http://healthaffairs.org/blog The Policy Journal of the Health Sphere Thu, 23 May 2013 13:15:19 +0000 en-US hourly 1 http://healthaffairs.org/blog/2013/05/23/how-ideas-from-private-industry-help-combat-medicare-fraud-waste-and-abuse/?utm_source=rss&utm_medium=rss&utm_campaign=how-ideas-from-private-industry-help-combat-medicare-fraud-waste-and-abuse http://healthaffairs.org/blog/2013/05/23/how-ideas-from-private-industry-help-combat-medicare-fraud-waste-and-abuse/#comments Thu, 23 May 2013 13:13:41 +0000 Marco Huesch http://healthaffairs.org/blog/?p=31394 well-known that improper payments cost taxpayers as much as $50 billion each year. These include reimbursements for billing for non-existent patients, falsified diagnoses, non-covered procedures, services not rendered or simply upcoded, as well as billing errors in favor of providers. Steps are being taken to address these issues through increased acceptance of approaches, tools and techniques from private industry and from industries outside of healthcare. More than just technology, some of the most powerful ideas to come along are that incentives matter, decentralization may achieve results faster and better, and stretch goals are crucial.

Scale of the problem

Safeguarding taxpayer resources and maintaining access to healthcare are clear public policy priorities. The Government Accountability Office (GAO) has long designated Medicare as a high-risk federal program due to its vulnerability to waste, fraud and abuse. Conservative estimates by the National Health Care Anti-Fraud Association are that improper payments represent 3 percent of national health care spending. The GAO and others estimate nearly 10 percent of the more than $500 billion in current annual Medicare payments are improper. At the same time, Medicare provides necessary -- and often much needed -- access to health care for 48 million Americans.]]> http://healthaffairs.org/blog/2013/05/23/how-ideas-from-private-industry-help-combat-medicare-fraud-waste-and-abuse/feed/ 0 http://healthaffairs.org/blog/2013/05/22/a-life-course-approach-to-vaccination-can-drive-healthy-aging/?utm_source=rss&utm_medium=rss&utm_campaign=a-life-course-approach-to-vaccination-can-drive-healthy-aging http://healthaffairs.org/blog/2013/05/22/a-life-course-approach-to-vaccination-can-drive-healthy-aging/#comments Wed, 22 May 2013 19:28:05 +0000 Michael Hodin, Javier Garau, and Alexandre Kalache http://healthaffairs.org/blog/?p=31512
Organizations at national and global levels have begun to pursue initiatives to promote healthy aging, and these efforts are going to intensify in the coming years. Thus far, the progress has been admirable, with the World Health Organization, the United Nations, the Organisation for Economic Co-operation and Development, and others taking leadership roles. Yet, despite many promising developments, the potential of “life-course immunization,” which stresses the administration of vaccines throughout all stages of life – including for adults – to prevent disease and promote health, has been largely overlooked, especially among adults.

This is a missed opportunity. There is a growing body of research and data to show that immunizations against some of the more specific age-related health challenges - such as pneumococcal disease, herpes zoster, and others - are economically feasible investments that can create large public health benefits.]]> http://healthaffairs.org/blog/2013/05/22/a-life-course-approach-to-vaccination-can-drive-healthy-aging/feed/ 0 http://healthaffairs.org/blog/2013/05/22/seven-policy-recommendations-to-improve-quality-measurement/?utm_source=rss&utm_medium=rss&utm_campaign=seven-policy-recommendations-to-improve-quality-measurement http://healthaffairs.org/blog/2013/05/22/seven-policy-recommendations-to-improve-quality-measurement/#comments Wed, 22 May 2013 14:23:26 +0000 Robert Berenson http://healthaffairs.org/blog/?p=31441
Harlan Krumholz and Peter Pronovost have been among the most important contributors to the development of performance measures for quality and safety of health care. At the same time, each has written powerful critiques of particular aspects of the current measurement enterprise with suggested improvements. I work mostly inside the Beltway in a world of policy makers who, despite good intentions, by their actions often display a lack of understanding of the challenges associated with measures, measurement, public reporting, and pay-for-performance. For example, the physician value-based modifier, which was mandated as part of the Affordable Care Act and now must be implemented by CMS, cannot produce a valid snapshot of an individual physician’s “value” but will be imposed nevertheless, unfortunately feeding those within the physician community who resist all efforts to improve accountability and transparency of performance.

With the encouragement of the Robert Wood Johnson Foundation, Harlan, Peter, and I joined in a collaborative endeavor to produce a comprehensive look at the state of play of performance measurement and public reporting -- their conceptual underpinnings and limitations, successes and failures, and, perhaps most importantly, recommendations for major steps that are needed now to put the measurement enterprise on track to achieve its potential to improve the value of U.S. health care without doing harm.]]> http://healthaffairs.org/blog/2013/05/22/seven-policy-recommendations-to-improve-quality-measurement/feed/ 1 http://healthaffairs.org/blog/2013/05/21/where-was-the-leadership-the-questions-raised-by-jonathan-welchs-narrative-matters-essay/?utm_source=rss&utm_medium=rss&utm_campaign=where-was-the-leadership-the-questions-raised-by-jonathan-welchs-narrative-matters-essay http://healthaffairs.org/blog/2013/05/21/where-was-the-leadership-the-questions-raised-by-jonathan-welchs-narrative-matters-essay/#comments Tue, 21 May 2013 19:38:38 +0000 S. Allan Adelman http://healthaffairs.org/blog/?p=31455 Dr. Jonathan Welch's Narrative Matters essay in the December, 2012 edition of Health Affairs, regarding the cascade of errors and omissions he witnessed in connection with the care provided to his mother, should raise profound questions about how the hospital allowed those failures of care to happen. Dr. Welch, an emergency medicine physician, watched helplessly as his mother received indifferent care from various nurses and doctors and ultimately died. Despite having classic signs of evolving sepsis, she was not closely monitored by the nursing staff which ignored alarming signs, was not put on a sepsis treatment protocol by her oncologist, and was not put in an intensive care unit where she could receive more intense monitoring and aggressive treatment from specialists.

While it is tempting to blame the nurse (for not taking vital signs frequently enough and not reacting to abnormal vital signs) and the oncologist (for not following the patient closely enough, not initiating appropriate treatment, and not involving other specialists), Dr. Welch’s story suggests that there were more deeply rooted systemic problems at the hospital that went beyond the shortcomings of the individuals involved in his mother’s care.

As health care attorneys who represent hospitals and physicians, we believe there are some fundamental questions which should be asked by this hospital’s administration, medical staff leadership and governing body to ensure Dr. Welch’s experience is not repeated. Those questions, which the leaders in all hospitals should consider, include the following:]]> http://healthaffairs.org/blog/2013/05/21/where-was-the-leadership-the-questions-raised-by-jonathan-welchs-narrative-matters-essay/feed/ 0 http://healthaffairs.org/blog/2013/05/20/implementing-health-reform-preexisting-condition-insurance-plan-medicaidchip-renewal/?utm_source=rss&utm_medium=rss&utm_campaign=implementing-health-reform-preexisting-condition-insurance-plan-medicaidchip-renewal http://healthaffairs.org/blog/2013/05/20/implementing-health-reform-preexisting-condition-insurance-plan-medicaidchip-renewal/#comments Mon, 20 May 2013 11:50:36 +0000 Timothy Jost http://healthaffairs.org/blog/?p=31405 Blog has been proud to host Tim Jost's series of posts, "Implementing Health Reform, tracking the implementation of the Affordable Care Act. In recent days the implementing agencies -- Health and Human Services, Labor, and Treasury -- have been issuing regulations, proposed regulations, frequently asked questions, and other guidances on an almost daily basis, and new posts by Tim have consequently often appeared almost daily as well. Going forward, to keep up with the flow of ACA guidance in an orderly fashion, Tim's posts will generally appear twice a week, usually Mondays and Thursdays. When major rules or proposed rules are released, such as the final rules on eligibility and appeals, wellness, and the SHOP marketplaces currently under final review by the Office of Management and Budget, we will feature additional posts in Tim's series.

You can continue to look to Tim's post for current information on ACA implementation. When new guidance appears, Tim will update his most recent post (a practice we have in fact already begun); we will note that there has been an addition at the beginning of the updated post and normally add the new material at the end of the post, so you can skip rereading the rest. We will also Tweet significant updates. From time to time, we correct a post when we find a typographical error or Tim receives new information as to the meaning of an issuance. If the correction is more than trivial, we will note this as well.

We hope that this new approach will make this series even more useful to our readers.

On May 17, 2013, at the end of an otherwise quiet week, CMS released an interim final rule on the Preexisting Condition Insurance Plan (PCIP). CMS also released a letter to state Medicaid directors on Facilitating Medicaid and CHIP Enrollment and Renewal in 2014. This post will discuss these issuances]]> http://healthaffairs.org/blog/2013/05/20/implementing-health-reform-preexisting-condition-insurance-plan-medicaidchip-renewal/feed/ 1 http://healthaffairs.org/blog/2013/05/17/narrative-matters-navigating-the-coverage-maze-in-pennsylvania/?utm_source=rss&utm_medium=rss&utm_campaign=narrative-matters-navigating-the-coverage-maze-in-pennsylvania http://healthaffairs.org/blog/2013/05/17/narrative-matters-navigating-the-coverage-maze-in-pennsylvania/#comments Fri, 17 May 2013 18:06:40 +0000 Chris Fleming http://healthaffairs.org/blog/?p=31385 May Health Affairs Narrative Matters essay, two graduate students describe their fight with the bureaucracy to gain coverage for their son under the Children's Health Insurance Program, and they express the hope that provisions of the Affordable Care Act will cut the red tape. The article, "To Cover Their Child, One Couple Navigates A Health Insurance Maze In Pennsylvania, is by Ari Friedman, a fifth-year medical-doctoral student in health economics at the University of Pennsylvania’s Perelman School of Medicine and Wharton School, and Tara Mendola is a sixth-year graduate student in comparative literature at New York University.]]> http://healthaffairs.org/blog/2013/05/17/narrative-matters-navigating-the-coverage-maze-in-pennsylvania/feed/ 0 http://healthaffairs.org/blog/2013/05/16/saving-money-while-providing-benefit-in-medicare-a-standard-applied-only-to-hospice/?utm_source=rss&utm_medium=rss&utm_campaign=saving-money-while-providing-benefit-in-medicare-a-standard-applied-only-to-hospice http://healthaffairs.org/blog/2013/05/16/saving-money-while-providing-benefit-in-medicare-a-standard-applied-only-to-hospice/#comments Thu, 16 May 2013 20:18:53 +0000 Donald Taylor http://healthaffairs.org/blog/?p=31361
The default is that Medicare covers acute care therapies, tests and procedures if there is a patient that wants to receive them and a provider who is willing to deliver them, whether there is evidence of any benefit to the patient or not. As I tell students in my Introduction to Health Policy Course, while Medicare sets payment rates (and is therefore like Marlon Brando in The Godfather: “I have an offer you can’t refuse”), when it comes to what is covered in the acute care setting, it is more like my Grandmother serving lunch (“whatever you would like, honey.”)

There are exceptions. Recently, the Medicare Evidence Development and Coverage Advisory Committee decided not to approve the payment of PET scans to aid in the diagnosis of Alzheimer’s disease. However, such a move is rare, and both provider and patient groups are protesting this decision.]]> http://healthaffairs.org/blog/2013/05/16/saving-money-while-providing-benefit-in-medicare-a-standard-applied-only-to-hospice/feed/ 0 http://healthaffairs.org/blog/2013/05/16/hospital-charges-and-the-need-for-a-maximum-price-obligation-rule-for-emergency-department-out-of-network-care/?utm_source=rss&utm_medium=rss&utm_campaign=hospital-charges-and-the-need-for-a-maximum-price-obligation-rule-for-emergency-department-out-of-network-care http://healthaffairs.org/blog/2013/05/16/hospital-charges-and-the-need-for-a-maximum-price-obligation-rule-for-emergency-department-out-of-network-care/#comments Thu, 16 May 2013 19:12:45 +0000 Robert Murray http://healthaffairs.org/blog/?p=31255 release of average charges for common procedures in more than 3,000 U. S. hospitals last week by the Centers for Medicare and Medicaid Services (CMS) elicited divergent reactions – not surprisingly. On one hand, it was front-page news for most of the major newspapers: “Hospital Billing Varies Wildly, Government Billing Data Shows,” was the headline in the New York Times. The article went on to speculate that these new data would likely “intensify a long debate over the methods that hospitals use to determine their charges.”

On the other hand the data were “old hat” to most health policy analysts. Several colleagues mentioned to me that “this is old news” and “it isn’t meaningful at all because we all know that charges don’t mean anything.”

“No one pays charges” is the common refrain. “Charges are merely an accounting fiction.”

Charges Do Matter -- They Matter A Great Deal

Counter to the belief of both hospital industry representatives and many of my colleagues, hospital charge levels and rapidly escalating charges matter a great deal. While individual states and the Affordable Care Act (ACA) have instituted limits on the amounts low-income uninsured patients pay hospitals, insured patients that receive care at hospitals that are “Non-Par” or “out-of-network” are still victims of hospital’s exorbitant charging practices. When patients receive emergency services at an out-of-network hospital, the patient and/or insurance company (depending on insurer cost sharing for out-of-network care) pay full charges.

High and increasing hospital charges, combined with increasing proportions of cases admitted through the hospital Emergency Department (ED), are major factors behind the ever-declining negotiating leverage of private health insurers. This situation, coupled with the increased pricing power of the ever-more-concentrated provider industry, will be a major contributor to the almost certain rapid escalation in total U.S. health care costs in coming years.]]> http://healthaffairs.org/blog/2013/05/16/hospital-charges-and-the-need-for-a-maximum-price-obligation-rule-for-emergency-department-out-of-network-care/feed/ 3 http://healthaffairs.org/blog/2013/05/15/in-one-state-cancer-patients-were-2-65-times-likelier-to-file-for-bankruptcy/?utm_source=rss&utm_medium=rss&utm_campaign=in-one-state-cancer-patients-were-2-65-times-likelier-to-file-for-bankruptcy http://healthaffairs.org/blog/2013/05/15/in-one-state-cancer-patients-were-2-65-times-likelier-to-file-for-bankruptcy/#comments Wed, 15 May 2013 20:01:05 +0000 Chris Fleming http://healthaffairs.org/blog/?p=31246 released today as a Web First by Health Affairs, reports that cancer patients in Washington state were 2.65 times more likely to file for bankruptcy than people without cancer. Of 197,840 cancer patients age 18 or older in the western district of Washington between 1995 and 2009, 4,408 (2.2 percent) filed for bankruptcy protection after being diagnosed with cancer. Among a control group of 197,840 people from that same region who did not have cancer, only 2,291 (1.1 percent) filed for bankruptcy.

“Although the risk of bankruptcy for cancer patients is relatively low in absolute terms, bankruptcy represents an extreme manifestation of what is probably a larger picture of economic hardship for cancer patients,” conclude Scott Ramsey of the Fred Hutchinson Cancer Research Center and coauthors. “As a policy issue, there may be a role for employers and governments in creating programs or incentives to reduce the likelihood of financial insolvency, given that bankruptcies are 'lose-lose’ events for debtors and creditors alike.”]]> http://healthaffairs.org/blog/2013/05/15/in-one-state-cancer-patients-were-2-65-times-likelier-to-file-for-bankruptcy/feed/ 1 http://healthaffairs.org/blog/2013/05/15/post-on-exchange-navigators-leads-health-affairs-blog-april-top-ten-list/?utm_source=rss&utm_medium=rss&utm_campaign=post-on-exchange-navigators-leads-health-affairs-blog-april-top-ten-list http://healthaffairs.org/blog/2013/05/15/post-on-exchange-navigators-leads-health-affairs-blog-april-top-ten-list/#comments Wed, 15 May 2013 18:59:07 +0000 Chris Fleming http://healthaffairs.org/blog/?p=31232 Health Affairs Blog posts for April includes four posts in Tim Jost's ongoing series on implementing the Affordable Care Act; number one on the top-ten list is Tim's post about proposed regulations on health insurance exchange navigators. The list also includes posts on accountable care organizations, patient-centered care, controlling health care costs. and more.

The full list is below:]]> http://healthaffairs.org/blog/2013/05/15/post-on-exchange-navigators-leads-health-affairs-blog-april-top-ten-list/feed/ 0