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The First Fill Factor: A Threat To Outcomes, Quality, And Payment Goals


April 1st, 2015

Enactment of the Medicare Part D Prescription Drug Program in 2003 led to the creation of the first medication adherence quality improvement goals of truly national import. But one gaping problem remains: the failure of many patients to secure and take medications when they are first prescribed — the “first fill” that never happens.

Recent research confirms that rates of failure to secure a first dose of newly prescribed medications in major chronic disease categories are disturbingly high. Indeed, the failure rates in community-based settings (at community pharmacies, for example) range from 22 to 28 percent. Substantial rates of failure (15 to 26 percent) have even been found among highly integrated health care systems that often feature in-house pharmacies.

And so, just as payment reforms are pushing providers towards accountability for safe and appropriate treatment and good patient outcomes, particularly among the chronically ill, a significant proportion of patients are walking away from their provider’s office with sound, evidence-based orders for new medication therapy … but they never pick up the medicine.

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Growth And Dispersion Of Accountable Care Organizations In 2015


March 31st, 2015

Beginning this January, an additional 89 provider organizations joined the Medicare Shared Savings Program (MSSP) as accountable care organizations (ACOs). While this year’s new entrants are a smaller cohort than those that joined in 2013 and 2014, they represent a continuation of the expansion of the accountable care movement. The recent Department of Health and Human Services (HHS) announcement of its goal to move fifty percent of Medicare payments to alternative payment models (including ACO-based arrangements) indicates the government’s strong backing of the model and, coupled with continuing endorsement of the approach from state Medicaid programs and commercial insurers, there is strong support for this care delivery approach to continue.

In an ACO, health care providers accept responsibility for the cost and quality of care for a defined population. Each ACO’s laudable goal is to achieve what Don Berwick has called the “triple aim” — to improve quality, increase patient satisfaction, and lower costs. The key to reaching those goals is to change how providers are paid, based on reaching certain cost and quality benchmarks. In effect, the objective is to change incentives so that it is in providers’ best interest to maximize health, rather than focus on increasing the volume of services rendered.

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Building A Quality Of Life National Movement: Igniting Advocacy To Integrate Palliative Care In Our US Health System


March 30th, 2015

Editor’s note: This post is part of a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on a recent volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.

As our health system faces dramatically rising numbers of people living longer with complex chronic conditions, we have an unprecedented opportunity to mobilize a “quality of life” movement promoting patients’ choices and priorities about how they want to live at all stages of illness. Most of the current public policies and discourse about quality of life in health care focuses on the end of life. That tradition may actually impede delivery of person-centered and goal-directed quality care from the onset of illness. It also falls short in supporting shared decision-making, which requires early and continuing identification of what is most important to seriously ill patients and their families, and what they are hoping for as they progress along the continuum of care.

All people want to live healthy and disease-free lives for as long as possible. When serious illness does strike, patients and families want to achieve, cure, or keep disease progression in check. In addition, they place a high premium on maintaining good functioning and quality of life for as long as possible so they can continue to pursue life goals and enjoy what matters most to them. They want coordination and connection, including clear communication and quality time with their health care team to help them understand treatment options and the implications of those treatments in terms of survival, functioning, and quality of life. In addition, they want support to make informed decisions during and after treatment that align with their personal preferences and goals.

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The Time Is Now To Fix Medicare ACOs


March 27th, 2015

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

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

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

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


March 25th, 2015

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

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

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

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Health Affairs Briefing: The Cost And Quality Of Cancer Care


March 25th, 2015

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

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

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

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

Register Now!

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

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Good And Bad News For Diabetes Prevention In The Community


March 25th, 2015

The findings from a recent synthesis of the literature about the effectiveness of prevention initiatives focused on reducing the risk of Type 2 diabetes among high-risk populations (people already obese or inactive or diagnosed as having prediabetes) are largely encouraging.

The synthesis includes a comprehensive and systematic review of the medical, diabetes, and public health literature for evaluation studies of interventions published between 2002 and 2013. The search was undertaken using medical subject headings and keywords related to diabetes and its risk factors.

A number of interventions—such as the National Institutes for Health’s Diabetes Prevention Program and the Group Lifestyle Balance Program—focused on helping people eat better and become more physically active are effective in reducing the risk of diabetes onset. Robust studies show that these interventions work even better than medication to prevent diabetes.

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What Kind Of Advance Care Planning Should CMS Pay For?


March 19th, 2015

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

Cultural And Policy Evolution In Advance Care Planning

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

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New Narrative Matters: How Health Care Fails Older Patients, And How It Can Be Done Better


March 13th, 2015

Health Affairs‘ March Narrative Matters essay features a chance meeting between an octogenarian and a geriatrician that shows how the US health system focuses on medical care at the expense of older adults’ well-being. Louise Aronson’s article is freely available to all readers, or you can listen to the podcast.

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Reconciling Prevention And Value In The Health Care System


March 11th, 2015

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

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

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

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


March 11th, 2015

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

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

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Effective Public Engagement To Improve Palliative Care For Serious Illness


March 10th, 2015

Editor’s note: This post is part of a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on a recent volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.

Public engagement is necessary to improve care for individuals suffering with serious illness. Fortunately, several drivers of potential change exist for advocacy. In the following blog post, we outline some areas for change and specify advocacy efforts we can undertake to improve the overall face of palliative care.

First, palliative care here is defined as being a type of specialized medical care for people with serious illness. Its goal is to improve quality of life for both person and family. It is provided by a team of doctors, nurses, and other specialists who work with the patient’s other providers to provide an extra layer of support. Although some people think palliative care is only for those at the end of life, it is actually appropriate at any age and at any stage in a serious illness and can be provided together with curative or disease-modifying treatment.

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The Payment Reform Landscape: Everyone Has A Goal


March 6th, 2015

It seems these days everyone is setting ambitious goals for making changes to how we pay for health care, including my organization Catalyst for Payment Reform (CPR).

Initially, our goal at CPR was to ensure that 20 percent of health care payments be value-oriented (seeking to improve quality and reduce costs) by the year 2020. But to reflect our desire for greater assurance that good would come of it, we recently refined that goal.

It’s great that commercial health plans report a significant increase in value-oriented payments. But, to avoid wasting valuable time and resources, there needs to be quantifiable evidence that new payment methods actually lead to improved health care while containing costs. as we’ve emphasized in our posts here. The “proof is in the pudding” as they say.

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Health Affairs’ March Issue: The Benefits And Limitations Of Information


March 2nd, 2015

The March issue of Health Affairs contains papers focusing on the benefits—and the limitations—of information-gathering processes as a way to solve health system problems. Studies in this variety issue examine US hospital rating systems, disclaimers on dietary supplements, state prescription drug monitoring programs, the value of US versus Western European cancer care and other topics.

National hospital rating systems show little agreement — what’s a consumer to do?

Matt Austin of Johns Hopkins Medicine and coauthors compared four well-known national hospital rating systems designed for use by US consumers: U.S. News & World Report’s Best Hospitals; HealthGrades’ America’s 100 Best Hospitals; Leapfrog’s Hospital Safety Score; and Consumer Reports’ Health Safety Score. They analyzed ratings covering the time period from July 2012 to July 2013.

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Health Affairs Web First: Assessing Health And Health Care Perceptions In sub-Saharan Africa


February 27th, 2015

A large share of Western aid to developing countries goes to sub-Saharan Africa, a region where spending on health care is around $100 per person in 2005 price-adjusted terms. This region, which experienced large gains in life expectancy in the years following World War II, suffered health-related setbacks in the closing years of the twentieth century as a result of the HIV/AIDS epidemic.

The authors of a February 25 Health Affairs Web First study used data from the Gallup Organization’s 2012 World Poll to investigate health and health care perceptions in sub-Saharan Africa compared to other regions of the world. The poll found that sub-Saharan Africans’ overall evaluation of their well-being was lower than that of any other population in the world. Additionally, only 42.4 percent of residents in that region were satisfied with the availability of high-quality health care in their community, also the lowest level in the world. Even so, when sub-Saharan Africans were asked to name the issues that should be the highest priorities for their government, health care was not seen as the most pressing issue.

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The Patient Access Imperative: A Potential Triple Win For Payors, Providers, And Patients


February 26th, 2015

Long patient wait times, frustratingly high no-show rates, lack-luster call center performance, and under-utilized physicians. Does any of this sound familiar? Although a small set of health systems have boldly declared that their physicians guarantee their outpatients same- or next-day appointments, across the United States patients more typically face long wait times to both make and get appointments, as well as poor access to care.

To succeed in the future, health systems will need to have the customer orientation of a five-star hotel and the operational discipline of a factory floor. Our experience suggests that many systems can achieve substantial improvements with their existing resources and generate a 10 to 20 percent improvement in outpatient profitability within 6 to 12 months — and improve patient satisfaction too.

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Top 5 Health Care Trends to Watch in 2015


February 25th, 2015

With a new Congress, health care is once again an issue of tremendous scrutiny and debate. Many of the federal policy debates in 2015 will be largely symbolic, resulting in little more than tweaks to existing law.

However, health care policy is not just a matter for Congress to consider. A range of issues will play out in the states and the private sector, effectively shaping the future. Below are the top trends we’re watching this year.

The Year of Living Interoperably

From electronic health records (EHRs) to clinical measures and decision support tools, providers are inundated with new technologies that automate processes and capture new types of data. However, these systems are limited in their potential because they don’t all “talk” to one another. They’re locked away within proprietary technologies that render them the equivalent of an email account that only sends messages to people in your company, or a phone that only makes calls in your house.

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Putting Humpty Dumpty Together Again: Consolidating Regulatory Authority Over Food Safety


February 23rd, 2015

The fragmented nature of regulatory authority over food in the United States is well known. More than a dozen federal agencies are responsible for the safety of the nation’s food supply. The Food and Drug Administration (FDA) and the Department of Agriculture (USDA) have the lion’s share of responsibility, together overseeing over 80 percent of the nation’s food safety.

Generally, the USDA regulates meat, and the FDA regulates everything else, but overlaps, exceptions, gaps, and therefore examples of resulting absurdities abound: the FDA regulates frozen pizza, unless it has pepperoni. The FDA regulates seafood, unless it’s catfish. The USDA has jurisdiction over packaged open-face meat sandwiches, but if the sandwiches are closed, authority shifts to the FDA.

This division in regulatory authority is neither planned nor rational. It is instead a historical accident, originating in the early twentieth century. When the Pure Food and Drug Act and Meat Inspection Act were passed on the same day in 1906, both targeting the adulteration of the food supply, their oversight was assigned to different departments within the USDA. The fissure widened when the FDA was moved out of the USDA in 1940. This divided regulatory framework is not the only reason for the fragmentation of regulatory authority over food in the US, but it is a main driver.

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Oregon Bridges The Gap Between Health Care And Community-Based Health


February 12th, 2015

It is now commonly accepted that to achieve health, the U.S. health system must address the social determinants of health. While the integration of health care with social services and public health is happening relatively infrequently across the country, one bright spot can be found in Oregon, where an innovative Medicaid health system model, referred to as the coordinated care model, is showing early signs of success in bridging the gap between the community and the health care system.

Under Oregon Governor John Kitzhaber’s leadership, newly created coordinated care organizations (CCOs)—partnerships between physical, behavioral, and oral health providers—have over the past two years adopted Oregon’s coordinated care model, which was created as the foundation for Oregon’s health system reform efforts to ensure care is coordinated, performance is measured, positive outcomes are rewarded, and that there is a shared responsibility for health, sustainable rate of growth, and transparency in price and quality—all with the goal of promoting positive health outcomes.

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Health Affairs Web First: Recent US Hospital Productivity Growth


February 11th, 2015

Between 2002 and 2011, US hospitals increased their productivity in treating Medicare patients for several serious illnesses, refuting fears about a “cost disease” in health care and potentially mitigating concerns about provider payment under the Affordable Care Act.

The study, released today by Health Affairs as a Web First, addresses the quality of care and the severity of patient illness (considerations not fully taken into account by previous studies on this topic) found that during those years, the annual rates of productivity growth were 0.78 percent for heart attacks, 0.62 percent for heart failure, and 1.90 percent for pneumonia.

When the authors John Romley, Dana Goldman, and Neeraj Sood calculated productivity growth rates without factoring in trends in the severity of patient conditions or outcomes achieved after hospitalization, the annual productivity rates were different: -0.64 percent for heart attacks, -0.91 percent for heart failure, and -0.39 percent for pneumonia.

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