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The Medicaid Boom And State Budgets: How Federal Waivers Are Advancing State Flexibility


July 18th, 2014

Note: The authors would like to thank Erica Socker, Senior Research Associate, and Michelle Shaljian, Associate Director of Communications, for their review and editorial assistance.

According to data released by the Department of Health and Human Services, one in five Americans now receive their health insurance through a state Medicaid program. Despite this increase in enrollment, it is estimated that 6 million Americans will likely remain uninsured because 20 states have decided not to expand Medicaid as the Affordable Care Act (ACA) envisioned. There are at least four states that are considering expanding Medicaid but have yet to do so.

Medicaid expansion continues to be one of the most politically charged directives of the health care law, mainly because the Supreme Court decision left the choice to states. This decision has generated an ongoing debate about whether and how states should expand their Medicaid programs. For example, an intense debate has been underway in Virginia, over the decision to include Medicaid expansion in the state budget; putting Democratic Governor Terry McAuliffe at odds with the Republican State Legislature. Similar debates are occurring in states across the country, and are further complicated by states’ option to pursue alternative expansion approaches under a Medicaid waiver. For states that have not yet expanded the program, the success of these alternative expansion models may influence whether they can find a politically feasible path forward.

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Payment And Delivery Reform Case Study: Cancer Care


July 3rd, 2014

Editor’s note: In addition to Darshak Sanghavi, Mark McClellan, and Kavita Patel, this post is also authored by Kate Samuels, project manager at Brookings. It is adapted from a forthcoming full-length case study, the second in a series from the Engelberg Center’s Merkin Initiative on Physician Payment Reform and Clinical Leadership designed to support clinician leadership of health care delivery, payment, and financing reform. The case study will be presented during the Merkin Initiative’s “MEDTalk” event on July 9 from 10:30 AM to 12:30 PM EDT, featuring live story-telling and knowledge-sharing from patients, providers, and policymakers.

Oncology practices and hospitals across the nation struggle with providing sustainable, comprehensive, and coordinated cancer care. Clinical leaders with strategies and models to improve the quality and value of health care often don’t know how to navigate the landscape of payment and delivery reform options to sustain their innovations.

We use a case study approach to investigate and tell the story of the New Mexico Cancer Center (NMCC), an independent cancer center that is experimenting with innovative ways to improve patient-centered oncology care. We identify challenges for creating sustainable and supportive payments models, and we share the broader strategic and policy lessons for adopting alternative payment models.

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Behind The Numbers: Slight Rise In Health Care Spending Growth Projected


June 24th, 2014

PwC’s Health Research Institute (HRI) released its ninth annual Medical Cost Trend: Behind the Numbers report today. This forward-looking report is based on interviews with industry executives, health policy experts, and health plan actuaries whose companies cover a combined 93 million members. Findings from PwC’s Health and Well-being Touchstone Survey of 1,200 employers from 35 industries are also included.

HRI projects that after a five-year contraction in spending growth in the employer-sponsored market, the growth rate will rise to 6.8 percent in 2015, up from the 6.5 percent projected last year.

What are the biggest drivers of the growth in health care costs? We identify four cost inflators in this report, and I would like to highlight two. First, the economy. More than five years after the end of the Great Recession, the improved economy is finally translating into greater medical spending. Consumers are now addressing health issues they ignored or postponed previously.

Secondly, the high cost of specialty drugs. While only four percent of patients use specialty drugs, those medications account for 25 percent of total U.S. drug spending. And estimates are that U.S. specialty drug spending will quadruple by 2020

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Implementing Health Reform: Premiums And Choice In The 2014 Health Insurance Marketplace (Updated)


June 18th, 2014

In the fall of 2013 the headlines were full of stories of individuals facing steep premium increases as the Affordable Care Act’s market reforms went into effect. The question was raised repeatedly whether Affordable Care Act premiums were really affordable. Commentators observed that major national commercial insurers were avoiding the exchanges and that in some states the ACA marketplace offered few choices and little competition.

On June 17, 2014, the Health and Human Services Assistant Secretary for Planning and Evaluation (ASPE) released a report surveying Premium Affordability, Competition, and Choice in the Health Insurance Marketplace, 2014. ASPE examined over 19,000 2014 marketplace plans within the four bronze, silver, gold, and platinum metal levels in each of the 501 geographic rating areas in the 50 states and the District of Columbia; the office analyzed premium levels, available choices, and market variables that might affect cost. It is always possible to find negative anecdotes (particularly if one is not too careful in checking their veracity), but when we look beyond anecdotes at the actual data, it is clear that the ACA was largely successful in achieving many of its goals for 2014.

One of the primary goals of the ACA is to make health insurance affordable to lower-income Americans. During the 2014 open enrollment period, 5.4 million individuals selected a plan in the 36 states served by the federal exchange (which are the states primarily covered by the report since state exchange data is still being assembled and analyzed). According to the report, 87 percent of these individuals qualified for a premium tax credit. They paid a premium that was, on average, 76 percent less than the full premium that they would have owed before the premium tax credit was applied.

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Treated Prevalence Versus Spending Per Case: Responding To Starr And Coauthors


June 17th, 2014

I was surprised but pleased to see the Martha Starr, Laura Dominiak, and Ana Aizcorbe article in the May issue of Health Affairs replicating earlier work of Charles Roehrig and David Rousseau. These papers attempt to understand the role that treated disease prevalence and spending per case treated assume in accounting for the growth in average per capita healthcare spending. (Treated disease prevalence can increase when either a disease becomes more common or is diagnosed more frequently.) Starr and coauthors, like Roehrig and Rousseau, conclude that spending per case treated accounts for more of the growth in per capita spending than treated prevalence.

In our own work, my colleagues and I have addressed a different question. Our line of research focuses on changes in total health care spending – as opposed to per capita spending — over time. We have updated this work now through 2011 and our major conclusion remains the same; the rise in treated disease prevalence accounts for a slightly larger share of the growth in total healthcare spending than spending per case treated.

The three research teams employ different methods and use different spending measures. (In an earlier appendix, we described in detail the differences between our approach and that of Roehrig and Rousseau.) For example, our expenditures include home health and dental services, which are excluded in the paper by Starr and colleagues.

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The Payment Reform Landscape: Capitation With Quality


June 6th, 2014

When I began this blog series in February, I explained how Catalyst for Payment Reform (CPR) views different payment reform models along a continuum of financial risk. Thus far, we have used this series to explore the evidence behind “upside only” models that give providers the chance for a financial upside, but no added financial risk, or downside. We’ve looked at the evidence behind pay-for-performance and per-member per-month payments to support patient-centered medical homes. This month, we move across the risk spectrum to examine a model that offers both upside and downside financial risk for providers—capitation.

What is Capitation? Is It Widespread?

Capitation is nothing new when it comes to paying for health care. It had its heyday in the HMO era of the 1990 s, but something was seriously lacking in the capitation arrangements of the past that led to a strong backlash from consumers. Consumers feared their health plans were more interested in saving money than providing them with the quality care they needed; in a Kaiser Family Foundation Survey at the time, most reported they or someone they knew had a problem with their plan. Some of these fears proved to be warranted. Fortunately, since the 90s, payers and providers have worked to put quality safeguards in place.

When tracking value-oriented payment, CPR only examines capitation arrangements with a quality measurement and incentive component — what we call “capitation with quality.” CPR defines capitation with quality as “a fixed dollar payment to providers for the care that patients may receive in a given time period, such as a month or year, with payment adjustments based on measured performance and patient risk.”

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The Cost Of A Cure: Medicare’s Role In Treating Hepatitis C


June 5th, 2014

Editor’s note: In addition to Tricia Neuman, Jack Hoadley and Juliette Cubanski also coauthored this post.

For a patient with hepatitis C, a potentially deadly disease, the prospect of finding a cure with minimal side effects is a really big deal. Also a big deal is the cost of Sovaldi (sofosbuvir), an oral drug approved by the Food and Drug Administration in December 2013 for the treatment of chronic hepatitis C. Sovaldi has been priced by its manufacturer, Gilead, at $1,000 per pill, or an estimated $84,000 for its entire 12-week regimen. It joins the treatment arsenal with several older drugs generally thought either to be less effective or to have more side effects, and another newly approved drug to be taken in combination with other drugs. More drugs are expected to gain approval within the year.

Sovaldi’s price tag has drawn attention in part because an estimated 3 million Americans have the hepatitis C virus and could be considered candidates for new drugs. Patients will clearly benefit from a long-awaited cure, and public and private payers could potentially see a reduction in health care spending over the long term if Sovaldi successfully cures this disease and fewer patients require high-cost liver transplants. But private insurers and public programs will face significant budgetary pressures if a large number of patients receive this treatment at current prices.

To date, attention has focused on cost implications for private health plans, Medicaid, and the Department of Veterans Affairs (VA). For example, UnitedHealth reported that the cost of Sovaldi was “multiple times” its expectations. State Medicaid officials and Medicaid plans have warned that the cost of the new treatments will pose significant fiscal challenges to state budgets and plan payment rates, even though Medicaid receives a 23.1 percent rebate (discount) for all brand drug purchases. The VA has decided to cover the drug and secured from Gilead a discount of 44 percent, one that applies to certain other federal purchasers, but is targeting treatment to the sickest patients while waiting for less expensive drugs to become available.

Less attention has been paid to the cost implications for Medicare, where coverage of Sovaldi will fall under Part D, the program’s outpatient prescription drug benefit administered by private plans. Given the drug’s effectiveness, most if not all of Part D plans will likely cover Sovaldi. The anticipated impact on costs to Medicare will be revealed to CMS later this month, when plans submit premium bids for 2015. Plans will increase their bids to cover the expected costs of new treatments, which will raise costs for both the federal government and Part D enrollees who pay premiums. CMS will release the average Part D premium for 2015 in August.

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Repeal, And Replace, The Employer Mandate


June 4th, 2014

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

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

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

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Making Markets Work In Health Care: What Does That Mean?


June 3rd, 2014

Editor’s note: See Robert Berenson’s post on consolidation and market power in health care, also published today, and watch for more on these subjects in Health Affairs Blog.

Health Affairs last week posted a set of papers that represent several perspectives on Provider Consolidation in Health Care: Challenges and Solutions. To provide a context for these papers and for the broader discussion of how to make markets work in health care, I suggest a couple of thoughts.

There are two types of markets in health care: the market for health services and the market for health coverage—these markets are interrelated, and both of them are broken.

The historical correlation between provider concentration and both higher prices and lower quality is well-documented. With the increased focus under health reform on collaboration across providers and settings, and the increase in physician and hospital consolidation and the purchase of physician practices by hospitals, the concern is that this trend may lead to adverse consequences for the health system.

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Acknowledging The Elephant: Moving Market Power And Prices To The Center Of Health Policy


June 3rd, 2014

Editor’s note: See Stuart Guterman’s post on consolidation and market power in health care, also published today, and watch for more on these subjects in Health Affairs Blog.

Health Affairs recently published a set of papers addressing the problem of provider consolidation and consequent increased prices. Perhaps even more striking than the specific arguments made in these papers is the very fact that smart and busy people other than antitrust economists and lawyers now are actually spending a great deal of their professional time thinking about this problem. High prices and the distortions in markets resulting from differential pricing power have been the unacknowledged elephant in the policy room for decades, even as the policy community and policy makers have wrung their hands over what to do about rising health care costs. More than 40 years ago, President Nixon declared that health care spending increases were “unsustainable.” And here we still are grappling with health care spending.

Over the decades I have been told by smart health economists that the main culprit behind increasing health spending is technology, although the definition of technology turns out to be pretty flexible — new ways of providing care are considered new technology, not just machines and drugs. And nominees for the reason our baseline spending exceeds other countries’ by so much have included administrative complexity in our multi-payer, crazy quilt organization of health care; defensive medicine caused by malpractice concerns; and fraud and abuse. Jack Wennberg and colleagues at Dartmouth have argued that variations in service use that do not increase quality explain spending variations, at least in Medicare where payment (price) variations are not permitted other than to reflect differences in input costs.

All of these explanations have merit, but for non-government payers, prices have actually been the main source of high spending and variations in spending, at least in the recent past and probably for much longer. Prices for commercial and self-funded insurance products result from market negotiations between insurers and providers; the balance of power in these negotiations has sometimes shifted, most recently toward many providers, but certainly not all of them — the relatively few remaining independent hospitals and the solo and small physician practices have become “price takers,” even as other providers are able to negotiate payment rates far higher than Medicare benchmarks.

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Health Affairs June Issue: Where Can We Find Savings In Health Care?


June 2nd, 2014

The June issue of Health Affairs, released today, features various approaches to cost-savings in the U.S. health care system. A variety of articles analyze the effects of potential policy solutions on the Medicare and Medicaid programs and their impact on the health of beneficiaries and tax payer wallets.

Federal approaches to reduce obesity and Type 2 diabetes rates by improving nutrition could work—but the how matters. Sanjay Basu of the Stanford University School of Medicine and coauthors modeled the effects of two policy approaches to reforming the Supplemental Nutrition Assistance Program (SNAP), which serves one in seven Americans. They found that ending a subsidy for sugar-sweetened beverage purchases with SNAP dollars would result in a decrease in obesity of 281,000 adults and 141,000 children, through a 15.4 percent reduction in calories by the lowering of purchases of this source. They also found that a $0.30 credit back on every dollar spent on qualifying fruits and vegetables could more than double the number of SNAP participants who meet federal guidelines for fruit and vegetable consumption.

With more than forty-six million people receiving SNAP food stamp benefits, the authors suggest that policy makers closely examine the implications of such proposals at the population level to determine which will benefit people’s health the most and prove most cost-effective.

If you’re between ages 15–39 when you are diagnosed with cancer, the implications later in life extend well beyond your health. Gery P. Guy Jr. of the Centers for Disease Control and Prevention and coauthors examined Medical Expenditure Panel Survey data and determined that survivors of adolescent and young adult cancers had annual per person medical expenditures of $7,417, compared to $4,247 for adults without a cancer history. They also found an annual per capita lost productivity of $4,564 per cancer survivor — because of employment disability, missed workdays, and an increased number of additional days spent in bed as a result of poor health — compared to $2,314 for adults without a cancer history.

The authors suggest that the disparities are associated with ongoing medical care needs and employment challenges connected to cancer survivorship, and that having health insurance alone is not enough to close the gap. They stress the importance of access to lifelong follow-up care and education to help lessen the economic burden of this important population of cancer survivors.

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Is Public Policy Changing The Practice of Medicine?


May 21st, 2014

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

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

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

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

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Tweeting Up A Data Revolution


May 16th, 2014

In the first 24 hours after the Department of Health and Human Services opened up data on CMS reimbursement for 880,000 Medicare providers, the deluge of analysis coming in 140-character increments was breathtaking. Critics have complained that such data tweets are, at best, a disservice and, at worst, an injustice.

Undoubtedly, many snap judgments will later be viewed as data caricatures—embellishments of a few outliers. Indeed, taken out of context, some providers may even be unfairly criticized when deeper analysis provides a logical explanation for data anomalies.

However, uncovering unwarranted variation in practice patterns has never been a linear exercise in finding the right answers. Forty years ago, when Jack Wennberg first published his seminal work in Science that uncovered dramatic variation in procedure rates, the data were far from perfect. There may have been many reasons why tonsillectomy rates more than 10 times higher in some Vermont communities than others, and Wennberg could not really know the root causes at that point. But unleashing the data did demonstrate that “geography was destiny,” and Wennberg’s brave research started a conversation — one that would evolve into the Dartmouth Atlas, and ultimately plant the seeds of an entire movement for measuring the value of care provided.

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Risk Corridors And Budget Neutrality


May 14th, 2014

Editor’s note: The topic of risk corridors will also be addressed in an upcoming Health Policy Brief. The briefs are produced by Health Affairs through a grant from the Robert Wood Johnson Foundation.

The Department of Health and Human Services (HHS) stated on March 11 in its Preamble to the Final Notice of Benefit and Payment Parameters for 2015 that it intends to implement the ACA’s risk corridor program “in a budget neutral manner.” HHS had previously indicated in its March 2013 Notice, when insurers were making decisions about marketplace participation, plan design, and pricing, that budget neutrality during the program’s three-year life was not required by statute and that “payments will be made regardless of the balance between receipts and payments.”

Then, on April 11, HHS issued a FAQ explaining how it will achieve budget neutrality. The upshot of the new policy is that health insurers can no longer be assured of receiving risk corridor payments as specified in the law. This has produced considerable angst among insurers, especially those who could be financially challenged if their costs turn out to be higher than projected when they priced policies for 2014.

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How Will 2015 Health Insurance Premiums Compare to 2014?


May 13th, 2014

The Affordable Care Act’s (ACA) 2014 open enrollment period for the individual health insurance market has only just ended, and actuaries for health insurers already are developing premium rates for the 2015 plan year. Much of the uncertainty regarding the health spending by plan enrollees that existed when insurers submitted their 2014 rates remains for 2015. Although insurers have information on enrollee demographics, only limited information will be available on enrollee health status and health spending when premium submissions are due this spring.

Key drivers of 2015 premium changes include how the composition of the risk pools in 2014 compares to what was expected, the reduction of funds available through the temporary reinsurance program, and the underlying growth in health costs. How enrollment differs from projected will vary by insurer and by state, with larger premium increases possible in states that adopted the transition policy allowing non-ACA-compliant plans to be renewed.

The composition of the risk pool and how it compares to what was projected

When calculating 2014 premiums, insurers had to make assumptions regarding which individuals would purchase coverage and what their medical spending would be. There was much uncertainty regarding these assumptions because insurers had only limited experience data on individuals who would be newly insured.

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Is Non-Profit Hospital Community Benefit Equally Distributed Across States?


May 8th, 2014

Editor’s note: In addition to David Kindig, this post is also coauthored by Erik Bakken.

In a recent Health Affairs Blog post, Sara Rosenbaum, Amber Rieke, and Maureen Byrnes discuss how IRS Community Benefit expenditures might be better directed to community building and community health improvement activities instead of primarily being reported as unreimbursed Medicaid expenditures. They cite an estimate from the Northwest Health Foundation “…that were hospitals to shift 20 percent of their community benefit expenditures toward community health improvement efforts, the annual yield would be $2.2 billion in additional funds for prevention…”

This is a significant amount of money. In a similar recent analysis for Wisconsin non-profit hospitals, we estimated the following alternative: a minimum 10 percent of total community benefit would be mandated toward the community health improvement category, with an increasing 2 percent obligation for each 2.5 percent increase in hospital profitability for any hospital over 2.5 percent profitability, up to a maximum of 20 percent profitability.

This scenario would more than triple the amount of community health improvement spending through community benefit provision, from $46 million to $139 million, or 13 percent of total community benefit. We presented this model as just one modest example of the amount of revenue that could be derived from such a regulation, and encourage the development of other scenarios or policy alternatives such as alternative modeling approaches varying the minimum or increasing profitability percentage scenarios.

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Issues Of Overuse In Health Care Tops Health Affairs Blog Most-Read List For April


May 7th, 2014

Shannon Brownlee, Vikas Saini, and Christine Cassel’s look at issues of overuse in health care is the most-read Health Affairs Blog post for April. Brownlee et al.’s post was followed by Dean Aufderheide’s post on mental illness in America’s jails and prisons, published in conjunction with the March issue of Health Affairs.

Next on the list was Glenn Melnick and Lois Green’s report on costs savings and other impacts four years into a commercial accountable care organization serving the California Public Employees Retirement System, followed by Rachel Davis’ discussion of connected health opportunities for low-income patients.

The full list appears below.

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The Payment Reform Landscape: Payment For Non-Visit Functions And The Medical Home


May 6th, 2014

As I’ve been discussing in Health Affairs Blog each month, payment reforms can pose a spectrum of financial risk for providers, with financial upside only — such as pay-for-performance programs — on one end, and downside-only models — such as nonpayment for care that shouldn’t happen — on the other. In March, we examined pay-for-performance, an upside-only model.  This month, we look at another upside-only model, typically used to support care coordination and patient centered medical homes (PCMH). The technical term Catalyst for Payment Reform (CPR) has coined for this payment model is “payment for non-visit” functions.

In its simplest form, this model is a per member per month (PMPM) payment, layered on top of another form of payment like fee-for-service. Providers typically receive this PMPM payment to help them manage their patients’ care and to support their coordination with other providers in the “medical home.” A lot has been written about care coordination and patient-centered medical homes and their ability to improve care outcomes; however, like their pay-for-performance “cousin,” the ability of these models to contain costs remains to be seen.

How common is this payment model?

According to CPR’s 2013 National Scorecard on Payment Reform, based on responses to eValue8, a nationwide survey of commercial health plans, 0.6 percent of commercial insurance payments to doctors and hospitals are payments for non-visit functions, such as care coordination fees for patient-centered medical homes. This percentage represents about 5 percent of all value-oriented payment as measured by CPR. (Approximately 11 percent of all commercial payments are value-oriented—designed to improve quality and reduce waste.)

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What Lies Ahead For US Hospitals? May Health Affairs Explores Post-Recession And ACA Environments


May 5th, 2014

Health Affairs’ May issue examines a number of concerns facing US hospitals in the wake of the recession and implementation of the Affordable Care Act (ACA). Several papers also analyze trends in US health care spending. Several of the authors of articles addressing hospital concerns will present their work at a National Press Club briefing on Wednesday, May 7.

Per capita health care spending growth for males outpaced females, while the oldest continued to spend the most from 2002–2010. David Lassman of the Centers for Medicare and Medicaid Services and colleagues examined personal health care spending in the United States for selected years from 2002–2010 and found that the average elderly person spent $18,424—three times more than working-age adults and five times more than children.

Yet the annual growth in spending for people ages sixty-five and older increased at the slowest annual rate (4.1 percent) and for children it was the fastest (5.5 percent). Growth in spending for males outpaced females, driven by a closing of the gender gap across most payers and goods and services, but most dramatically for prescription drug spending. The researchers also discussed the impacts of aging baby boomers, the recession, and the implementation of Medicare Part D during this period.

EDs are already money makers for hospitals, and the ACA could push profits even higher. Michael Wilson of Harvard Medical School and David Cutler of Harvard University examined 2009 hospital financial reports and patient claims data and found a 7.8 percent profit margin that year in emergency department (ED) revenue over costs, or $6.1 billion. They found that the profits stemmed largely from privately insured patients, compensating for underpayments from other groups.

Of the 120 million ED visits analyzed, 35 percent of patients were privately insured, 26 percent were covered by Medicaid, 21 percent by Medicare, and 18 percent were uninsured. As more Americans gain insurance through the ACA, hospital-based EDs stand to increase their profit margins with a changing insurance payer mix. Policy makers looking to reduce health care costs, say the authors, should be cognizant of the dependence of ED profitability on payer mix and its implications for hospital-based accountable care organizations with varied patient populations.

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The ACA After The First Open Enrollment: A Health Affairs Conversation With Paul Ginsburg, Sherry Glied, and Bill Hoagland


May 1st, 2014

The first open enrollment period for the Affordable Care Act’s health insurance exchanges recently closed. In the latest edition of our Health Affairs Conversations podcast series, Paul Ginsburg, Sherry Glied, and Bill Hoagland discuss what we can learn from that experience. They also look at other aspects of ACA implementation, such as Medicaid expansion and payment and delivery reforms.

Paul Ginsburg is the Norman Topping Chair in Medicine and Public Policy at the University of Southern California. From 1995 through the end of 2013 he was President of the Center for Studying Health System Change (HSC). He also served as the founding Executive Director of the Physician Payment Review Commission (now the Medicare Payment Advisory Commission.)

Sherry Glied is Dean of New York University’s Robert F. Wagner Graduate School of Public Service. Glied served as Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services from July 2010 through August 2012. Before that she chaired the Department of Health Policy and Management at Columbia University’s Mailman School of Public Health.

G. William Hoagland is a senior vice president at the Bipartisan Policy Center (BPC). Previously he served as vice president of public policy at CIGNA Corporation. He came to CIGNA after a distinguished Capitol Hill career culminating in service as the director of budget and appropriations in the office of Senate Majority Leader Bill Frist.

You can access the podcast recording here.

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