Health Affairs

The first few days of the week of May 20, 2013 were quiet on the regulatory front, with no new Affordable Care Act regulations or guidance (at least that I could find). HHS released power point slides from an earlier webinar that usefully describe the different kinds of assisters who will be available in the marketplaces (navigators, in-person assisters, certified application counselors, and agents and brokers). It also has apparently updated its navigator and assister frequently-asked-questions paper, although most of these FAQs were released earlier.

In other news, however, the Fourth Circuit Federal Court of Appeals has released the recording of the May 17, 2013, oral argument in the case of Liberty University v. Jacob Lew. The Liberty University case aroused quite a stir in November of 2012, when the Supreme Court reversed its earlier decision to deny certiorari in the case, granted certiorari, vacated the earlier decision of the Fourth Circuit rejecting the plaintiff’s case, and remanded the case to the Fourth Circuit for further proceedings.

In the case’s first incarnation, Liberty University challenged the authority of Congress under its constitutionally enumerated powers to adopt the Affordable Care Act’s individual and employer mandates. Liberty also claimed that the ACA violated the Constitution’s Establishment Clause, by granting privileges to certain religious groups but not to Liberty, and the Free Exercise Clause (and Religious Freedom Restoration Act), by requiring Liberty to purchase insurance that covered abortion. Liberty was joined by two individual plaintiffs in the case, who asserted similar rights for themselves.

As life spans increase and birth-rates decrease, the world’s population is aging. From 2000 to 2025, the over-60 demographic segment will double from 600 million to almost 1.2 billion. By 2050, it will nearly double again, surpassing two billion and accounting for an incredible 22% of the total global population. A society this “old” has never before existed, and it is a social, ethical, and economic imperative to keep older adults healthy and engaged. It is timely for the global public health community to re-align its thinking, policies and activities to this new demographic reality.

Organizations at national and global levels have begun to pursue initiatives to promote healthy aging, and these efforts are going to intensify in the coming years. Thus far, the progress has been admirable, with the World Health Organization, the United Nations, the Organisation for Economic Co-operation and Development, and others taking leadership roles. Yet, despite many promising developments, the potential of “life-course immunization,” which stresses the administration of vaccines throughout all stages of life – including for adults – to prevent disease and promote health, has been largely overlooked, especially among adults.

This is a missed opportunity. There is a growing body of research and data to show that immunizations against some of the more specific age-related health challenges – such as pneumococcal disease, herpes zoster, and others – are economically feasible investments that can create large public health benefits.

Three years after wellness was hailed as perhaps the only truly bipartisan component of the Affordable Care Act, both lay and trade commentators have begun observing that the assumptions behind it were incorrect while downsides were overlooked. As a predictable result, savings have proven elusive even in seemingly ideal baseline circumstances for health improvement. For example, a wellness program at BJC HealthCare in St. Louis reduced hospitalizations for wellness-sensitive medical events, but the savings were limited (and offset by other cost increases) by the fact that older employees there on average were hospitalized for a wellness-sensitive medical event only once every 12 years to begin with. (See Note 1.)

Consistent with that finding, commentators (including the authors) have noted that every vendor claiming savings from what the Affordable Care Act (ACA) terms “health contingent” wellness programs has employed obviously flawed study design (like comparing the results from active motivated participants to non-motivated non-participants, and crediting the program, rather than the obvious difference in motivation, for the savings) and/or has simply made up or misinterpreted their own outcomes .

One reason for the absence of savings is that the biometric screenings themselves on which wellness economics are based cost far more money than they can conceivably save, due to both the likelihood of overdiagnosis and the marginal benefit of taking frequent measurements in generally healthy adults. Routine screening lacks an evidence basis and is eschewed by the medical community. For example, the federal government recommends lipid screening only once every five years.

This commentary is in response to the March 5, 2013 Health Affairs article, “Wellness Incentives in the Workplace: Cost Savings through Cost Shifting to Unhealthy Lifestyles.” In that article, Jill Horwitz and coauthors express concerns about new rules governing workplace health promotion (wellness) programs due to take effect in 2014 as part of the Patient Protection and Affordable Care Act of 2011, Public Law 111-148 (“ACA”). In addition to increasing access to health care services for all Americans, the ACA aims to place greater emphasis on health promotion and disease prevention and to encourage employer adoption of workplace wellness programs.

As I discuss below, some of the concerns raised by Horwitz et al. are legitimate points that I agree with. However, I believe that Horwitz and her colleagues go too far when they appear to question the basic idea that employees with modifiable health risks cost more than those without such risks, calling into question the entire concept of workplace wellness programs and indeed of prevention in general. In this post, I explain how well-designed wellness programs can benefit both employers and employees, and I offer some suggestions to ensure that such programs are both effective and fair.

A specific provision of the ACA (Section 2705), which is at the heart of the controversy addressed by Horwitz et al., will allow employers to design incentive-based wellness programs that reward not only participation in health promotion programs but also “outcomes” related to having healthy habits and managing biometric values within “normal” ranges. Under the new rules, financial incentives (e.g., different health plan designs, payment terms, premiums levels, deductibles, co-insurance or co-payments) could be offered to workers who are nonsmokers, are at a given weight or BMI, or are effectively controlling their blood pressure, total cholesterol, and blood glucose. Rewards or incentives would also be made available to employees who eat a healthy diet or are physically active.

Editor’s note: The February issue of Health Affairs was a thematic issue focused on patient engagement. In conjunction with the Patient-Centered Outcomes Research Institute (PCORI), the journal launched a new initiative inviting questions from patients and others via Facebook for Health Affairs authors on patient-centeredness and patient engagement. Questions are then answered on Health Affairs Blog.

Below, Ming Tai-Seale of the Palo Alto Medical Foundation Research Institute answers a reader query; previously, Jessie Gruman and Rachael Fleurence answered questions. Watch for a Health Affairs Facebook post tomorrow inviting questions for Benjamin Moulton of the Foundation For Informed Medical Decision Making.

Paul Gionfriddo: Ming, you’ve concluded both that we need a better system of communication between clinicians and patients with less variation in clinicians’ responses and that clinicians appear to be out of their comfort zone communicating with patients about mental health concerns. Would you argue that more universal use of screening tools like the PHQ-9, coupled with better training of primary care clinicians about how to interpret results, respond to patients, and refer (via collaboration to or integration with) behavioral health professionals would create more effective give-and-take with patients and address some of the issues you raised in your paper?

Ming Tai-Seale: Thank you, Paul, for your thoughtful question. Indeed, the United States Preventive Services Task Force (USPSTF) has recommended that screening adults for depression be done in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up.

The Affordable Care Act (ACA) includes several changes to the Medicare fee-for-service (FFS) program that seek to create higher-quality and more affordable care for Medicare beneficiaries. Program-wide changes to FFS such as Shared Savings programs and demonstration projects such as Multi-Payer Advanced Primary Care Practice and Comprehensive Primary Care initiatives are seeking to change the way healthcare is organized and delivered. A common feature across these programs is the increasing emphasis on population health management (PHM) in FFS and an increasing expectation that providers accept and manage the health and health care of defined populations.

A set of elements have been identified in the literature as being core to PHM. These include identifying and stratifying risk, promoting health and wellness, implementing targeted programs based on identified risk, integrating community and other resources in managing patients, and monitoring health and quality-of-life outcomes on an ongoing basis. While some providers have the capability to implement PHM practices, many organizations have a fairly steep learning curve and will likely need training and assistance with specific functions that are viewed as being central to PHM.

Theoretical frameworks are helpful, but examining practical experience with PHM can provide useful lessons. Since the inception of what is now known as the Medicare Advantage (MA) program, health plans have developed and implemented programs that are designed to manage the health of a defined population. Given the increased interest and focus on PHM, an understanding of the approaches used by MA to manage their enrollee population can be useful to the implementation of ACA FFS provisions and to other payers, providers, and policy makers who might be considering similar efforts.

For decades before the passage of the Affordable Care Act, health care costs outstripped inflation, without corresponding improvements in health care quality. Our system didn’t incentivize quality or efficiency. We paid providers for the quantity of care, not the quality of care. And we were not using technology to deliver smarter care.

The Affordable Care Act includes steps to improve the quality of health care and lower costs for you and for our nation as a whole. This means avoiding costly mistakes and readmissions, keeping patients healthy, rewarding quality instead of quantity, and creating the health information technology infrastructure that enables new payment and delivery models to work.

Here are just a few ways that the health care law builds a smarter health care system and incentivizes quality of care – not quantity of care – to drive down costs and save you money.

Use rates for inpatient and certain hospital outpatient services are declining in many areas of the country, reflecting fundamental change brought by the new business model. Importantly, as evidenced by trends in Chicago and Minnesota, there also appears to be a correlation between the level and pace of a market’s shift toward value-based care and the level and pace of utilization decline.

We believe this trend is here to stay and that it has significant strategic and financial implications for health care providers. Specifically, providers that embrace the migration to value-based care will need to work aggressively to eliminate unnecessary and/or ineffective activities in order to thrive under risk contracts. This requires a fundamental change in mindset, culture, and attitude about volume and activity. It also requires providers to rethink the organization and structure of their delivery networks to avoid supporting unnecessary capacity, and to drive patients into the lowest-possible cost setting in which quality care can be delivered.

The goal will be to manage a population’s health across the care continuum, keeping patients healthy through preventive and primary care services, and out of acute care facilities whenever possible. The right place to provide the right care at the right time with the right quality, cost, and access increasingly will be a setting other than a hospital. By eliminating waste and redirecting patients to ambulatory centers, physician offices, clinics, and online and/or telephonic interactions, less work will be done in the hospital. To reduce well-documented overutilization, tests and services deemed inappropriate or unnecessary based on medical evidence will be eliminated in all settings. (See Note 1) Acute care will be one, and only one, component of the population-centric health management services continuum.

Recently, the Institute of Medicine and the National Research Council reported that Americans die earlier and live in poorer health than people in other industrialized countries. This is the latest evidence of the urgent need for health reform, as embodied in the Affordable Care Act.

The ACA’s recent enactment has triggered a series of new and concerted efforts to address some of the many challenges relating to health care cost, access and quality that the U.S. faces today. One of the most important challenges involves the number and mix of health providers that will be needed to meet the demand resulting from changing demographics, more expansive availability of health insurance, and a new emphasis on wellness and preventive care.

In this post, I discuss some of the factors that bear on this challenge, and I suggest some policy steps that we could take to help develop the workforce needed for the post-health reform world.

The loud cries warning that rising health care costs are going to destroy the nation’s economy have been shouted so often that the will to move firmly in any one direction has almost halted. We’ve all heard them: health care costs are unsustainable, excessive spending is fueling our nation’s debt, and despite high costs, health outcomes are behind much of the world and aren’t improving.

The way doctors are paid is one of the most significant drivers of escalating health care costs. The National Commission on Physician Payment Reform, which we chair, was formed by the Society of General Internal Medicine to provide the public and private sector with recommendations for transforming the way we pay doctors in order to rein in spending and improve quality.

On Monday, after a year of intensive study, the 14-member Commission issued a blueprint for exactly how to move the nation toward a physician payment system that will yield better results for payers and patients.

The US spends far more per person on health care than any other nation. But a growing body of research demonstrates that Americans – rich or poor, minority or not – suffer from a widening “health disadvantage” when compared to citizens of other high-income countries. On January 9, the Institute of Medicine (IOM) and the National Research Council released “U.S. in International Context: Shorter Lives, Poorer Health.” Commissioned by the National Institutes of Health, a panel chaired by Professor Steven H. Woolf at Virginia Commonwealth University painstakingly investigated whether Americans of all ages were affected by a growing health gap previously observed between older Americans and their foreign counterparts.

The panel examined several decades of data from the US and 16 comparable high-income countries, most of which are European. What they found is, or should be, alarming, even for seasoned health advocates and policymakers. The report’s authors sound the alarm at the outset: “We uncovered a strikingly consistent and pervasive pattern of higher mortality and inferior health in the United States, beginning at birth.”

What does this report mean for clinicians and health systems, especially at a time when doctors, nurses and other health care professionals are adjusting to a shifting landscape of structural reforms? Is this a clarion call for clinicians, educators and policymakers to engage in realigning the way we deliver care? Or will this news drive clinicians to sound a retreat from the front lines of population health-oriented system change?

On January 11, two days after the release of the IOM report, I talked with one of the IOM panelists behind the report, Paula Braveman MD MPH, Professor of Family and Community Medicine and Director, Center on Social Disparities in Health at UCSF. I spoke with her on behalf of HealthBegins, a social enterprise and online community of clinicians and others committed to improving health care and the social determinants of health. We discussed the report and what it means for America’s clinicians.

States are in the midst of deciding whether and how to expand their Medicaid programs to nonelderly individuals with income below 133 percent of Federal Poverty Level (FPL), as permitted under the Affordable Care Act (ACA). The group that perhaps stands to benefit the most from Medicaid expansion is women of childbearing age and their future children.

One of the ACA’s main goals was to address the upstream determinants of health, shifting the focus of the health care system “sick care” to “well care.” However, the promise of preventive care will not be realized if women of childbearing age are denied access to health insurance coverage. Medicaid expansion has the potential to drive meaningful improvements in maternal and child health by promoting health at every stage of life, including before and between pregnancies.

Today, Medicaid coverage is unavailable in most states to childless women who are not pregnant.

As a result, low-income women may have little or no source of regular health care before or between pregnancies, or after their childbearing is concluded. These women often lack a medical home and go without both regular preventive care and acute care for illness or injury. This lack of preconception and interconception care can have a significant impact on women’s health, and on the health of future pregnancies and children. The ACA has the potential to transform this dynamic.

On January 10, 2013 the Centers for Medicare & Medicaid Services (CMS) announced that 106 Accountable Care Organizations (ACOs) will join the Medicare Shared Savings Program (MSSP). CMS reports that this brings the total number of MSSP ACOs to “more than 250” and that they cover up to 4 million Medicare beneficiaries.

These new Medicare ACOs, though, only tell part of the accountable care story. ACO growth has also continued apart from the Medicare program with 428 total ACOs now existing in 49 states. Additionally, physician groups have overtaken hospital systems and have now become the largest backer of ACOs.

Background Of The ACO Program

Public sector. ACOs are health care entities intended to lower health care costs, improve quality outcomes and improve the experience of care. The premise of the ACO is that each of these results can be obtained by moving away from volume-driven fee-for-service based reimbursement toward payment models that reward care coordination and quality outcomes.

The pharmaceutical drugs developed over the past two decades have helped us more effectively manage, and in some cases dramatically change, the outcomes of patients with hypertension, high cholesterol, diabetes, and even some cancers. Increasingly, though, the stroke of a prescription pen doesn’t solve all patient problems. Nor does it solve the problems in our health systems.

To really fulfill the potential of health care, we need patients who are engaged, patients who take “actions (as) individuals … to obtain the greatest benefit from the health care services available to them.” (See Exhibit one below, click to enlarge)

Leonard Kish recently called patient engagement “the blockbuster drug” of the century. It’s an exciting idea and an apt label that raises an interesting question: what would an “engagement pill” actually look like?

Now that the Obama Administration has secured a second term, health reform is a “go”. Yet, gaps and questions remain, some of them potentially far more substantial than originally anticipated. While the mandate on individuals to purchase health insurance has survived as a “tax,” states will have much more flexibility to opt in or out of expanded Medicaid coverage without losing all of their federal Medicaid funding. And there is always the possibility of further cuts.

In the meantime, “wait and see” is no longer an option. With a “cup half full” vision, health reform can be viewed as a basic platform from which gaps can be filled. How can we make the most of this platform? How can we connect the people to the coverage offered by the exchanges and persuade people to buy it? How can we connect the people who buy coverage to the care they will need? And how can we do so in a way that doesn’t break the bank?

Some answers to these questions are offered below. I also invite you to join us on February 13-14, 2013 in Washington, D.C. at the Health Care Industry Access Initiative’s Access Summit where you can hear more from our experts in a variety of panel discussions about what will and won’t work to achieve access, and how health industry efforts are key to access and, in turn, the success of health reform.

Editor’s note: For more on the attitudes of Americans toward medical care and empowering patients to be active participants in their own care, see the February issue of Health Affairs, “New Era Of Patient Engagement.”

The attention now devoted to defining the proper role of patients and consumers in clinical decision-making is unusual, both in terms of who is addressing the issue and the intensity of the concern. Once, it was physicians and bioethicists who took the lead; now it is health policy analysts and health care administrators. Their aims go well beyond improving doctor-patient communication or promoting patient autonomy. The primary goal is to enlist patients in the effort to bring fundamental change to health care delivery.

The obligations conferred upon or assumed by patients have changed dramatically over the past half-century. Well into the 1950s, prevailing norms reflected Talcott Parsons’ formulation of the sick role. Patients were duty-bound to seek medical care when ill and follow physicians’ orders. In the 1970s and ‘80s, the new field of bioethics successfully challenged this paradigm, demanding that physicians obtain patients’ informed consent for all interventions, particularly in end-of-life decision-making.

Current expectations are different, less concerned with bioethical principles like autonomy and more committed to the idea that unless patients are genuine partners in medical decision making, altering the health care delivery system is not likely to succeed. The goal is not to advance patient rights but to transform patterns of care.

One of the most contentious, and certainly most litigated, questions that has arisen in the course of the implementation of the Affordable Care Act is the validity of the regulatory requirement that employers cover contraceptive services for their employees as a preventive women’s health service. On February 1, 2013, the Departments of Health and Human Services, Labor, and Treasury issued a joint notice of proposed rulemaking and fact sheet describing how they intend to implement this provision as it affects religious organizations. This post discusses the proposed rule and its context.

As discussed in earlier posts, the ACA requires that insurers and group health plans cover designated preventive services without cost sharing. The provision specifies that the Health Resources and Services Administration must determine the women’s preventive services that must be covered. Based on recommendations from the Institute of Medicine, HRSA designated all FDA-approved contraceptives for required coverage. This requirement was effective for the first plan year following August 1, 2012.

Some religious groups, however, most notably the Catholic Church, believe that the use of contraceptives is sinful. Other religious groups do not object to all contraceptives, but do object to specific contraceptives that they believe to be abortifacients. When HHS issued initial rules adopting the HRSA determination, therefore, it excluded religious employers, defined as churches, religious orders, and similar groups, from the contraceptive coverage requirement.

This commentary is in response to a January 16, 2013 Health Affairs Blog post entitled “Is It Time to Re-Examine Workplace Wellness ‘Get Well Quick’ Schemes?” by Al Lewis and Vik Khanna. After the initial blog appeared, my email box was filled with messages asking for a rebuttal to the initial posting, which, to many, seemed like a condemnation of the worksite health promotion (wellness) field and its lack of credibility and honesty in reporting program savings. Instead of just immediately posting a response, I called Al Lewis to discuss the value of worksite health promotion in order to “set the record straight.” It turns out that we agree on many issues but there are also differences.

We agree that there are unscrupulous wellness vendors who claim very large and often implausible savings from worksite health promotion programs. The return-on-investment (ROI) figures bantered about, sometimes as high as 10:1, are not credible. At the same time, I believe it would be wrong to “throw out the baby with the bath water.” In this case, the “baby” refers to well-designed, evidence-based, comprehensive, appropriately resourced, non-gimmick, and well-executed worksite health promotion programs.

Stated positively, good worksite programs deserve credit and should be supported by the business community, not condemned. This is because there is good and growing evidence, reported in a rigorous scientific literature, that “best-practice” worksite health promotion programs improve population health and save money for businesses. Savings are realized from lower health care cost trends, reduced absenteeism, and heightened worker productivity.

In August, the Center for Sustainable Health Spending (CSHS) was awarded a grant from the Robert Wood Johnson Foundation to, among other things, examine the relationship between disease prevention and health care costs. This project heightened my interest in the wonderfully-researched report from the Congressional Budget Office (CBO) entitled Raising the Excise Tax on Cigarettes: Effects on Health and the Federal Budget, and its excellent summary in the New England Journal of Medicine (NEJM).

The report was years in the making and is noteworthy for its original research and its thorough and insightful literature review. As the title suggests, its economic focus is on the federal budget. In some ways this is a very broad perspective as it brings into play smoking’s impact on employment and earnings (hence tax payments), as well as health care costs and Social Security payments. But in other ways it is quite narrow, being limited to federal revenues and costs. Before discussing this CBO report, and the complex economics of disease prevention and longevity it underscores, I’d like to create some context.

For the previous Health Wonk Review, Brad Wright chose a Baby New Year theme. However, there were some problems with the new beginning represented by the turnover from 2012 to 2103. For example, with the New Years fiscal cliff deal, one might have hoped that we would leave our budget crisis behind for a while and start with a fresh fiscal slate. But of course, that did not happen. Not only did we not escape our budget crisis, it multiplied into three crises: the debt ceiling, the still looming sequester, and the coming expiration of government funding –“The Trouble With Trillions,” one might say.

So I decided to give us a fresh chance at a new start by choosing an “Inauguration” theme for this Wonk Review, referring both to Monday’s celebration of a new presidential term but also to the word’s broader meaning of a formal beginning. And in the spirit of looking forward, we’ll lead with a post from Health Wonk Review cofounder Joe Paduda laying out his health policy predictions for the coming year. At Managed Care Matters, Joe offers five predictions, including these: most states will end up expanding Medicaid, and there will be a lot more mergers and acquisitions at the highest levels, among providers, health care systems, and payers.