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Moving Beyond Wellness ROI Toward Employment-Based Cultures Of Health: Part I


January 26th, 2015

With their recent post declaring that employment-based wellness initiatives “increase rather than decrease employer spending on health care with no net health benefit,” Al Lewis and coauthors are continuing to exert a clarifying presence in a field with a history of unsubstantiated claims and suspect methods. This conclusion is not supported by the work with which we and others have been associated and is thus not one with which we agree.

Nevertheless, Lewis et al. are to be acknowledged for fueling the need for a sharper focus on the core challenge at hand for employers: how best to improve the value of their health care investment—that is, how to manage health care costs while improving employee health and productivity—in ways that are sustainable. Incremental, inconsistent and, at times, maddeningly slow progress has been made. Employment-based wellness has been at the forefront, even as the need for quality improvement continues.

Moreover leading employers with well-developed management and measurement approaches have moved well beyond calculating the return on investment of individual wellness efforts and are demonstrating the more comprehensive value of building “cultures of health.”

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Additional Requirements For Charitable Hospitals: Final Rules On Community Health Needs Assessments And Financial Assistance


January 23rd, 2015

On December 29, the Department of the Treasury and the Internal Revenue Service released long-awaited final regulations implementing Affordable Care Act provisions that impose additional obligations on charitable hospital organizations covered by §501(c)(3) of the Internal Revenue Code.  Published in the Federal Register on December 31 2014, the regulations are massive, consolidating a series of prior proposals into a single final body of regulatory law.  The regulations affect more than 80 percent of U.S. hospitals, both the 60 percent that operate as private nonprofit entities and the 23 percent that operate as governmental units.

Because state and local governments typically condition their own sales, property, and corporate income tax exemptions for nonprofit entities to a hospital’s §501(c)(3) status, the final regulations carry broad and deep implications from both a policy and financial perspective.  According to the Congressional Budget Office the 2002 the national value of the federal tax exemption exceeded $12 billion, a figure that undoubtedly has risen considerably.

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Moving From Mandate To Reality: A Roadmap For Patient And Family Engagement


January 20th, 2015

The 2010 Affordable Care Act (ACA) moved patient and family engagement to center stage in health care reform. The law mentions “patient-centered care” at least 40 times, with explicit references to patient engagement, patient experience, health literacy and shared decision making. Evidence is growing that meaningful patient and family engagement can help achieve the triple aim of better quality, better outcomes and lower health care costs and substantially reduce preventable harm.

Yet, despite these advances, the full promise of engagement remains mostly untapped, and much confusion remains about what constitutes meaningful patient and family engagement, and importantly, how to translate this evidence broadly into routine health care practice.

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CMS Spending Report Leads Health Affairs 2014 Top-Ten List


January 13th, 2015

A report on 2012 health spending by analysts at the Centers for Medicare and Medicaid Services Office of the Actuary was the most-read Health Affairs article in 2014. To celebrate the New Year, Health Affairs is making this piece and all the articles on the journal’s 2014 top-ten list freely available to all readers for two weeks.

Health Affairs publishes annual retrospective analyses of National Health Expenditures by the CMS analysts, as well as their health spending projections for the coming decade. In the latest installment in this series — which also made our 2014 top ten — the analysts reported on 2013 health spending and discussed their findings at a Washington DC briefing. The two reports documented continued slow growth in health spending; the 2013 report featured the slowest rate of health spending growth since CMS began tracking NHE in 1960.

Next on the 2014 Health Affairs most-read list was an article on PepsiCo’s workplace wellnesss program. John Caloyeras and coauthors at RAND and PepsiCo found that the diseases management component of the program saved money, but the lifestyle management component did not. This was followed by two Narrative Matters essays by Charlotte Yeh and Diane Meier; another Narrative Matters piece, by Janice Lynn Schuster, rounded out the list at number ten.

The full top-ten list is below. And check out the 2014 most-read Health Affairs Blog posts and GrantWatch Blog posts.

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Reconsidering Pauly And Coauthors’ ‘Economic Framework For Preventive Care Advice’


January 12th, 2015

In the November issue of Health Affairs, Mark Pauly and coauthors criticize the lack of cost-effectiveness considerations in the Affordable Care Act (ACA), which mandates that health plans include preventive care free at the point of use. The bodies critiqued, the Advisory Committee on Immunization Practices (ACIP) and the U.S. Preventive Services Task Force, convene health experts to develop recommendations for immunizations and other preventive services.

According to the authors, the task entrusted to these bodies by the ACA, of offering sound advice on preventive care without considering its cost-effectiveness, is “impossible to do well.” They propose instead an “economic framework” under which only services with “substantial external benefits” (e.g. a vaccination for contagious disease) would be mandated for coverage. We believe this position is misguided.

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Sovaldi, Harvoni Payment Issues Lead Health Affairs Blog November Most-Read List


December 24th, 2014

A piece by Laura Fegraus and Murray Ross on the challenges of paying for lifesaving but high-priced drugs like Sovaldi and Harvoni from was the most-read Health Affairs Blog post for November. This was followed by a critical analysis of workplace wellness programs from Al Lewis, Vik Khanna, and Shana Montrose.

Next came a post on the 2016 Notice of Benefit and Payment Parameters Proposed Rule from Tim Jost, and then a look at health care policy after the mid-term elections from James Capretta.

The full top-ten list for November is below.

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The Value of Workplace Health Promotion (Wellness) Programs


December 22nd, 2014

The recent Health Affairs Blog post by Al Lewis, Vik Khanna, and Shana Montrose titled, “Workplace Wellness Produces No Savings” has triggered much interest and media attention. It highlights the controversy surrounding the value of workplace health promotion programs that 22 authors addressed in an article published in the September 2014 issue of the Journal of Occupational and Environmental Medicine titled, “Do Workplace Health Promotion (Wellness) Programs Work?”  That article also inspired several follow-up discussions and media reports, including one published by New York Times columnists Frakt and Carroll who answered the above question with: “usually not.”

There are certainly many points of contention and areas for continued discussion on this topic. It turns out that Lewis et al. and I agree on many things, and there are other areas where we see things differently.

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Investing In The Health And Well-Being Of Young Adults


December 15th, 2014

Young adulthood — ages approximately 18 to 26 — is a critical time in life. What happens during these years has profound and long-lasting implications for young adults, and — because many are parents — for the next generation.  Healthy, productive, and skilled young adults are critical for the nation’s workforce, global competitiveness, public safety, and national security.

Although young adults are resilient and adaptable, they are surprisingly unhealthy, showing a worse health profile than both adolescents and adults in their late 20s and 30s. Recent national attention on young adults has focused primarily on enrolling them in health care insurance to offset the higher costs associated with care for older adults under the Affordable Care Act 2010 provisions — mistakenly implying that it is not in their own interest to have health insurance. Unfortunately, too little attention has been paid to young adults’ specific health needs and the transitions they face once they are in the health care delivery system.

The Institute of Medicine and National Research Council recently released a new report titled Investing in the Health and Well-Being of Young Adults, which reviews what is known about the health, safety, and well-being of young adults and offers recommendations for policy and research. It was prepared by a committee with expertise in multiple disciplines, including public health, health care, behavioral health, sociology, social services, human development, neuroscience, economics, business, occupational health, media, and communications. We served as chair and a member of the committee, respectively.

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Does Public Health Have A Future?


December 10th, 2014

Ebola’s arrival in the U.S. hit Americans with a jolt. Regardless of how you feel about the response to date, it should remind everyone of the importance of public health.

Fortunately, public health in the U.S. has built an extraordinary track record of success. Smallpox, one of the most dreaded diseases in history, was eradicated worldwide. New vaccines have sharply cut the toll of deaths and disabilities from H flu meningitis, tetanus, pneumococcal sepsis and other deadly diseases.

Adding folate to foods dramatically reduced neural tube defects in newborns. Safer cars and better roadway designs cut fatal crashes per million vehicle miles traveled by 90 percent. Because smoking is far less popular than it once was, 8 million Americans have been spared early and agonizing deaths from cancer, heart disease, emphysema, and other smoking-related diseases.

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Workplace Wellness Produces No Savings


November 25th, 2014

During the last decade, workplace wellness programs have become commonplace in corporate America. The majority of US employers with 50 or more employees now offer the programs. A 2010 meta-analysis that was favorable to workplace wellness programs, published in Health Affairs, provided support for their uptake. This meta-analysis, plus a well-publicized “success” story from Safeway, coalesced into the so-called Safeway Amendment in the Affordable Care Act (ACA). That provision allows employers to tie a substantial and increasing share of employee insurance premiums to health status/behaviors, and subsidizes such program implementation by smaller employers. The assumption was that improved employee health would reduce the employer burden of health care costs.

Subsequently, however, Safeway’s story has been discredited. And the lead author of the 2010 meta-analysis, Harvard School of Public Health Professor Katherine Baicker, has cautioned on several occasions that more research is needed to draw any definitive conclusions. Now, more than four years into the ACA, we conclude that these programs increase, rather than decrease employer spending on health care with no net health benefit. The programs also cause overutilization of screening and check-ups in generally healthy working age adult populations, put undue stress on employees, and incentivize unhealthy forms of weight-loss.

Through a review of the research literature and primary sources, we have found that wellness programs produce a return-on-investment (ROI) of less than 1-to-1 savings to cost. This blog post will consider the results of two compelling study designs — population-based wellness-sensitive medical event analysis, and randomized controlled trials (RCTs). Then it will look at the popular, although weaker, participant vs. non-participant study design. (It is beyond the scope of this posting to question non-peer-reviewed vendor savings claims that do not use any recognized study design, though those claims are commonplace.)

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Recalling To Err’s Impact — And A Small But Telling IOM Mistake


November 25th, 2014

This year marks the 15th anniversary of the Institute of Medicine (IOM)’s To Err is Human report, which famously declared that from 44,000 to 98,000 Americans died each year from preventable mistakes in hospitals and another one million were injured. That blunt conclusion from a prestigious medical organization shocked the public and marked the arrival of patient safety as a durable and important public policy issue.

Alas, when it comes to providing the exact date of this medical mistakes milestone, the IOM itself is confused and, in a painful piece of irony, sometimes just plain wrong. That’s unfortunate, because the date of the report’s release is an important part of the story of its continued influence.

There’s no question among those of us who’d long been involved in patient safety that the report’s immediate and powerful impact took health policy insiders by surprise. The data the IOM relied upon, after all, came from studies that appeared years before and then vanished into the background noise of the Hundred Year War over universal health insurance. This time, however, old evidence was carefully rebottled in bright, compelling new soundbites.

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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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Health Affairs Event Reminder: Collaborating For Community Health


November 4th, 2014

Policymakers are paying increasing attention to the relationship between the characteristics of communities and the health of the people living in them. The November 2014 issue of Health Affairs, “Collaborating For Community Health,” examines new possibilities created by alignment of the fields of health and community development.

These possibilities come from both sides, including recent changes in the community development field that have set the stage for the new focus on improving health, as well as new approaches to health care financing that create incentives for improving health outcomes.

You are invited to join us on Wednesday, November 5, at a forum featuring authors from the new issue at the National Press Club in Washington, DC.

WHEN:
Wednesday, November 5, 2014
9:00 a.m. – 12:00 p.m.

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

REGISTER NOW!

Follow live Tweets from the briefing @Health_Affairs, and join in the conversation with #HA_CommunityHealth.

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Lessons from Ebola: The Infectious Disease Era, And The Need To Prepare, Will Never Be Over


October 28th, 2014

With the wall-to-wall news coverage of Ebola recently, it’s hard for many to distinguish fact from fiction and to really understand the risk the disease poses and how prepared we are to fight it.

Fighting infectious diseases requires constant vigilance. Along with Ebola, health officials around the globe are closely watching other emerging threats: MERS-CoV, pandemic flu strains, Marburg, Chikungunya and Enterovirus D68. The best defense to all of these threats is a good offense — detecting, treating and containing as quickly and effectively as possible.

And yet, we have consistently degraded our ability to respond to these new, emerging and re-emerging threats by underfunding and undercutting existing capabilities and expecting the country to ramp up overnight when new threats emerge.

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Tax-Exempt Status For Nonprofit Hospitals Under The ACA: Where Are The Final Treasury/IRS Rules?


October 23rd, 2014

Months have now stretched into years, and there still remains no sign of final Treasury/IRS regulations interpreting the Affordable Care Act (ACA)’s provisions covering the expanded obligations of nonprofit hospitals that seek tax-exempt status under §501(c)(3) of the Internal Revenue Code.

The ACA amendments do not depend on formal agency policy to take effect. Nonetheless, Congress directed the Treasury Secretary to issue regulations and guidance necessary to carry out the reforms (26 U.S.C. §501(r)(7)). To this end, two important sets of proposed rules were issued: the first in June, 2012; and the second, in April 2013. While an informative IRS website lists various proposed rules and guidelines important to nonprofit hospitals, final rules seem to have performed a disappearing act.

Apparently recognizing the problems created by its delays, the agency has gone so far as to issue a special Notice letting nonprofit hospitals (and presumably the public) know that they can rely on its proposed rules. But this assurance overlooks the fact that the proposed rules themselves contained crucial areas in which final agency policy has not yet been adopted.

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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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Implementing Health Reform: New Accommodations For Employers On Contraceptive Coverage


August 22nd, 2014

On August 22, 2014, the Departments of Health and Human Services, Labor, and Treasury released an interim final  and a proposed  rule providing for the accommodation of religious objections on the part of an employer or institution of higher learning to providing their employees or students coverage for contraceptive services.  A fact sheet on the rules was also released,   as was a notice on the revision of the form used to collect information on religious objections to contraceptive coverage.

The proposed rule, which applies to for-profit entities, is being issued in response to the Supreme Court’s decision in Burwell v. Hobby Lobby, which ruled that closely-held for-profit corporations may refuse to cover contraceptives for religious reasons.  The interim final rule responds to the Court’s interim order in Wheaton College v. Burwell  (and to 31 lower court injunctions) that released religious non-profit organizations from accommodations earlier proposed by HHS.

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Health Policy Brief: The Relative Contribution Of Multiple Determinants To Health Outcomes


August 22nd, 2014

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) examines factors that can contribute to health status. In the United States, less than 9 percent of health expenditures go to disease prevention, and there is little support for social services, such as programs for older adults, housing, and employment programs.

This brief focuses on “multiple determinant” studies that seek to quantify the relative influence of some of these factors on health. It is part of a larger project, supported by the Robert Wood Johnson Foundation, which aims to create a structure for conducting analyses that demonstrate the value of investments in nonclinical primary prevention and their impact on health care costs.

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Spokane County: A Community Comes Together To Improve Health And Education For Every Child


August 18th, 2014

Editor’s Note: This post is part of an ongoing series written for Health Affairs Blog by local leaders from communities honored with the annual Robert Wood Johnson Foundation Culture of Health Prize. In 2014, six winning communities were selected by RWJF from more than 250 applicants and celebrated for placing a priority on health and creating powerful partnerships to drive change. Interested communities are encouraged to apply for the 2015 RWJF Culture of Health Prize. Applications are due September 17, 2014.

Spokane County is a metro area of more than 470,000 people, yet it’s still driven by the spirit of a small town. That sense of community is an essential part of the county’s ongoing work to improve the health of all residents by focusing on education.

In 2006, Spokane Public Schools’ high school graduation rate was less than 60 percent overall, while Spokane County’s rate was 72.9 percent. Spokane County educators were increasingly concerned about the future health and well-being of the county’s children, especially the 18 percent living in poverty.

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Health Affairs Web First: Small Medical Practices Had Fewer Preventable Hospital Admissions


August 14th, 2014

The Affordable Care Act and other federal policy initiatives have created incentives for smaller practices to consolidate into larger medical groups or be acquired by hospitals. It is often assumed that larger practices provide better care. However, a new study, recently released as a Web First by Health Affairs, showed unexpected results: Practices with 1-2 physicians had 33 percent fewer preventable hospital admissions than practices with 10-19 physicians.

This study, which used data from the National Study of Small and Medium-Sized Physician Practices (NSSMPP) and surveyed 1,745 physician practices between July 2007 and March 2009, is believed to be the first of its kind in the United States. The study sample was limited to practices where at least 60 percent of the physicians were primary care providers, cardiologists, endocrinologists, and pulmonologists.

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