http://healthaffairs.org/blog The Policy Journal of the Health Sphere Tue, 21 May 2013 19:38:38 +0000 en-US hourly 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/ 0 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 http://healthaffairs.org/blog/2013/05/15/implementing-health-reform-more-guidance-on-health-insurance-marketplaces/?utm_source=rss&utm_medium=rss&utm_campaign=implementing-health-reform-more-guidance-on-health-insurance-marketplaces http://healthaffairs.org/blog/2013/05/15/implementing-health-reform-more-guidance-on-health-insurance-marketplaces/#comments Wed, 15 May 2013 15:19:55 +0000 Timothy Jost http://healthaffairs.org/blog/?p=31204
This post deals with three sets of FAQS released by HHS on May 13 and 14. (It may be updated on May 15 or May 16 to note further guidance released over the course of those days.) Two of the FAQs concern the use of section 1311 funding, one dealing with section 1311 funding in state partnership marketplaces and in states with federally facilitated marketplaces, the other addressing the use of such funding in consumer partnership marketplaces. The third FAQ is simply titled “Frequently Asked Questions on Health Insurance Marketplaces,” but primarily deals with enforcement, reporting, and administration requirements. (Since HHS seems irrevocably committed to the unfortunate term “marketplace,” I am going to try to use the term from now on, rather than "exchange," in these posts.)

Section 1311 of the ACA establishes the marketplaces. It also appropriates an unspecified amount of funding, to be determined by the Secretary of HHS, to make awards to the states as necessary to establish the exchanges. HHS has issued more than $3.5 billion in establishment grants to date. Section 1311 is one of the few uncapped sources of implementation funding available to the agencies, which are otherwise being starved by Congress of necessary ACA appropriations.]]> http://healthaffairs.org/blog/2013/05/15/implementing-health-reform-more-guidance-on-health-insurance-marketplaces/feed/ 0 http://healthaffairs.org/blog/2013/05/14/why-medicare-for-all-is-not-the-answer/?utm_source=rss&utm_medium=rss&utm_campaign=why-medicare-for-all-is-not-the-answer http://healthaffairs.org/blog/2013/05/14/why-medicare-for-all-is-not-the-answer/#comments Tue, 14 May 2013 20:53:00 +0000 Dana Goldman http://healthaffairs.org/blog/?p=31171 Paul Krugman and Robert Reich -- to argue that the best approach would be to extend Medicare to everyone. A January National Research Council report on the relative disadvantage of America in global health outcomes, especially compared to countries with national health insurance, added further fuel to the fire. But is a larger government role in health insurance the best approach?

The idea of universal Medicare is powerful and attractive. Mr. Krugman points out that in the last forty years, average Medicare costs per person have grown by 400 percent while those for private insurance have increased more than 700 percent. His numbers suggest that if everyone had Medicare for the last 40 years, we might now spend only 14 percent of GDP on health care instead of nearly 18 percent, while also reaching universal coverage. Mr. Reich argues that “Medicare-for-All” would save between $58 billion and $400 billion annually, and similarly concludes: “Medicare isn’t the problem. It’s the solution.” Critics of the U.S. system are also quick to point out that Americans don’t live as long as their counterparts in countries that spend much less, suggesting universal Medicare could save money and improve our health.

The argument for universal Medicare basically comes down to three key claims: (1) Medicare gets lower prices, (2) Medicare’s administrative costs are lower; and (3) Greater spending does not mean better health. Each of these deserves closer attention.]]> http://healthaffairs.org/blog/2013/05/14/why-medicare-for-all-is-not-the-answer/feed/ 6 http://healthaffairs.org/blog/2013/05/13/implementing-health-reform-medicaid-dsh-payments-utah-exchanges-and-more/?utm_source=rss&utm_medium=rss&utm_campaign=implementing-health-reform-medicaid-dsh-payments-utah-exchanges-and-more http://healthaffairs.org/blog/2013/05/13/implementing-health-reform-medicaid-dsh-payments-utah-exchanges-and-more/#comments Mon, 13 May 2013 22:06:29 +0000 Timothy Jost http://healthaffairs.org/blog/?p=31150 HHS proposed rule on Medicaid disproportionate share hospital payment reductions; an IRS notice of proposed rulemaking on medical loss ratios for Blue Cross and Blue Shield plans that receive certain tax preferences; and a set of frequently asked questions on the Utah SHOP exchange.

Medicaid DSH payments. The Department of Health and Human Services issued a proposed rule for cuts in disproportionate share hospital payments on May 13, 2013. The DSH program has since 1981 provided federal funding to state Medicaid programs to allow those programs to offer additional support to hospitals that serve a disproportionate share of low-income patients with special needs. The Medicaid DSH program, together with a similar Medicare program, has provided essential support to hospitals that have often borne the brunt of providing services to the uninsured.

With the Affordable Care Act’s expansion of coverage of the uninsured through the expanded Medicaid program and premium tax credits and cost-reduction payments, Congress concluded that DSH payments would be less necessary and cut both the Medicaid and Medicare programs. Since 1998, Medicaid DSH payments to each state have been limited to an annual allotment. The ACA requires reductions in these allotments, beginning with $500,000 for 2014 and increasing to $5.6 million for 2019, before dropping to $4 million of 2020. It also lists five factors that HHS must consider in reducing the state allotments. It does not specify, however, how those factors should be applied or weighted. The proposed rule addresses this question.]]> http://healthaffairs.org/blog/2013/05/13/implementing-health-reform-medicaid-dsh-payments-utah-exchanges-and-more/feed/ 2