From The Staff

Medicaid Expansion Post Leads Health Affairs Blog 2014 Top-Fifteen List

January 8th, 2015

As we begin 2015, we present the fifteen most-read Health Affairs Blog posts from 2014. Topping the list is “Opting Out Of Medicaid Expansion: The Health And Financial Impacts,” by Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhander. “Low-income adults in states that have opted out of Medicaid expansion will forego gains in access to care, financial well-being, physical and mental health, and longevity that would be expected with expanded Medicaid coverage,” the authors write, and they offer a state-by-state projection of these consequences.

Next on the list is Susan DeVore‘s overview of health care trends to watch in 2014, followed by David Muhlestein‘s look at the likely growth of accountable care and an examination of declining inpatient hospital utilization by Robert York, Kenneth Kaufman, and Mark Grube. The list also includes two posts from Tim Jost’s comprehensive series on implementing the Affordable Care Act, on waiting periods for employer-sponsored health insurance and Medicaid asset rules.

Stay tuned for the 2014 most-read lists for Health Affairs journal and GrantWatch Blog.

The full top-fifteen list is below: Read the rest of this entry »

Health Affairs’ January Issue: Aging And Health

January 5th, 2015

The January issue of Health Affairs includes a number of studies examining issues pertaining to aging and health or health care. Other subjects covered include: the effect of Medicare’s Hospital Compare quality reports on hospital prices; how the Affordable Care Act’s provisions impact Americans shouldering high medical cost burdens; and whether California’s Hospital Fair Pricing Act has benefited uninsured patients.

Content on aging and health was supported by the John A. Hartford Foundation. Read the rest of this entry »

Exhibit Of The Month: Federal Health Spending On Children

January 5th, 2015

Editor’s note: This post is part of an ongoing “Exhibit of the Monthseries. Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

As we begin the new year and look forward to the release of our January issue later today, we also take a look back at the “exhibit of the month” from our December thematic issue on children’s health. The exhibit, from the article, “The Scheduled Squeeze On Children’s Programs: Tracking The Implications Of Projected Federal Spending Patterns,” looks at health spending on children as a percentage of total federal spending on children from 1960 to 2013. Read the rest of this entry »

New On GrantWatch Blog

December 31st, 2014

Health Affairs GrantWatch Blog brings you news and views of what foundations are funding in health policy and health care.

Here are the most recent posts: Read the rest of this entry »

Sovaldi, Harvoni Payment Issues Lead Health Affairs Blog November Most-Read List

December 24th, 2014

A piece by Laura Fegraus and Murray Ross on the challenges of paying for lifesaving but high-priced drugs like Sovaldi and Harvoni was the most-read Health Affairs Blog post for November. This was followed by a critical analysis of workplace wellness programs from Al Lewis, Vik Khanna, and Shana Montrose.

Next came a post on the 2016 Notice of Benefit and Payment Parameters Proposed Rule from Tim Jost, and then a look at health care policy after the mid-term elections from James Capretta.

The full top-ten list for November is below: Read the rest of this entry »

Narrative Matters: Child Welfare In Indian Country

December 24th, 2014

In the December Health Affairs Narrative Matters essay, a member of the Seneca Nation and a Lakota youth call for equitable child welfare for American Indians and Alaska Natives. Terry Cross’ article is freely available to all readers, or you can listen to the podcast.

In addition, Cross spoke about the issue of Native children in foster care at the recent 2014 Narrative Matters Symposium on “Vulnerable Children: Using Stories to Shine a Light on Child Health.”

Read the rest of this entry »

The Latest Health Wonk Review

December 23rd, 2014

Last Thursday, Julie Ferguson at Workers’ Comp Insider published the “holiday edition” of the Health Wonk Review. Her merry band of posts include a two-part Health Affairs Blog essay on payment reform by our very own editor-in-chief Alan WeilRead the rest of this entry »

New Health Policy Brief: Reenrollment

December 22nd, 2014

This year open enrollment under the Affordable Care Act (ACA) began on November 15, allowing new customers to sign up for health insurance. Open enrollment also provided current policyholders the chance to change plans and request a redetermination on the amount of subsidy they received. During this second year of open enrollment for the ACA’s insurance Marketplaces, insurers and policy makers are working to keep last year’s enrollees in the system — and the Department of Health and Human Services (HHS) estimates that 95 percent of them are eligible for automatic renewal.

A new policy brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) examines the pros and cons of reenrollment options for consumers, whether they are using the federal Marketplace or live in states that operate their own exchanges. Automatic reenrollment means that almost seven million people already enrolled will not necessarily need to flood and exchanges during open enrollment. On the other hand, it also may discourage consumers from exploring alternative coverage that might better fit their needs and getting a more accurate determination of eligibility for subsidies. Read the rest of this entry »

New Findings About The ACA’s Impact On Employer-Sponsored Health Insurance

December 19th, 2014

Since the Affordable Care Act (ACA) was signed into law, some of its critics have predicted that businesses would discontinue offering employer-sponsored health insurance, moving employees into the individual Marketplaces. If widespread dropping of employer-sponsored health insurance were to occur, government costs could increase since many low-wage workers would qualify for federal subsidies in the Marketplaces.

A new study, released today as a Web First by Health Affairs, examines data from the Health Reform Monitoring Survey for June 2013 through September 2014, assessing any early changes of employer-sponsored insurance under the ACA. Authors Fredric Blavin, Adele Shartzer, Sharon Long, and John Holahan report that the percentage of workers with employer offers for health insurance was basically unchanged between June 2013 and September 2014: 82.7 percent versus 82.2 percent. The authors are all affiliated with the Health Policy Center at the Urban Institute, in Washington, D.C.  Read the rest of this entry »

Request For Abstracts: Health Affairs Non-Communicable Disease Theme Issue

December 19th, 2014

Health Affairs is planning a theme issue on non-communicable diseases (NCDs) in September 2015. The issue will present work that describes the burden of NCDs, approaches to prevention and treatment of NCDs, and analysis of policies and initiatives aimed at prevention and treatment. The issue will have a global perspective.

We invite interested authors to submit abstracts for consideration for this issue.

We are using a broad definition of NCDs to include cancer, cardiovascular disease, respiratory illness, diabetes, mental illness, and the like. The issue will not focus on injuries, per se, but will address disability as an element of the disease burden of NCDs.

We plan to publish 15-20 peer-reviewed articles including research, analyses, and commentaries from leading researchers and scholars, analysts, industry experts, and health and health care stakeholders. Some papers will provide an overview of an issue relevant to NCDs, but we are particularly interested in empirical analyses of specific policies, care models, and other approaches to addressing NCDs. All papers must focus on issues of interest to public policy makers and private leaders in health care and related sectors. Read the rest of this entry »

Contributing Voices

Early Evidence On Medicare ACOs And Next Steps For The Medicare ACO Program (Updated)

January 22nd, 2015

Note: Pratyusha Katikaneni and Carmen Diaz also contributed to this post. They are both research assistants at the Engelberg Center for Health Care Reform, The Brookings Institution.

January 23 update comparing this analysis to one by Scott Heiser, Carrie Colla, and Elliott Fisher: Yesterday, Health Affairs Blog published two analyses of Medicare ACO results, one by Scott Heiser and colleagues and one by us (below). These analyses should be viewed as complementary.

In their post, Heiser and colleagues note a greater likelihood of early financial success (i.e., qualifying for shared savings) in relatively high-cost areas of the country. They reach this conclusion by linking each ACO to their hospital referral region (HRR) and finding a significant relationship with early shared savings. They conclude that ACOs in higher cost regions are more likely to begin the program with a higher benchmark relative to costs, making it easier to attain shared savings.

Our analysis focuses on the specific benchmark for each ACO (not the regional cost) and also concludes that there is a statistically significant correlation between ACOs with higher financial benchmarks and their total savings. However, we note that the beginning financial benchmark explains less than 10 percent of the variation in early financial performance, and note that there are many successful ACOs in lower-cost areas as well.

The results of the two analyses are not contradictory, but rather reflect that while historical spending matters in early success, many other factors matter as well.

Original post: On December 1, CMS released a Notice of Proposed Rulemaking (NPRM) for the Medicare Shared Savings Program (MSSP), which requests feedback for changes CMS is considering for the Medicare accountable care organization (ACO) programs in 2016 and beyond. The proposal suggests significant potential alterations to the program, many of which we recently reviewed, that would address major issues that ACOs and others have raised: uncertainty and inexperience at transitioning to increasing levels of risk, lack of timely and accurate data, changes in attributed patient populations from year-to-year, and financial benchmarks that fail to account for regional variations and continue to reward high ACO performance over time. Read the rest of this entry »

Unpacking The Medicare Shared Savings Proposed Rule: Geography And Policy

January 22nd, 2015

The Centers for Medicare and Medicaid Services (CMS) recently announced a Notice of Proposed Rulemaking (NPRM) for Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs). The rulemaking contains several proposals that if enacted, would fundamentally change the underlying incentives for providers to participate in the program. These proposed reforms address issues such as data sharing, renewals of participation agreements, beneficiary attribution, incentives to move to two-sided risk, and lastly, reforms to the benchmark calculations against which ACOs compete to earn savings.

The NPRM comes on the heels of a September 16, 2014 release of performance results for MSSP ACOs that began their performance years by 2013. Under the current program rules, ACOs that successfully reported quality performance data and whose savings exceeded their “minimum savings rate” were eligible to share in savings with Medicare. The MSSP program allows ACOs to choose either one-sided risk (Track 1, only upside potential to earn savings) or two-sided risk (Track 2, both upside and downside potential to earn savings/incur losses) with the final sharing amount based on achieving quality targets (up to 50 percent for Track 1 and 60 percent for Track 2). A vast majority of ACOs enrolled in Track 1, the one-sided risk option. Of the 220 ACOs in the program that participated in the first performance year, 53 earned shared savings, 52 saved money but not enough to meet the required “minimum savings rates,” and the other 115 did not accrue savings (spending on patients assigned to the ACO was greater than projected).

In February 2014, the CMS asked stakeholders for input as to how to improve its ACO programs, feedback which they used to generate the NPRM. Many ACOs and other stakeholders argued that failures to achieve savings over and above minimum savings rates were a partial result of residing in low spending areas. In this post, we examine the merits of this contention and consider the policy implications of our results and their bearing on some of the modifications of the MSSP program that CMS has proposed.

We also discuss other strategies for improving the program CMS did not mention in the NPRM. Read the rest of this entry »

Last Year Was A Wild One For Health Law — What’s On The Docket For 2015?

January 22nd, 2015

Everywhere we look, we see the tremendous impact of new legal developments—whether regulatory or statutory, federal or state—on health and health care. These topics range from insurance to intellectual property to religion to professionalism to civil rights. They remain among the most important questions facing Americans today.

This post is the first in a series that will stem from the Third Annual Health Law Year in P/Review event to be held at Harvard Law School on Friday, January 30, 2015. The conference, which is free and open to the public, brings together leading experts to review major developments in health law over the previous year, and preview what is to come.

The event is sponsored by the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard Law School and the New England Journal of Medicine, and co-sponsored by Health Affairs, The Hastings Center, and the Center for Bioethics at Harvard Medical School. Below, we will highlight a few themes that have emerged so far. The conference’s speakers will author a series of posts that follow on more specific topics. Read the rest of this entry »

Academic Medical Centers Should Lead The Charge On Price Transparency

January 21st, 2015

A bipartisan campaign to increase price transparency in the medical world has been reverberating through the press, government, and hospitals. Recent examples include CMS’ release of datasets for inpatient and outpatient charges and North Carolina’s House Bill 834, which was signed into law on August 21, 2013 and mandates that the state’s Department of Health and Human Services publish hospital charges. In Time Magazine, Steven Brill’s article, “Bitter Pill,” provided stunning real world examples of how the lack of price transparency can create enormous uncertainty and confusion among both patients and providers.

The momentum will only continue as Section 2718(e) of the Affordable Care Act is implemented. The provision, which took effect on October 1, 2014, mandates that each hospital establish, update, and publicize a list of standard charges for items and services provided. At this critical moment, there is one set of institutions that are uniquely positioned to ensure that price transparency is implemented deliberately and successfully: Academic Medical Centers.

For good reason, there is excitement about the potential of the price transparency movement. A recent Health Affairs study by Wu et al. suggests that when patients have access to health care prices for an intervention such as an MRI, a significant number select the lower-price option. This proof of concept shows that price transparency has the potential to lead to competition between hospitals, thus reducing costs to the patient and health care system. Read the rest of this entry »

Moving From Mandate To Reality: A Roadmap For Patient And Family Engagement

January 20th, 2015

The 2010 Affordable Care Act (ACA) moved patient and family engagement to center stage in health care reform. The law mentions “patient-centered care” at least 40 times, with explicit references to patient engagement, patient experience, health literacy and shared decision making. Evidence is growing that meaningful patient and family engagement can help achieve the triple aim of better quality, better outcomes and lower health care costs and substantially reduce preventable harm.

Yet, despite these advances, the full promise of engagement remains mostly untapped, and much confusion remains about what constitutes meaningful patient and family engagement, and importantly, how to translate this evidence broadly into routine health care practice. Read the rest of this entry »

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. Read the rest of this entry »

The Payment Reform Landscape: Drilling Down

January 15th, 2015

Catalyst for Payment Reform’s 2014 National Scorecard on Payment Reform revealed a dramatic jump in the percent of commercial health care payments that is value-oriented, meaning the payments are tied to the quality of care in some way. In last year’s Scorecard, commercial health plans reported 40 percent of payments were value-oriented, up from just 11 percent in 2013. So on the face of it, as the “health care payment reform arms race” continues among commercial health plans, we’re well on our way to a reformed approach to payment.

But we can’t jump for joy or shout from the rooftops just yet. As I shared in my December blog, we’ve learned not all payment reform models are created equal, and a lot of the jump can be explained by an increase in pay-for-performance — not the most ambitious model when it comes to reining in costs. Meanwhile, there was a very sluggish uptick in the use of models that place providers at financial risk (such as shared risk payment arrangements for ACOs). Moreover, while the National Scorecard tells us how plans are paying for care, it cannot answer other lingering questions: Which models should purchasers adopt if they want the best savings and improvements in care? Which models are spreadable and scalable so a broader swath of the population can reap their benefits?

Since Catalyst for Payment Reform (CPR) works on behalf of large employers and other big health care purchasers, we field these kinds of questions frequently. Unfortunately, there are no easy answers. And we often find ourselves stuck at a crossroads. Purchasers say they want payment reform, and they attempt to spell out what they want and need. Health plans work to build it, but often the purchasers don’t come, saying it’s not what they asked for, or citing concerns about return on investment and scalability. Plan leaders, who think they understood the “specs” and tried to deliver, become frustrated. Over time they can become reluctant to get creative. Purchasers can become jaded and start to wonder if the plans just don’t understand their needs. Read the rest of this entry »

How Policy Makers In Emerging Health Systems Can Advance Innovative Care For The Chronically Ill

January 15th, 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 or follow @HCMatColumbia.

Discussions of innovation in health care often focus on new technologies, big data, and refined population health strategies within the context of mature Western health care systems. But innovation is just as important, with perhaps greater impact, in evolving systems where more foundational opportunities exist to deliver affordable, quality care to the most expensive and challenging patients: those with chronic illnesses. In that context, public policy and regulation can spur innovation. Read the rest of this entry »

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. Read the rest of this entry »

Implementing Health Reform: FAQs On Taxes And The ACA (January 24 Update)

January 13th, 2015

Update, January 24, Multi-State Plan Program and Enrollment Snapshot:  On January 22, 2015, the Office of Personnel Management (OPM) issued it’s draft Multi-State Plan (MSP) Program Issuer Letter for 2016.  The draft letter notes that in 2014, the MSP Program offered more than 150 plan options in 30 states and the District of Columbia and covered approximately 371,000 individuals.  For 2015 the MSP Program offers more than 200 plans in 35 states.

The draft letter is brief, and refers interested parties to the proposed rule issued by OPM for the MSP in November of 2014 for greater program detail.  The letter specifically notes two program requirements imposed by the ACA: MSP Program plans must use the MSP Program external review process; and MSP Program insurers must offer at least one gold and one silver plan that do not cover abortions, except “where a pregnancy is the result of rape or incest, or for a pregnancy which, as certified by a physician, places the woman in danger of death unless an abortion is performed.”  This is the standard for abortions that can be funded with federal funds at this time.  Whether or not a particular MSP Program plan covers abortion must be disclosed in the plan Statement of Benefits and in all MSP documents.

On January 21, 2015, the Centers for Medicare and Medicaid released their enrollment snapshot for week nine of the 2015 open enrollment period, covering January 10 to 16.  During that week, over 400,000 individuals selected plans through the federally facilitated marketplace, bringing total plan selections through the FFM to 7,156,691.  Charles Gaba now estimates total enrollment in the marketplaces at 9.75 million with a month of open enrollment to go.

Update on ACA-related tax issues, January 22. The Internal Revenue Service has recently issued two releases relating to the implementation of the Affordable Care Act.  First, Revenue Procedure 2015-15 establishes the monthly national average premium for a bronze plan offered through the exchanges for 2015 at $207 for an individual, $1035 for a family of five or more.  This figure determines the maximum shared responsibility payment that will be owed by an individual or family — for failing to obtain minimum essential coverage or qualify for an exemption for a month in 2015 — if the individual or family is required to pay a penalty based on the 2-percent-of-income-above-the-filing-limit method.

The basic flat-dollar individual responsibility penalty for 2015 is $325 per adult, half that per child up to a maximum of $975 per family.  However, higher-income individuals or families must pay 2 percent of their household income above the filing limit if that amount exceeds the flat dollar amount.  The 2015 amount is marginally higher than the maximum penalty for 2014 or $204 per month per individual or $1020 for families of five or more.  The maximum annual payment for 2015 will be $2484 for an individual or $12,420 for families of five or more.

The IRS has also released Notice 2015-8; this provides access to the small employer tax credit for small employers in the 84 of Iowa’s 99 counties in which no qualified health plans are available through the SHOP exchange in 2015.  Otherwise eligible small employers in these counties can access the tax credit for 2015 by purchasing coverage that would have qualified for the tax credit prior to 2014, when it first became obligatory that coverage be purchased through a SHOP exchange.  Small employers may, however, claim the tax credit for this coverage at the rate that became effective in 2014: 50 percent of the employer’s contribution (35 percent for nonprofits).  This relief is the same as that granted last year to small employers in certain counties in Washington and Wisconsin where SHOP exchange coverage was not available

Update, January 16: On January 16, 2015, CMS announced the availability of three important resources that will help individuals comply with their ACA tax filing obligations.  First, CMS is making available an online calculator that individuals can use to determine the lowest-cost bronze plan that was available to them in 2014.  An individual who claims an affordability exemption from the individual responsibility requirement has to establish that he or she could not have afforded a bronze plan for 8 percent or less of modified adjusted gross income.  The calculator will provide a determination of how much that plan would have cost.  A tax filer can — by entering his or her zip code, the age of all family members, and information on months of employer coverage for any family member — receive a cost figure for the lowest cost bronze plan.

A second calculator provides the cost of the second-lowest-cost silver plan available to an individual.     This cost will be needed for premium tax credit reconciliation if information on a 1095-A that a tax filer receives from a marketplace is incorrect because a tax filer who received a tax credit had an unreported change in his or her household (such as a baby born or a family member getting job-based coverage).  It will also be needed if a qualified health plan enrollee did not apply for or accept advance premium tax credits during 2014 but wants to claim a credit at tax filing time.  Finally, the cost of the second-lowest cost silver plan will be required by someone claiming an exemption from the individual responsibility requirement on the grounds that Marketplace coverage was unaffordable, as the cost figure is necessary to determine what premium tax credit would have been provided through the marketplace had the individual applied.

For this calculator the applicant will need zip code, age of each family member, and months during which a family member was covered or eligible for coverage outside the marketplace.  Brian Haile and I in an earlier post had urged that CMS provide these calculators, and we are pleased that they have done so.

In another tax-related matter, the IRS announced that free-file is now available for 2014.  Free-file makes free tax filing software from 14 tax software companies available to the 70 percent of Americans who earn $60,000 or less a year and makes free forms available to higher income filers.  For 2014, free-file has been designed to assist taxpayers in complying with the new ACA tax filing requirements.  ACA tax filing information is also available from the IRS.  CMS has also released a tax filing fact sheet.

Finally, on January 16, 2015, CMS released the final 2016 actuarial value calculator and AV methodology. This information will be needed for calculating the metal level of 2016 health plans.

Original post: In the next few days, consumers who enrolled in qualified health plans through the marketplaces in 2014 will begin receiving IRS form 1095-As from the marketplaces, be they the federally facilitated marketplaces (FFMs) or state-operated marketplaces.  The form 1095-A is the form that provides individuals who have enrolled in qualified health plans through the marketplaces the information they need to fill out form 8962, which in turn is the form enrollees will need to reconcile the advance premium tax credits (APTC) they received in 2014 with the premium tax credits they were actually entitled to.  The marketplace also reports the information on the 1095-A to the IRS.

On January 12, 2015, HHS released a series of frequently asked questions about the 1095-A at its REGTAP website, which are reviewed below. This post also briefly covers other ACA-related developments. Read the rest of this entry »

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