI.

While PCORI is the first national comparativeness effectiveness research institute to be established in the U.S., it fortunately can draw several lessons from its international counterparts which have been operating for two decades. The U.K.’s NICE, considered by most to be the most comprehensive and effective CER program, will be the main comparator for this analysis.

PCORI must address two themes that are at tension with one another. On one hand, PCORI needs to foster stakeholder involvement in order to establish itself as a legitimate body of CER knowledge that is relevant and accepted in clinical practice. However, it also must avoid the pitfalls of having a democratic, iterative process that moves too slowly to issue findings and recommendations in a timely manner.

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Implementing Health Reform: A Summary Health Insurance Marketplace Enrollment Report


May 1st, 2014

On May 1, 2014, the Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE) released a summary enrollment report for the federal and state marketplaces (exchanges) for the entire 2014 open enrollment period — from October 1, 2013 to March 31, 2014, including special enrollment (SEP) activity reported through April 19, 2014. The report was accompanied by a press release, an infographic, and an addendum reporting state level data, as well as the March Medicaid and CHIP enrollment report.

The headline of the report is old news by now: Over 8 million individuals selected a qualified health plan through the federally facilitated marketplace (FFM) and state-based marketplaces (SBM) during the covered period. The Medicaid report adds that as of March, 2014, Medicaid and CHIP enrollment has grown by 4.8 million, 8.2 percent, over baseline figures from the third quarter of 2013.

Both the marketplaces and Medicaid programs saw a dramatic surge in enrollment in March. Nearly 3.8 million people selected a marketplace plan during March and April, 47 percent of the total (including 910,495 who enrolled during the April SEP). Medicaid and CHIP enrollment in March increased by 1.8 million over that that reported in February.

Age distribution. As expected, enrollees trended younger as the open enrollment period ended. The number of young adults aged 18 to 34 who selected a marketplace plan doubled during the last month, accounting for 31 percent of March and April enrollment. This surge increased the total proportion of young adult enrolled only to 28 percent, compared to 66 percent of enrollees above age 35 and 25 percent between ages 55 and 64 (with 6 percent below age 18).

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Travels In Hyperreality: What If Bipartisan ACA Fixes Were Possible?


April 23rd, 2014

Since enactment of the Affordable Care Act in March 2010, a strange, relatively unnoticed phenomenon has occurred: Congress has passed bipartisan changes to it. These amendments were generally to such esoteric components of the law that they dodged the political block-aid that otherwise surrounds it.

But what would happen if things were different? If Congress could act to change the ACA in a meaningful way, what would it do? Here we briefly review the previous sub rosa changes to launch into a broader examination of macro ACA reforms that have a fighting chance of enactment in the not too distant future.

Tinkering. Most recently, in the Medicare “doc fix” in March, both parties acted to repeal the section of the ACA that capped deductibles for small group health plans. That legislation also delayed, again, implementation of the ACA’s Medicaid cuts to disproportionate share hospitals.

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


April 14th, 2014

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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