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Unpacking The Burr-Hatch-Upton Plan


March 24th, 2015

Anticipating the upcoming Supreme Court decision on King v. Burwell, which could halt health insurance subsidies available through the federal exchange, Republican Senators Richard Burr and Orrin Hatch joined with Representative Fred Upton to propose a comprehensive replacement for the Affordable Care Act (ACA). The Patient Choice, Affordability, Responsibility, and Empowerment Act, or Patient CARE Act, is modeled on a proposal of the same name offered last year by Senators Burr, Hatch, and Tom Coburn, who has retired from the Senate. The Burr-Hatch-Upton plan, like its predecessor, adopts consumer-based reforms of the insurance market, modernizes the Medicaid program, and makes other changes intended to lower cost and increase choices.

In an earlier post, we described in detail the provisions of the Burr-Coburn-Hatch bill. In this post, we discuss how the Burr-Hatch-Upton plan differs from the earlier proposal. We also discuss the impact of the new proposal on health insurance coverage, premiums, and the federal budget based on a new analysis from the Center for Health and Economy (H&E), a non-partisan think tank focused on producing informative analyses of trends in U.S. health care policy and reform ideas. We conclude by commenting on the direction Republicans are likely to take in reforming the health system in the aftermath of a Supreme Court decision in the King v. Burwell case.

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


March 2nd, 2015

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

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

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

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From The Supreme Court: A Strong Endorsement Of Health Care Competition


March 2nd, 2015

The Supreme Court has spoken by a 6-3 vote, with Justice Anthony Kennedy writing an opinion for the Court joined by Chief Justice Roberts and Justices Breyer, Ginsburg, Sotomayor, and Kagan.  In a strong, clear voice, the Court upheld the enforcement of a major federal statute against a state entity that had failed to embrace federal policy with respect to health care.  Although not formally a constitutional decision, the Court’s interpretation of congressional intent played out against the backdrop of an important constitutional question: the permissible and appropriate balance between federal lawmaking and residual state authority.  And it was the federal government’s seeming disregard of state sovereignty that led what has become the Court’s conservative rump – here Justice Alito, joined by Justices Scalia and Thomas – to write bluntly in dissent.

The case is North Carolina State Board of Dental Examiners v. Federal Trade Commission, not King v. Burwell, and the major federal statute is the Sherman Antitrust Act, not the Affordable Care Act.  Oral argument in North Carolina State Board took place last October (David Hyman and I wrote about it here); the Court’s decision was issued on February 25, 2015.

North Carolina State Board has nothing to do with “Obamacare,” but it may turn out to be the most important health care (and general public law) decision of the year.  (Note to Pundits and Hypesters: King v. Burwell will only matter if the Court rules for the plaintiffs, and is unlikely to create enduring law even then. If the government wins, the case will soon be forgotten.)  The Supreme Court’s ruling will give professional licensing boards throughout the country significant pause before adopting ad hoc policies that disadvantage competing professionals or non-professionals, and it should lead to a constructive conversation (and perhaps uniform or model legislation) regarding the accountability of self-regulatory bodies to actual state government.  Its impact could be comparable to a major revamping of Joint Commission standards for health care facilities – low in visibility but dramatic in operational change.

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What Ebola Teaches Us About Public Health In America


February 9th, 2015

Editor’s note: This post is part of a series stemming from the Third Annual Health Law Year in P/Review event held at Harvard Law School on Friday, January 30, 2015. The conference brought together leading experts to review major developments in health law over the previous year, and preview what is to come. A full agenda and links to video recordings of the panels are here.

2014 saw an epidemic of Ebola in Sierra Leone, Guinea, and Liberia, and an epidemic of fear in the US. Neither epidemic covered public health in glory. For Science, Ebola was the “breakdown of the year;” the Association of Schools and Programs of Public Health called it “the most important public health story” of the year; Politfact labeled it the political “lie of the year,” and Time magazine named “the Ebola fighters” its “Person of the Year.” All of these characterizations contain some truth.

Response to the epidemic in Africa relied heavily on volunteer organizations, especially Christian charity groups like Samaritan’s Purse and SIM (Serving In Mission), and medical NGOs, most notably Doctors Without Borders (MSF). It was MSF that called out the World Health Organization (WHO) for its failure to recognize the epidemic, and then its inability to respond to it. Their International Health Regulations, it turned out, were much more like guidelines than any form of law, and the WHO had no capacity to effectively respond to a new epidemic.

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After The Worst In Liberia And Sierra Leone


February 9th, 2015

From January 19-27, we traveled to Liberia and Sierra Leone to engage with national leaders, health workers, citizens, non-governmental organization (NGO) implementers, international organizations, and United States, United Kingdom (UK), and other officials, including the African Union (AU), Chinese, and Cuban medical delegations. It was a moment of hope and nervous adjustment, as Ebola cases dropped suddenly and unexpectedly in Liberia, followed by reductions in Sierra Leone and Guinea.

We listened to the reflections of those who lived through and led the mobilization to roll back the unprecedented Ebola emergency, as it raged in the second half of 2014. We sought to understand the latest phase, as complicated efforts have begun to move beyond an emergency response and seek to achieve “zero” Ebola infections in 2015 — while safeguarding against new outbreaks. We discussed briefly early plans for long-term recovery. Across these different phases and concerns, we had a special interest in examining the US contribution.

The visit generated countless conversations with diverse experts who were remarkably gracious, insightful, and candid in their remarks. In this post we share select major impressions we carried home. These opinions are, of course, ours, and ours alone.

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How The Ebola Crisis Could Help Save 75,000 Patients


February 4th, 2015

It has taken an epidemic in West Africa to expose a troubling issue for U.S. hospitals and health policy: the short shrift given infection prevention.

In a thoughtful December Health Affairs Blog post, Dr. Leonard Mermel, an epidemiologist and infection control specialist, noted that over a three-month period his hospital’s work on Ebola preparedness “significantly strained our ability to manage other infection control challenges.”

That is a red flag for health care policymakers. As hospitals focus on Ebola preparations, we can’t lose sight of the fact that more than 700,000 Americans contract health care associated infections (HAIs) each year. About 75,000 people die from HAIs, such as Clostridium difficile (C. diff), Methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE).

This is more than 10 times the number of patients who have died from Ebola across the globe.

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Innovation In Health Care Education: A Call To Action


January 29th, 2015

Health care administration educators are at a crossroads: the health care sector is rife with inefficiencies, erratic quality, unequal access, and sky-high costs, complex problems which call for innovative solutions. And yet, according to our content analysis of top U.S. health administration schools and a recent article in the Lancet, our educational systems focus their curricula on isolated, theoretical subjects, such as analytics and quantitative problem solving, rather than the team-oriented, practical problem-solving skills required for innovation.

All too often, when graduates of these programs enter the workforce, they find themselves unequipped to meet the challenges for innovation of 21st century health care. The following blog post examines the current educational gaps in traditional health care administration and efforts underway to address them. One such effort is the Global Educators Network for Health Care Innovation Education (GENiE) Group, created by Harvard Business School (HBS) Professor, Regina Herzlinger, whose members are working to make innovation a central part of the education of the future leaders in health care.

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Finding And Supporting A Workforce With The Right Skill Mix


January 27th, 2015

Editor’s note: This post is part of a series of several posts related to the 4th European Forum on Health Policy and Management: Innovation & Implementation, to be held in Berlin, Germany on January 29 and 30, 2015. For more information or to request your personal invitation contact info@centerforhealthcaremanagement.org or follow @HCMatColumbia.

Many health systems are experiencing shortages of health care workers. Policymakers and practitioners have tried for a long time to figure out how to assess workforce productivity, skills and roles, in order to achieve the best mix of professionals needed to deliver high quality care while preserving sustainability.

Unfortunately, many obstacles have slowed progress toward this goal. Open questions still concern not only how many doctors or nurses are needed in any given system or organization level, but also over what roles and responsibilities fall to different health professionals and specialists.

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Beyond Law Enforcement: The FTC’s Role In Promoting Health Care Competition And Innovation


January 26th, 2015

By now, the Federal Trade Commission’s (FTC) law enforcement efforts in the health care area are well known. We have successfully challenged several hospital and physician practice mergers in the last few years. We also continue to pursue anticompetitive pharmaceutical patent settlements, following a victory at the Supreme Court in the Actavis case. Speaking of the Court, it is currently reviewing a case we brought against the North Carolina Board of Dental Examiners, alleging that its members conspired to exclude non-dentists from providing teeth whitening services in North Carolina.

Perhaps less publicized are the FTC’s various non-enforcement efforts in health care. Arguably most significant among those is the advocacy that the agency conducts in favor of competition principles before state legislatures and other policymakers. I will discuss our advocacy efforts in the health care space in this post, and then turn to the subject of telemedicine, an area in which FTC competition policy may play a significant role.

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How Community Health Workers Can Reinvent Health Care Delivery In The US


January 16th, 2015

As health policy, research and practice are becoming increasingly focused on improving the health of populations and addressing social determinants of health, Community Health Workers (CHWs) may be just what the doctor ordered. As part of the public health workforce with ties to the local community, CHWs can now be reimbursed by Medicaid for providing preventive services if recommended by a physician or other licensed practitioner.

This groundbreaking CMS regulatory change, along with policy support from the Affordable Care Act, holds the promise of bridging the gap between mainstream health care and community health through expanding the CHW profession and its impact on clinical care. Much like other disruptive changes in health care, however, fulfilling this potential will require a new way of thinking among state policymakers and the health care system at large.

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Graduate Medical Education: The Need For New Leadership In Governance And Financing


January 14th, 2015

With the creation of the Medicare program in 1965, a funding stream was established to support the training of medical residents who provided care for Medicare beneficiaries. In subsequent years, Medicare has maintained these payments to teaching hospitals and remains the largest payer for Graduate Medical Education (GME), with expenditures totaling about $10 billion annually. This represents two-thirds of Federal GME support, with another $4 billion per year provided to hospitals through State Medicaid GME support.

This expenditure was a major motivation for the Senate Finance Committee to request the Institute of Medicine (IOM) to issue a report entitled “Graduate Medical Education That Meets the Nation’s Health Needs.”  The Report proposed major reforms to create a GME system with greater transparency, accountability and strategic direction, in order to increase its contribution to achieving the nation’s health goals. Prior to publication of this long awaited report on July 29, 2014, GME financing policies received substantial attention in the last two sessions of Congress, with a particular focus on increasing the number of federally funded GME positions. The House and Senate committees with GME jurisdiction produced multiple legislative initiatives.

However, there was considerable opposition from primary care stakeholders to some of the proposed changes because of inadequate emphasis on ambulatory training. Possible redistribution of Medicare GME funding was also of concern to many. This seemed to dissuade Congress from passing reform of GME policies. Nevertheless, 1,500 new GME positions were authorized in the recent Veterans Health Administration legislation.

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The Strategic Challenge Of Electronic Health Records


December 16th, 2014

Despite a 2005 prediction that electronic health records (EHRs) would save $81 billion, RAND Corporation just validated clinicians’ complaints in a report describing EHRs as “a unique and vexing challenge to physician professional satisfaction.” The American Medical Association also published EHR “usability priorities” – strong evidence that current EHRs don’t support doctors in practicing medicine.

In a world of Apple-typified simplicity, why is it so hard to get the right EHR? Because, unlike Apple, EHR designers haven’t started with the question of how value can be created for users of the technology. Technology isn’t the problem. The challenge is in articulating clinicians’ information needs and meeting them by making the right tradeoffs between corporate and business unit strategies.

EHRs can, and should, provide relevant information when and where clinicians need it, recognizing that care is not a commodity and that different care processes have different information needs. User interfaces must anticipate clinicians’ needs rather than require individual user design. EHRs need to eliminate low-information pop-ups and alarms and instead provide alerts and reminders that are both timely and relevant. They must be designed with assiduous attention to data entry requirements, replacing blind mandates with thoughtful assignment of the task and the timing.

In this post I look at how rethinking the design of EHRs can better balance the different strategic needs within care delivery organizations.

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Preparing US Hospitals To Safely Manage Ebola Virus-Infected Patients: At What Cost?


December 11th, 2014

Since Ebola first reached US shores this summer, hospitals nationwide have attempted to prepare. National guidance has been helpful, but no such guidance can deal with the fastidious attention to every minute and mundane aspect of caring for a patient with Ebola virus infection that could place a healthcare worker at risk if a breach occurs. Simulation training has helped to uncover defects and to assess our capacity to mitigate those defects.

Additionally, innumerable hours of countless healthcare workers, hospital administrators, infection control staff, facilities and environmental services providers, communications specialists, security personnel and others have been brought to bear focused on the task at hand. Despite this effort, in the 30 years since becoming a physician, I have never witnessed a greater, more palpable level of stress and anxiety among my peers.

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Should Doctors Deny Ebola Patients CPR?


December 11th, 2014

The first time I did CPR, coagulated blood spurted onto my new white coat from a wound in the patient’s chest. Another time a patient’s urine soaked through the knees of my pants as I knelt at his side.

Even in the best of conditions, cardiopulmonary resuscitation (CPR) is a spit-smeared, bloody business that can expose health care workers to all kinds of body fluids. Like all health care workers, I put on gloves and a game face and accept such things as part of patient care.

The 2014 Ebola outbreak changes all that. Hospitals all around the world are now training staff in personal protective equipment (PPE) use and convening rapid response teams. A key part of this process involves grappling with how dangerous it will be to perform CPR on patients with Ebola.

Fully 70 percent of those stricken with Ebola in 2014 have died. That means in countries like the United States where we attempt CPR routinely to save dying patients, health care workers will be called to resuscitate Ebola patients.

From placement of an artificial airway to the administration of chest compressions and beyond, each step in CPR can expose health care workers to body fluids containing as many as a million viral particles in each drop and well-proven to transmit Ebola. In contradistinction to the bowling alley and subway exposures that have drawn so much media attention, health care workers performing CPR on Ebola patients will truly be in the direct line of viral fire.

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California’s Proposition 46 And The Uncertain Future Of Medical Malpractice Liability Reform


December 10th, 2014

On November 4, 2014, Californians voted against Proposition 46, an unprecedented statewide ballot initiative that would have, among other things, raised the $250,000 cap on noneconomic damages to $1.1 million and indexed it to the rate of inflation in future years. The margin was significant — 67 percent voted against it.

For nearly 40 years, noneconomic damages, which entail payments to patients for pain and suffering resulting from medical malpractice (as opposed to economic damages such as lost wages and medical costs), have been at the forefront of debates over the U.S. medical liability system. Currently, 22 states have caps on noneconomic damages of varying sizes in place. If it had passed, the ballot initiative would have raised the cap on noneconomic damages in California from among the most restrictive to the least restrictive among all states with caps.

Opponents of Proposition 46, and supporters of malpractice reform more generally, argued that raising the noneconomic damages cap would have increased malpractice awards and subsequently malpractice premiums, which would be passed on to patients and insurers as higher costs.

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The Health Care Holy Grail?


December 9th, 2014

A friend practicing internal medicine in Massachusetts is a pillar of his community, a beloved physician — and he is miserable.

“The practice of medicine has deteriorated to that point where many of my colleagues would like to get out,” he told us. “I certainly would. Medicine now is about production lines, insurance company power, regulations. It is one fire drill after another throughout the day, day after day with a bureaucrat peering over your shoulder all the while.”

In countless conversations in recent years we have found that these sentiments are as common as they are troubling. Imagine going through the rigors of medical school and training and then looking back and regretting your career choice? Burnout is sweeping physician ranks throughout the country.

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Transforming Rural Health Care: High-Quality, Sustainable Access To Specialty Care


December 5th, 2014

Editor’s note: This post is also authored by Kate Samuels, a project manager at Brookings. It is informed by a case study, the fourth  in a series made possible through the Merkin Initiative on Physician Payment Reform and Clinical Leadership, a special project to develop clinician leadership in health care delivery and financing reform. The case study will be presented on Monday, December 8 using a “MEDTalk” format featuring live story-telling and knowledge-sharing from patients, providers, and policymakers.

Health care for patients in rural communities across the United States remains a unique challenge.  Despite many programs aimed at improving access to physicians and hospitals, access to health care providers remains limited.  While 19.3 percent of Americans live in a rural area, only about 10 percent of physicians practice in rural areas.  Similarly, 65 percent of all Health Professional Shortage Areas are in rural areas.  Rural residents often face long travel distances to see a specialist after what can be months waiting for an appointment.

Even in areas where rural primary care providers (PCPs) remain committed and engaged in the community, often having been raised and educated there, these providers often lack close connections to specialists who tend to be based in larger, urban academic medical centers (AMC).  The result is a worsening gap in specialty care access, in turn leading to a deteriorative effect on rural provider morale and retention.

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The Council On Graduate Medical Education (COGME)—Not Yet Ready For End-Of-Life Care


December 4th, 2014

In November, 1985, twenty-nine years ago, members of the first session of the 99th Congress addressed growing concern and controversy regarding Graduate Medical Education (GME). Although Medicare had financed GME for the previous twenty years, Congress began to recognize that our rapidly evolving health care system could require significant changes in the composition of our physician workforce, and that these changes could impact the appropriate governance and funding of GME.

In this setting, the Council on Graduate Medical Education (COGME) was conceived and underwent rapid gestation, with its birth achieved via enactment of authorizing legislation in 1986. Its charter charged the Secretary of Health and Human Services (HHS), under Title VII of the Public Health Service Act, with responsibility for taking national leadership in the development of policies related to GME, and in the research, development, and analysis of such policies that impact on the health workforce needs of the nation. COGME was instructed to provide advice and make policy recommendations to the Secretary and committees of the House and Senate within their jurisdiction.

Contrary to a sunset provision in the legislation, COGME still survives. While continuing to function on very limited support, it recently issued a noteworthy report entitled “Improving Value in Graduate Medical Education” in 2013. COGME presently is preparing its 22nd Report, which addresses the need for change in GME due to changes in the U.S. health care system and focuses on opportunities to improve training through more effective targeting of public resources.

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What Is The Future For Community Health Workers?


November 25th, 2014

I recently attended a symposium entitled “Community Health Workers: Getting the Job Done in Health Care Delivery.” (My concluding remarks begin at the 6:00:40 mark in the video.) Speakers examined the evolving role of Community Health Workers (CHWs) in the current era of delivery system reform. Health Affairs has published work documenting the importance of this part of the workforce, and our November issue is dedicated to the topic of “Collaborating for Community Health.”

I was asked to summarize some key points from the day-long conversation. In this post I highlight some of the themes covered.

Over the course of the day I heard the elements of two very different paths forward for community health workers. Each path was coherent and compelling, but they lead in very different directions.

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Spreading Like A Wildfire: Interprofessional Education – The Vanderbilt Experience


November 20th, 2014

Well before the Affordable Care Act was passed in 2010, efforts to expand interprofessional education (IPE) were beginning to change the mindset that permeated much of health professional education in the US. One such example is the Vanderbilt Program in Interprofessional Learning (VPIL) that was established in 2010 with initial support from the Josiah Macy Jr. Foundation, and later from the Baptist Health Trust.

To learn about the challenges, successes, and surprises experienced by those who developed and lead IPE at Vanderbilt, I interviewed Linda Norman, Dean of Vanderbilt University School of Nursing, Bonnie Miller, Associate Vice Chancellor for Health Affairs and Senior Associate Dean for Health Sciences Education at Vanderbilt University Medical Center, and Heather Davidson, Director of Program Development for VPIL.

Peter Buerhaus: What were the key challenges faced when you started IPE at Vanderbilt?

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