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Arkansas Payment Improvement Initiative: The First Year


August 25th, 2014

Editor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. The authors of this post are part of the team evaluating the Arkansas model.

Arkansas payers and providers actively participated in the design of both the episodic payment and patient-centered medical home (PCMH) models the state has recently implemented. We’ve written about each of these components of the multi-payer Arkansas Payment Improvement Initiative (APII) in our previous Health Affairs Blog posts.

The state’s fragmented and largely rural provider environment presents an important test for a novel episodic payment model that may, if successful, have broader applicability in other states sharing a similar health care landscape. Fourteen episodes have now been launched and provider participation is mandatory. While our first posting goes into greater detail on the nuances of Arkansas’ approach to episodes, we provide the following brief summary here to add context to this discussion.

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Mental Health Reform: Treating Before Stage 4


August 11th, 2014

When I talk about mental illnesses, I often point out that as a matter of public policy they are the only chronic conditions we wait until Stage 4 – the final stage in a chronic disease process – to treat, and then often only through incarceration.

To me, it is clear why this is the case. We have adopted a behavioral standard – danger to self or others – as a trigger to treatment.

But waiting until injury or death is imminent is no way to treat a chronic health condition. David Mechanic’s thoughtful Health Affairs article, “More People Than Ever Before Are Receiving Behavioral Health Care in the United States, But Gaps and Challenges Remain,” published in the recent August issue, examines the result of this Stage 4 thinking.

Beginning with “the devastating effects on the well-being of individuals, families, and communities,” Mechanic lays out the current state of mental health care in America. Mental illnesses rob individuals of both dignity and decades of life expectancy.

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Implementing Health Reform: The Supreme Court Rules on Contraception Coverage (Updated)


June 30th, 2014

On June 40, 2014, the Supreme Court issued its opinion in Hobby Lobby v. Burwell and Conestoga Wood Products v. Burwell. The Court’s decision has very important ramifications for religious liberty in the United States, for women’s access to health care, for employers’ and employees’ rights, even for corporate law. Its importance justifies its being released on the final day of the term, an honor usually reserved for only the most notable cases. But unlike the Court’s decision in National Federation of Independent Business v. Sebelius on the last day of its term two years ago, Hobby Lobby does not pose a serious threat — indeed any threat at all — to the Affordable Care Act.

From the perspective of the ACA, the case involves only the application of one particular provision of a regulation to one particular group of employers. The Court’s decision does not invalidate any provision of the ACA. It does not even fully invalidate any regulatory requirement. It simply says that the Department of Health and Human Services must extend to one group of employers an accommodation HHS has already extended to another group.

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Course Correction: Better Preparing Today’s Nurses For 21st Century Health Care Service


June 20th, 2014

Nursing has always been considered a highly established profession with solid job security for many, even in the midst of troubling economic conditions. In fact, a recent US News and World Report’s list of the Best 100 Jobs shows both nurse and nurse practitioner in the Top 10.  And it’s a respected profession as well: A 2013 Gallup poll showed 82 percent of Americans rate the ethical and honesty standards of nurses as “high or very high,” the highest of all professions.

Yet despite talk of an impending nursing shortage over the next few years, some believe there is an even bigger crisis looming, one that stems from the very heart of the career — education.  Quite simply, nursing students are not as prepared as they should be for the “real world” of nursing and patient care.

This skills deficit is all-encompassing. There is a lack of the basic technical skills, such as physical assessment and emergency response. But the equal lack of “soft skills,” such as critical thinking, problem recognition, prioritization and recognition of urgency, and communication with physicians, is just as alarming.

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ACO Results: What We Know So Far


May 30th, 2014

Editor’s note: For more on this topic, stay tuned for the upcoming June issue of Health Affairs, which features a series of articles on accountable care organizations. 

Accountable care is a relatively recent addition to the health care vernacular, but its roots can be traced to the decades-long effort to coordinate medical care. In the United States, health care has evolved into a fragmented pay-for-volume system which has both driven up cost and decreased quality. Coordination of care is meant to reverse this trend. Through such solutions as Health Management Organizations (HMOs), Integrated Delivery Networks (IDNs) and now Accountable Care Organizations (ACOs), policymakers, providers and payers have sought to consolidate and coordinate patient care.

Contemporary care coordination efforts focus on accountable care which increases provider accountability for the cost and quality of care. The driving principle behind the formation of ACOs is the Institute for Healthcare Improvement’s triple aim: improving the patient experience of care, improving the health of populations and reducing the per capita cost of health care.

One of the broadest applications of this concept is the creation of Medicare ACOs under the Patient Protection and Affordable Care Act. This includes the Pioneer ACO Program and the Medicare Shared Savings Program. More recently, states have also pursued ACO contracts to cover Medicaid populations. In the private sector, providers have forged ACO contracts with commercial payers. At the close of 2010, only 41 preliminary Accountable Care Organizations existed. The number of ACOs more than tripled to 138 a year after the passage of the PPACA. By 2012 the number nearly tripled again, and by the end of 2013 more than 600 ACOs were operating across the U.S.

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Chinese Doctors In Crisis: Discontented And In Danger


May 27th, 2014

Chinese doctors are unhappy about their pay and work conditions.  Moreover, they are in danger of physical attack by angry patients and families.  The Ministry of Health estimated that in 2010, 17,243 attack and agitation incidents occurred in Chinese hospitals, an increase of almost 7,000 over five years. Patients, bereaved families of patients who have died in hospitals, and sometimes paid protestors called yinao or “medical troublemakers,” invade hospitals, berate or attack staff, create loud disruptions, and stage mock funerals.

About 30 percent of the attacks were carried out by patients, 60 percent by family members, and the remainder by others, including yinao. About 75 percent of attacks were aimed at doctors.  According to a 2012 survey of nearly 6,000 Chinese physicians in 3,300 hospitals, 59 percent of doctors had been verbally assaulted and 6 percent had been physically assaulted. News accounts for 2002-2011 yielded 124 incidents of “serious violence” against hospitals, including 29 murders and 52 serious injuries. Often violence accompanies demands for cash compensation for harm to patients, including patient deaths in hospitals.

In response, the Chinese Ministry of Public Security has recently announced a new set of security measures for hospitals. Approximately one thousand top-tier hospitals will now have a police presence in addition to their own security guards; alarm systems linked with local law enforcement; enhanced audio-visual surveillance systems; and security posts at entrances similar to those at airports.

The wave of violent attacks on doctors and other medical workers constitutes a significant problem in its own right.  But it is also a reflection of a broader set of problems faced by today’s generation of Chinese doctors.  They are badly paid, both in relation to doctors in other countries, and in relation to other Chinese professionals. As a result, doctors often supplement their low salaries in ways that strengthen the popular impression that they are corrupt, fostering still greater distrust and anger among their patients and patients’ families. A recent survey showed that 67 percent of the Chinese public does not trust doctors’ professional diagnoses and treatment.

The doctors themselves are also dissatisfied with the current state of affairs. A 2011 Chinese Medical Association survey of its members showed fewer than 20 percent of responding doctors to be satisfied with their medical practice environments, while 48 percent rated them “poor” or “very poor”. Doctors were particularly dissatisfied with their pay. They were also concerned about their work conditions.

When respondents were asked to identify sources of work pressure, the most frequent response, at 77 percent, was “high patient expectations.”  Only 21 percent wanted their own children to become doctors. Interestingly, this survey showed that fewer than 10 percent of respondents blamed patients, doctors, or hospitals for their problems; the majority (83 percent) blamed “the system” for the tension between doctors and patients.

In this post, we review that system and highlight sources of doctors’ discontent and the distrust between doctors and patients.

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Patient-Centered Medical Home Evaluations: Let’s Keep Them All In Context


May 21st, 2014

Editor’s note: This post is authored by eleven participating leaders of the Pennsylvania Chronic Care Initiative; the full list is included at the end.

Since the American Academy of Pediatrics (AAP), American Academy of Family Physicians (AAFP), American College of Physicians (ACP) and American Osteopathic Association (AOA) issued their Joint Principles of the Patient-Centered Medical Home in 2007, there has been an explosion in medical home transformation activity in the United States. According to National Committee for Quality Assurance (NCQA), which offers one of multiple medical home recognition programs in the U.S., 5739 practices representing 27,820 clinicians had received NCQA medical home recognition status as of May 2013.

Medical homes have represented a promising approach to improving care for patients, reducing avoidable utilization, and improving professional satisfaction for clinicians. Extensive research by Ed Wagner and colleagues provided an evidence-supported basis for optimism, but only over the last several years has the model been implemented broadly.

Taking concepts tested in small application to broader context is challenging, as experience has shown. The state of Pennsylvania, along with its community of primary care practices and insurers, has been committed to testing and adopting the medical home model. A key catalyzing effort was the Pennsylvania Chronic Care Initiative.

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Patient-Centered Medical Homes In Arkansas


May 20th, 2014

Editor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. The authors of this post are part of the team evaluating the Arkansas model.

In 2011, Arkansas embarked on a multi-payer comprehensive payment reform to convert a majority of private and public payments to a value-based purchasing model. An underlying goal of this effort, the Arkansas Payment Improvement Initiative (APII), is to incentivize quality and cost-effective care delivery rather than volume of services provided.

In our previous blog post, we described the design and implementation of the episode-based component of Arkansas’ system. This episodic approach focuses mostly on acute conditions and rewards providers who meet quality targets and provide lower average risk-adjusted spending per episode. Chronic care patients are more difficult to fit into an episode-based system due to the longitudinal nature of service delivery and the presence of multiple comorbidities. It would be challenging to design chronic care management episodes to account for simultaneous presentations in one patient, such as diabetes, hypertension and congestive heart failure.

Given these issues, Arkansas has also developed a Patient Centered Medical Home (PCMH) payment model to work in tandem with its episodic payment reforms. (A third component of the APII, the health home, for populations with the most complex care needs, is still being developed.) In this post, we outline the state’s PCMH approach.

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Health Affairs May 19 Event: Provider Consolidation In Health Care


May 8th, 2014

The clinical and economic virtues of provider consolidation have long been recognized by policy experts, but in recent years, research has shown that large provider organizations may use market power to obtain relatively high prices from payers without necessarily delivering superior quality. On May 19, Health Affairs will release a package of “Web First” papers examining the issue from various perspectives.

We invite you to a Health Affairs Briefing at the National Press Club in Washington, DC, at which we will release the papers and where the authors will discuss their findings and  engage in a high-level discussion of the issues with a panel of expert responders and the audience.  The papers and the briefing are supported by a generous grant from The Commonwealth Fund.

When:
Monday, May 19, 2014
9:00 a.m. – 10:30 a.m.

Where:
National Press Club
529 14th Street NW
Washington, DC 13th Floor (Metro Center)

REGISTER NOW!

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

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Recent Health Policy Briefs: Regulating Compounding Pharmacies and Basic Health Program Update


May 1st, 2014

The latest Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation examines the Compounding Quality Act, a law signed by President Obama in November 2013, which seeks to fill the gaps in the Food and Drug Administration’s (FDA’s) inspection and enforcement oversight of compounding pharmacies.

This law was enacted in the wake of a 2012 fungal meningitis outbreak, linked to a Massachusetts drug compounding company. The outbreak caused more than 700 people to become ill and left sixty-four dead. Before the new law was passed, compounding pharmacies were primarily regulated by states, not the FDA.

The compounding pharmacy industry initially catered to patients with specialized needs. Since the 1990s, many compounding pharmacies have also begun engaging in what is now called nontraditional compounding: manufacturing certain drugs in large quantities for sale to doctors’ offices and hospitals. This health policy brief traces the evolution of compounding pharmacies and the changes brought to this industry by the new law.

Also posted today: an update to an earlier brief that provides more information on the issues surrounding the Basic Health Program and outlines options for states.

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Ethical Dilemmas In Prison And Jail Health Care


March 10th, 2014

Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health.

Prison and jail health care, despite occasional pockets of inspiration, provided by programs affiliated with academic institutions, is an arena of endless ethical conflict in which health care providers must negotiate relentlessly with prison officials to provide necessary and decent care.  The “right to health care” articulated by the Supreme Court pre-ordained these ongoing tensions.  The court reasoned that to place persons in prison or jail, where they could not secure their own care, and then to fail to provide that care, could result in precisely the pain and suffering prohibited by the Eighth Amendment to the Constitution.

Good reasoning was followed by a deeply flawed articulation of the “right” that defines the medical care entitlement as care provided to inmates without “deliberate indifference to their serious medical needs.” By forging a standard which was, and remains, unique in medicine and health care delivery — designed to avoid intruding on state malpractice litigation regarding adequacy of practice and standards of care — the court guaranteed that dispute would surround delivery.  That first framing, which did not establish a right to “standard of care” or to care delivered according to a “community standard,” set the stage for endless ethical and legal conflict.

The Eighth Amendment’s deliberate indifference standard, forbidding cruel and unusual punishment, presents a relatively demanding standard for proving liabil­ity.  The Eighth Amendment, as interpreted by the federal courts, does not render prison officials or staff liable in federal cases for malpractice or accidents, nor does it resolve inter-professional disputes — or patient-professional disputes — about the best choice of treatment. It does require, however, that sufficient resources be made available to implement three basic rights: the right to access to care, the right to care that is ordered, and the right to a professional medical judgment.

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When The Only Cure Is A Transplant


February 21st, 2014

On Christmas Eve 2011, protesters from a local church marched to the entrance of our hospital, Rush University Medical Center in Chicago. They demanded we provide organ transplants for sick members of their congregation. We invited them in and listened to their gut wrenching stories. George, twenty-two, was brought to the United States as a six-month-old. He developed renal failure at age sixteen while covered under the Children’s Health Insurance Program. Now he was uninsured, on dialysis and refused a transplant evaluation at the same institution that treated him as a child. Another undocumented immigrant, Martin, was twenty-six. He too was uninsured and on dialysis.

Chicago has six adult transplant centers. Initially none would evaluate George or Martin for transplantation because they were uninsured. In the Narrative Matters essay, “Undocumented Immigrants And Kidney Transplant: Costs And Controversy,” published in the February issue of Health Affairs, Vanessa Grubbs tells a similarly heartfelt story of a patient in need of a transplant: Mr. Rojas. George, Martin and Mr. Rojas are not US citizens, but it was their lack of health insurance that kept transplantation out of reach. Foreign-born immigrants always have access to a transplant evaluation (the prerequisite for organ transplant) if they have insurance or the cash to pay.

In theory, the organ allocation system in the United States is based on justice and equity. The National Organ Transplant Act (NOTA) was passed in 1984 to create a fair system of organ transplantation in the United States. A federal task force, created by the act, was charged to design an organ allocation system “based on medical criteria that are publicly stated and fairly applied.” The task force emphasized that organs should be distributed to those eligible “regardless of their ability to pay.” Both NOTA and the bylaws of the United Network for Organ Sharing, the nonprofit organization that manages the national transplant network, require that need, not financial or citizenship status, guide transplant allocation decisions. Undeniably, the system of altruistic donation is only viable if a donating individual believes organs are allocated fairly.

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Progress Report: The Affordable Care Act’s Extended Dependent Coverage Provision


December 16th, 2013

This week Health Affairs is releasing a Health Policy Brief by T.R. Goldman on Young Adults and the ACA. The brief focuses on the importance of enrolling young adults in coverage through the law’s new marketplaces and Medicaid expansion beginning in 2014. But another provision of the law also aimed at young adults took effect more than three years ago. Here Goldman provides a progress report on the ACA’s dependent coverage expansion.

One of the earliest and most popular provisions in the Affordable Care Act requires insurers to extend dependent coverage on a family plan until the age of 26. The requirement is essentially unconditional and does not depend on whether the young adult lives at home, is a full-time student, is married, is a tax dependent, or is eligible to buy insurance on a state health exchange.  Until 2014, dependent coverage was not available if the young adult had a separate offer of employer-based coverage, but starting on Jan. 1, 2014, even that exception will no longer apply. Typically, most employer-based health insurance plans have ended dependent coverage at either 19 or upon college graduation.

The law is straightforward: any insurance plan that already offers dependent coverage must offer the same level of coverage at the same price of coverage to dependents under 26.  This applies to insurance offered by employers who either self-insure or purchase insurance through an insurance company.  And it includes insurance plans parents buy for their families in the non-group market.  Dependent coverage under a parent’s plan, however, does not extend to the children and spouses of those dependents.

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Implementing Health Reform: Final Letter to Issuers on Federally Facilitated and State Partnership Exchanges


April 6th, 2013

On April 5, 2013, the Department of Health and Human Services released its final Letter to Issuers on Federally Facilitated and State Partnership Exchanges. This letter lays down guidelines for insurers that will sell qualified health plans on the federal exchanges in 2014. A proposed version of this letter was published for comment on March 1, 2013, which I blogged about here. The final issuer letter tracks the proposed letter with few significant changes. In part because I am supposed to be on vacation in France and in part because of limited access to technology, I am not going to review the issuer letter in depth, but rather refer the reader to my earlier post, providing here only a brief overview of the final letter that highlights the respects in which it differs from the proposed rule discussed in my earlier post.

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Competing Visions: A Response to John Goodman


April 4th, 2013

In his post “Why don’t Republicans Have a Vision for Health Reform” (April 2, 2013) John Goodman offers interesting comments on my earlier post “Reflections on The Federal Budget Resolutions” (March 21, 2013). I thank him for the comments.

My post was focused strictly on the vision for U.S. health care that Democrats and Republicans on Capitol Hill now project through the Senate budget resolution and the House budget resolution. Goodman, on the other hand, builds from my post a bridge to the vision some Republicans – including Goodman himself – have in the past projected for U.S. health care.

I can understand why Goodman used the well-known technique of the bridge, because he believes that Republicans currently do not have vision for health care. On this point, however, I beg to differ. There actually is a current Republican vision. It has been expressed through the House budget resolution.

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In Rural China, a Successful Payment Reform Pilot Project


April 4th, 2013

Today, Health Affairs released a Web First article by Tsung-Mei Cheng describing early results from a pilot project underway in several of China’s rural provinces that combines new case-based payments for providers and evidence-based clinical pathways for management of patients. Before and after studies and analyses show a reduction in overall length of hospital stays, drug spending and usage, and patients’ out-of-pocket spending. Patient-provider communication and relations reportedly improved, and hospitals did not experience any revenue losses.

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Implementing Health Reform: Proposed Regulations for Exchange “Navigators”


April 4th, 2013

On April 3, 2013, the Department of Health and Human Services released proposed regulations establishing standards to govern navigators and non-navigator assisters in the federally facilitated exchange as well as clarifying standards on the role of navigators and on who can serve as a navigator in all exchanges.

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Rachael Fleurence on Patient Engagement


April 3rd, 2013

In today’s Q and A on Patient Engagenment, we feature Rachael Fleurence, a Senior Scientist at PCORI where she leads the research prioritization initiative to help identify important patient and stakeholder generated questions and establish a rigorous research prioritization process to rank these questions. (Also, check out her recent blog post and follow the link to her February Health Affairs article here.)

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Health Affairs Briefing: The Triple Aim Goes Global


April 1st, 2013

You are invited to join us on Wednesday, April 11, when Health Affairs will hold a briefing to discuss its April 2013 issue, “Triple Aim Goes Global.”

The April issue examines how all high-income countries are struggling to pursue better health, better care, and lower cost – and to bring all of these goals into alignment. The issue received funding support from The Commonwealth Fund, the Nuffield Trust, and Imperial College London.

The briefing will take place at the Barbara Jordan Conference Center at the Kaiser Family Foundation, 1330 G Street, NW, in Washington, DC, on Thursday, April 11, 2013, 8:00 a.m. – 12:30 p.m.

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Implementing Health Reform: Final Rule on Increased Federal Medicaid Matching Funds and FAQ on Medicaid Premium Assistance Programs


March 31st, 2013

On Good Friday, March 29, 2013, the Department of Health and Human Services released a final rule regarding increased federal Medicaid percentage changes under the Affordable Care Act for covering adults who are newly eligible under the ACA’s Medicaid expansions. HHS published the original proposed rule on this topic in August of 2011 as part of a larger rule on the ACA’s Medicaid changes. Other parts of this rule dealing with Medicaid eligibility were finalized in March of 2012, but the parts of the proposed rule dealing with federal financial assistance were not included at that time. Because the final rule contains significantly more detail than the proposed rule, HHS is publishing the rule as final, but soliciting further comment on parts of the rule. HHS also released on March 29, 2013, a series of Frequently Asked Questions, explaining its approach to the expansion of Medicaid through the use of Medicaid funds to purchase private insurance for Medicaid recipients in the exchange, the approach that Arkansas and possibly other states are proposing. This FAQ is discussed at the end of this post.

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