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Recent Health Policy Briefs: Mental Health Parity And ICD-10 Update


April 3rd, 2014
by Tracy Gnadinger

The latest Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation examines the issue of mental health parity. The push to make coverage for mental health treatment equal to that of physical health has been on legislative to-do lists for some time, both in Congress and in state houses. This brief looks […]

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New Health Policy Brief: Transitioning To ICD-10


March 20th, 2014
by Tracy Gnadinger

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation looks at an important change expected in the American health system later this year: the transition to the ICD-10 coding system by all health providers for diagnoses and inpatient procedures. ICD stands for the International Classification of Diseases, which is maintained by the World Health Organization. The ICD system, which began in the nineteenth century, is periodically revised to incorporate changes in the practice of medicine.

While the most current version, ICD-10, has been used in most countries since its initial adoption in 1990, the United States has until now limited its use to the coding and classification of mortality data from death certificates. This brief examines the debates that have accompanied the broad conversion in this country to ICD-10, set to take place on October 1, 2014.

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Exhibit Of The Month: Virtual Visits On The Rise


February 27th, 2014
by Rob Lott

At Health Affairs Blog, we’re excited to introduce a new regular feature. Each month, Health Affairs editors will review all the tables, charts, graphs and maps that have run in the latest print edition of the journal. After deliberating in a dark, but smoke-free, backroom, we’ll emerge to crown the most compelling, creative or surprising exhibit as our Exhibit of the Month!  Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

This exhibit shows how, within the Kaiser Permanente Northern California system, the number of virtual physician visits grew from 4.1 million in 2008 to 10.5 million in 2013.

According to Pearl, “In 2008 KPNC implemented an impatient  and ambulatory care electronic health record system for its 3.4 million members and developed a suite of patient-friendly Internet, mobile, and video tools.”  Among these tools is a system that allows patients to send secure e-mail messages to their primary care physician.  KPNC physicians are now expected to respond within 24 hours of receiving the message.  This system builds on the 10-15 minute physician telephone visits that KPNC has offered patients for more than a decade.

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Doctors Without State Borders: Practicing Across State Lines


February 18th, 2014
by Robert Kocher

Note: In addition to Robert Kocher (photo and bio above), this post is authored, by Topher Spiro, Vice President, Health Policy, Center for American Progress ; Emily Oshima Lee, Policy Analyst, Center for American Progress; Gabriel Scheffler, Yale Law School student and former Ford Foundation Law Fellow at the Center for American Progress with the Health Policy Team; Stephen Shortell, Blue Cross of California Distinguished Professor of Health Policy and Management and Professor of Organization Behavior at the School of Public Health and Haas School of Business at the University of California-Berkeley; David Cutler, Otto Eckstein Professor of Applied Economics in the Faculty of Arts and Sciences at Harvard University; and Ezekiel Emanuel, senior fellow at the Center for American Progress and Vice Provost for Global Initiatives and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania.

In the United States, a tangled web of federal and state regulations controls physician licensing. Although federal standards govern medical training and testing, each state has its own licensing board, and doctors must procure a license for every state in which they practice medicine (with some limited exceptions for physicians from bordering states, for consultations, and during emergencies).

This bifurcated system makes it difficult for physicians to care for patients in other states, and in particular impedes the practice of telemedicine. The status quo creates excessive administrative burdens and like contributes to worse health outcomes, higher costs, and reduced access to health care.

We believe that, short of the federal government implementing a single national licensing scheme, states should adopt mutual recognition agreements in which they honor each other’s physician licenses. To encourage states to adopt such a system, we suggest that the federal Center for Medicare and Medicaid Innovation (CMMI) create an Innovation Model to pilot the use of telemedicine to provide access to underserved communities by offering funding to states that sign mutual recognition agreements.

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Low ACA Knowledge And Health Literacy Hinder Young Adult Marketplace Enrollment


February 12th, 2014

Since October, the focus within the media and the health policy community has been on the troubled roll-out of Healthcare.gov and some of the state websites set up to enroll people in coverage under the Affordable Care Act (ACA).  But most Americans have paid little attention to how the changes taking place can affect their health insurance coverage.

Despite the media frenzy, findings from the Health Reform Monitoring Survey show that only about a third of adults have heard some or a lot about the Marketplaces, and only a quarter have heard about the Medicaid expansion to low-income adults.  Even for the more well-known ACA provisions, such as the expansion of dependent coverage to 26 year olds, the elimination of pre-existing condition exclusions, and the individual mandate, only about 50 percent report having heard much about those changes.

This gap in awareness of the ACA’s coverage provisions may be as much to blame as the widely publicized IT problems in driving the low levels of Marketplace enrollment. As shown in the figure below, only 24.3 percent of young adults (age 18 to 30) in the target population for the Marketplaces—defined as adults with incomes above 138 percent of the federal poverty level who are either uninsured or who have private non-group coverage—were aware of the availability of subsidies for coverage purchased through the Marketplace, compared to 43.6 percent of adults age 50 to 64.

Further, only 25.4 percent of young adults in the target population were aware of the availability of the Marketplaces themselves. Only 40.9 percent were aware of the individual mandate.

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The Changing Health Care World: Trends To Watch In 2014


February 10th, 2014
by Susan DeVore

While today’s news is bombarding us with headlines about Healthcare.gov, the Affordable Care Act isn’t just about insurance coverage. The legislation is also about transforming the way health care is provided. Consequently, it has ushered in new competitors, services and business practices, which are in turn generating substantial industry shifts that affect all players along healthcare’s value chain. Following are some of the top trends that our alliance is preparing for in 2014:

Chronic Care, Everywhere. It’s no secret that providers are moving quickly to implement accountable care organizations (ACOs). Recently, the Premier healthcare alliance released a survey of hospital executives projecting that ACO participation will nearly double in 2014. As providers work to improve their way to shared savings payments, look for a more intensive focus on the biggest health care consumers: those with multiple chronic conditions.

Since each chronic condition increases costs by a factor of three, managing this population is the sweet spot for the ACO, and the deepest pool from which to pull savings. To do it, an increasing number of providers will deploy Ambulatory Intensive Care Units (A-ICUs) or patient centered medical homes as part of their ACO, which will be charged with better managing chronic conditions exclusively within a clinically integrated, financially accountable primary care practice. As part of the approach, providers will develop care pathways for better managing chronic conditions and behavioral health needs, with an eye toward lowering hospital utilization, including inpatient bed days, length of stay, admissions, readmissions, and ED visits.

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New Health Affairs Issue: Successes And Missing Links In Connected Health


February 3rd, 2014
by Chris Fleming

Health Affairs’ February issue focuses on the current evidence and future potential of connected health — encompassing telemedicine, telehealth, and mHealth. The importance of connected health is sure to grow as more Americans gain access to health care and new, team-based models seek to provide better quality care in more efficient ways. The issue offers a variety of articles that explore what can entice hospitals, health systems, and individual providers to embrace telehealth, as well as the policy solutions that can better facilitate adoption across the health care system:

Want to increase telehealth adoption among U.S. hospitals? Look to state legislatures. Julia Adler-Milstein of the University of Michigan School of Information and co-authors emphasize that state policies are influential. According to their findings, states that wish to encourage the use of telehealth should promote private payer reimbursement and relax licensure requirements.

Overall, Adler-Milstein and coauthors found that 42 percent of US hospitals had adopted telehealth by late 2012, with significant variation across the country: Alaska was the highest with 75 percent, and Rhode Island had minimal adoption.


Market forces and individual hospital features also influence telehealth adoption rates. Factors that positively influence adoption rates include serving as a teaching hospital, being part of a larger system, having greater technological capacity, and higher rurality. Factors negatively affecting adoption include high population density, being for-profit, and operating in a less competitive market.

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Health Affairs Connected Health Briefing: Reminder And Webcast Information


February 3rd, 2014
by Chris Fleming

An explosion of knowledge that is increasingly available through mobile devices and an array of telehealth and telemedicine technologies are linking the marvels of medicine to more patients and providers separated by geography. The February 2014 thematic issue of Health Affairs examines these disruptive technologies and innovative services and their promise for improving health and access to care; potential for cost savings; rates of adoption and impact; and challenges of privacy, liability and regulatory policy.

Please join Health Affairs Founding Editor John Iglehart on Wednesday, February 5, at the Kaiser Family Foundation in Washington, DC, for a Health Affairs briefing at which we unveil the issue.

WHEN:
Wednesday, February 5, 2014
8:30 a.m. – 12:15 p.m.

WHERE:
Barbara Jordan Conference Center
Kaiser Family Foundation
1330 G Street NW, Washington, DC (Metro Center)

REGISTER ONLINE

If you can’t join us in person, you can watch the event via live Webcast. Follow live Tweets from the briefing @HA_Events, and join in the conversation with the hashtag #HA_ConnectedHealth.

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The Need For A Smart Approach To Big Health Care Data


January 27th, 2014

Today, academic medicine and health policy research resemble the automobile industry of the early 20th century — a large number of small shops developing unique products at high cost with no one achieving significant economies of scale or scope. Academics, medical centers, and innovators often work independently or in small groups, with unconnected health datasets that provide incomplete pictures of the health statuses and health care practices of Americans.

Health care data needs a “Henry Ford” moment to move from a realm of unconnected and unwieldy data to a world of connected and matched data with a common support for licensing, legal, and computing infrastructure. Physicians, researchers, and policymakers should be able to access linked databases of medical records, claims, vital statistics, surveys, and other demographic data. To do this, the health care community must bring disparate health data together, maintaining the highest standards of security to protect confidential and sensitive data, and deal with the myriad legal issues associated with data acquisition, licensing, record matching, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Just as the Model-T revolutionized car production and, by extension, transit, the creation of smart health data enclaves will revolutionize care delivery, health policy, and health care research. We propose to facilitate these enclaves through a governance structure know as a digital rights manager (DRM). The concept of a DRM is common in the entertainment (The American Society of Composers, Authors and Publishers or ASCAP would be an example) and legal industries.  If successful, DRMs would be a vital component of a data-enhanced health care industry.

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Health Affairs Issue Briefing: The Rise of Connected Health


January 17th, 2014
by Chris Fleming

An explosion of knowledge that is increasingly available through mobile devices and an array of telehealth and telemedicine technologies are linking the marvels of medicine to more patients and providers separated by geography. The February 2014 thematic issue of Health Affairs, “The Rise Of Connected Health,” examines these disruptive technologies and innovative services and their promise for improving health and access to care; potential for cost savings; rates of adoption and impact; and challenges of privacy, liability and regulatory policy.

Please join Health Affairs Founding Editor John Iglehart on Wednesday, February 5, at the Kaiser Family Foundation in Washington, DC, for a Health Affairs briefing at which we unveil the issue.

WHEN:
Wednesday, February 5, 2014
8:30 a.m. – 12:15 p.m.

WHERE:
Barbara Jordan Conference Center
Kaiser Family Foundation
1330 G Street NW, Washington, DC (Metro Center)

REGISTER ONLINE

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

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New Health Affairs: Examining Alternatives To Malpractice Litigation


January 6th, 2014
by Chris Fleming

Health Affairs’ January issue, released today as major portions of the Affordable Care Act are taking effect, includes several papers reporting new evidence on the effects of early Medicaid expansions, as well as an examination of ACA implementation over the last four years. The issue also includes national health expenditure estimates for 2012 by authors at the Centers for Medicare and Medicaid Services Office of the Actuary.

In addition, the issue contains a cluster of papers exploring alternatives to malpractice litigation. This cluster was supported by a grant from Ascension Health. These papers reflect a research-based effort, administered through the Agency for Healthcare Research and Quality (AHRQ), to identify new approaches to litigation. The cluster includes:
.

  • “Let’s Make A Deal: Trading Malpractice Reform For Health Reform,” William Sage of the University of Texas School of Law and David A. Hyman of the University of Illinois
  • “Implementing Hospital-Based Communication-And-Resolution Programs: Lessons Learned in New York City,” Michelle Mello of Harvard School of Public Health and coauthors
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A Policy Dialogue On Connected Health


December 19th, 2013
by Janet Marchibroda

Editor’s note: In addition to Janet Marchibroda (photo and linked bio above), this post was coauthored by Chris Fleming, Health Affairs Blog Editor.

What is telehealth or “connected health”? What is driving the use of connected health and what are its benefits? To achieve its full potential, what key challenges must be overcome? What are the central policy issues that must be addressed?

These are some of the questions explored by a group of leaders representing providers, payers, research and philanthropic organizations, and technology companies (listed at the end of this post), convened by Health Affairs and the Bipartisan Policy Center (BPC) last month. The session was organized partly to prepare for an upcoming Health Affairs thematic issue on connected health, to which former Senate Majority Leader and BPC Health Project Co-Chair Bill Frist—who chaired the discussion—will contribute.

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Health Policy Brief: mHealth And FDA Guidance


December 6th, 2013
by Tracy Gnadinger

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation explores the promise and challenges surrounding Mobile Health, or mHealth: the use of smartphones, tablets, and other mobile and wireless devices in public health. Mobile Health provides consumers greater personal control over their health care, and can help physicians provide day-to-day medical care in regions where access to care is often not widely available. The benefits of Mobile Health can also create problems for regulatory agencies tasked with ensuring that these devices are both safe and effective. Guidance is needed for companies making and selling mHealth apps so that they know when regulations apply and how to comply when introducing new products into the health care market.

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Implementing Health Reform: Program Integrity Amendments And Other Issues


October 25th, 2013
by Timothy Jost

Although the nearly three-week government shutdown did real damage to the nation’s economy, it did have its bright side. For three weeks those of us who scan the Federal Register for new regulatory issuances had time to catch up on our other work, even to relax a little. But the federal government has been back in business for a week, and on October 24, 2013, the Department of Health and Human Services issued its first post-shutdown final rule: Program Integrity: Exchange, Premium Stabilization Programs, and Market Standards; Amendments to the HHS Notice of Benefit and Payment Parameters for 2014.

The rule ties up a number of odds and ends that have been pending for some time. It finalizes portions of the program integrity rule proposed in June, 2013, much of which had gone final in August. I blogged about the proposed rule here. The regulation also finalizes interim final provisions of the 2014 HHS Notice of Benefit and Payment Parameters Rule published in March, 2011.

The rule is quite technical and is indeed concerned primarily with program integrity. It provides for oversight of state-operated reinsurance and risk adjustment programs, state exchanges, qualified health plan issuers in the federally facilitated exchange, and enrollee satisfaction survey vendors. The rule establishes requirements and standards for refunds where an exchange or QHP improperly applies advance premium tax credits or cost-sharing reduction payments, or assigns an enrollee incorrectly to the wrong plan variation or to a standard plan without cost-sharing reductions.

The rule includes provisions to align risk corridor calculations with the single risk pool and to provide an alternate methodology for calculating the value of cost-sharing reductions for reconciliation with estimated cost-sharing reduction payments made in advance. It sets out procedures for the administrative review of QHP issuer sanctions (civil penalties and decertifications) in the federally facilitated exchange. And finally, the regulation touches on a few issues not directly related to program integrity, such as establishing a special enrollment period for individuals who are harmed by enrollment in an inappropriate plan because of misconduct by non-exchange entities, such as navigators or agents and brokers.

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The Latest Health Wonk Review


October 24th, 2013
by Chris Fleming

Over at the Disease Management Care Blog, Jaan Sidorov has the latest edition of the Health Wonk Review. Jaan presents a great collection of posts interspersed with his own entertaining observations. Among the posts Jaan highlights: Tim Jost’s Health Affairs Blog post looking at the challenges that will be presented if Healthcare.gov’s dysfunction persists and potential ways to address those challenges.

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Implementing Health Reform: Website Developments And Contingencies; ACA Litigation And Guidance


October 23rd, 2013
by Timothy Jost

It is October 22, 2013, three weeks after the healthcare.gov website opened its doors. The website is still not working properly. Parts of it are working reasonably well, and a few people are getting all the way through the enrollment process. But multiple failures are still occurring throughout the system. In particular, there are serious concerns about the functioning of the “back end” of the process, where applicants are actually enrolled in qualified health plans with insurers.

The President’s frustration was demonstrated in his remarks of October 21. He noted that there are alternative pathways to eligibility — the call center and paper applications — and promised that the exchange will in the coming weeks contact people who initiated but were unable to complete the application process. He also reminded listeners that “the Affordable Care Act is not just a website.”

The President committed the full power of the federal government to making the website work. On October 22, Health and Human Services Secretary Sebelius proclaimed a “technology surge” to fix the website. She announced that HHS is bringing in Jeff Zients, who has extensive technology leadership experience in both the private and public sector, to provide management advice and counsel to the website repair project. She also stated that HHS is drawing in experts from across the government and industry “as part of a cross-functional team that is working aggressively to diagnose parts of HealthCare.gov that are experiencing problems, learn from successful states, prioritize issues, and fix them.”

The healthcare.gov website will get fixed. This is not cold fusion. It is a website, and the technology to build websites is known. But the task of matching millions of individuals to the health plan of their choice while providing financial assistance to pay for coverage is terribly complex. The marketplace securely connects four federal agencies, state governments, and dozens of insurers, and must accurately verify an enormous volume of information. It is disappointing that HHS could not have the website ready in time, and it was unwise for HHS to have launched a website that was not adequately tested. But at some point in the future, the website will be fully functional.

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Implementing Health Reform: The State Of The Exchanges, Income Verification, And More


October 16th, 2013
by Timothy Jost

It is October 16, 2013 and we are over two weeks into the federal government shut-down and the failed launch of the Affordable Care Act federal marketplace. The two are probably not wholly unrelated. With the nation’s borrowing capacity nearly exhausted, it is hard to believe that Congress will not soon take action to resolve the debt crisis, and, as part of the package, reopen the government. Once the Department of Health and Human Services returns to full staffing, one can only hope that the problems with the federal exchange will be more quickly resolved, although it appears that the problems with the exchange are predominantly the responsibility of private contractors.

It is frustrating that HHS has failed to provide information as to what precisely is wrong with the exchange. Some of the problem is clearly due to the high volume of website visits during the first few days of the exchanges operation — a reported 14.6 million during the first 11 days according to the Administration — but visits have dropped dramatically and problems persist. Moreover, it is becoming increasingly clear that problems persist throughout the enrollment process, and particularly at the back end where applicants are actually supposed to be enrolled with insurers, as Robert Laszewski has been reporting. There has been excellent investigative reporting on what is going wrong with the marketplace, but in the end, it is the responsibility of HHS, or perhaps the White House, to explain to the American public what exactly is wrong and when we can expect it to be fixed. This has not yet been done.

There is some good news. Some of the state exchanges have been quite successful in enrolling applicants in health plans. This would suggest that parts of the federal computer system are in fact working, as the states must go through the federal data hub to determined eligibility for premium tax credits. Also, the flood of interest in the exchange is an undeniable sign of success. In particular, there are indications that much of the interest is coming from young people, who must enroll for the ACA insurance plans to be viable.

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A Health Affairs Conversation On The Exchanges With Sarah Dash, Joel Ario, And Joe Antos


October 14th, 2013
by Chris Fleming

Where do we stand after the first days of open enrollment in the health insurance marketplaces (aka exchanges) created under the Affordable Care Act? What was behind the widespread computer problems, particularly on the federal exchange, and how significant will they be in the long run? What sort of risk pool will the exchanges attract, and what are the challenges in getting younger, healthier Americans to enroll? How will the relationship between Medicaid and the exchanges develop?

These are some of the questions addressed in the latest installment of the Health Affairs Conversations podcast series by Sarah Dash, a member of the research faculty at Georgetown University’s Health Policy Institute; Joel Ario, a managing director at Manatt Health Solutions who previously served as Director of the Office of Health Insurance Exchanges at the U.S. Department of Health & Human Services; and Joe Antos, the Wilson H. Taylor Scholar in Health Care and Retirement Policy at the American Enterprise Institute. You can access the podcast recording here or subscribe to iTunes and listen to this recording and other Health Affairs podcasts. (Please note there may be a delay in some browser configurations while the podcast file loads.)

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Implementing Health Reform: A Draft Operating Manual For The Federally Facilitated Marketplace


October 9th, 2013
by Timothy Jost

One of the many effects of the government shutdown that has been in effect since October 1, 2013, is that it has staunched the flow of Affordable Care Act regulations and guidance. As far as I can tell, the Department of Health and Human Services, Center on Health Insurance Information and Insurance Oversight has neither added any new information to its website nor published any new rules at the Federal Register Site (which, curiously, is still updated at least daily) since the shutdown.

HHS continues, however, to add new material to the RegTAP.info technical assistance website, through which it communicates with insurers, exchanges, and brokers. As the exchanges are open for business (sort of), this is understandable.

On October 3, 2013, HHS posted at the RegTAP website a draft Federally Facilitated Marketplace Enrollment Operational and Policy manual. Most of the information in this draft manual has appeared previously in rules or guidance, but it is useful to have it collected all in one place. Also, in some instances more detail is provided than had previously been available.

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Will Health Insurance Exchanges Work?


September 30th, 2013
by Daniel Schuyler

Tomorrow, the doors will open for consumers to enroll in health insurance exchanges in all fifty states and the District of Columbia. With the opening of exchanges, the burning question on everyone’s mind is this: Will health insurance exchanges work? To help answer this question, we need to have a better understanding of what makes an exchange work and what some of the metrics are that will be used to measure how an exchange is performing.

The establishment of health insurance exchanges is one of the most complex information technology (IT) projects ever initiated by the federal government. (See figure 1 at the end of this post.) This is true in part because insurance exchanges have to integrate disparate data sources at the state and federal levels and share data with each carrier participating on a health exchange. As the former Director of Technology of Avenue H (formally the Utah Health Exchange), I can tell you from first-hand experience that building a health exchange is a very complex process and requires clear lines of communication and collaboration from both state and federal stakeholders.

The primary goals of a health exchange as specified in the Patient Protection and Affordable Care Act (PPACA) are to provide consumers with a sufficient choice of affordable health insurance products while also providing them with intuitive decision support tools. To assist consumers with obtaining affordable coverage, exchanges will provide some consumers with an Advanced Premium Tax Credit (APTC), commonly referred to as a premium subsidy. Premium subsidies are available to consumers whose income level falls between 133 percent and 400 percent of the federal poverty level (FPL) and are available to these consumers to help offset the cost of an insurance plan. However, in order to accomplish this, many complex processes, calculations, and verifications have to take place behind the scenes.

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