From The Staff

Exhibit Of The Month: More HIV Testing With Medicaid Expansion


March 28th, 2014
by Tracy Gnadinger

Editor’s note: This is the second post in the new “Exhibit of the Month” series. Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

This month’s exhibit examines the potential impact of the Affordable Care Act’s Medicaid expansion on HIV testing from 2013-2017, comparing a nationwide eligibility expansion with one limited to the eighteen states that had committed to expansion as of July 2013.

. Read the rest of this entry »

A March Madness Health Wonk Review


March 27th, 2014
by Chris Fleming

Welcome to the “March Madness” edition of the Health Wonk Review. The NCAA college basketball tournament seemed like a natural theme for a health care policy blog post: huge amounts of money floating around in ways that only sometimes correlate with performance, and head-to-head match-ups that can yield results no one expected (though in the tournament those unexpected results produce quicker and more certain changes than is often the case in health care).

We considered illustrating each blog post with pictures of a college basketball team from the author’s home state celebrating a championship, but we thought better of that after seeing this cautionary tale. So let’s get to the great collection of posts from our Wonkers. Read the rest of this entry »

Health Affairs Briefing: Long Reach Of Alzheimer’s Disease


March 26th, 2014
by Chris Fleming

Despite decades of effort, finding breakthrough treatments or a cure for Alzheimer’s has eluded researchers. In the April 2014 issue of Health Affairs, The Long Reach Of Alzheimer’s Disease, we explore the many subjects raised by the disease: the optimal care patients receive and the testing of new models, international comparisons of how the disease is treated, families’ end-of-life dilemmas, a new public-private research collaboration designed to produce improved treatments, and others.

Please join us on Wednesday, April 9, at W Hotel in Washington, DC, for a Health Affairs briefing where we will unveil the issue.  We are delighted to welcome Dr. Richard Hodes, director of the National Institute on Aging at the National Institutes of Health to deliver the Keynote.

WHEN:
Wednesday, April 9, 2014
8:30 a.m. – 12:30 p.m.

WHERE:
W Hotel Washington
515 15th Street NW, Washington, DC (Metro Center)
Great Room, Lower Level

 REGISTER ONLINE

Follow live Tweets from the briefing @HA_Events, and join in the conversation with the hashtag #HA_Alzheimers. Read the rest of this entry »

HA Web First: New Medicaid Recipients Healthier Than Pre-ACA Enrollees


March 26th, 2014
by Tracy Gnadinger

The Affordable Care Act (ACA) gives states the option of expanding Medicaid coverage to individuals and families with incomes of up to 138 percent of the federal poverty level. A new study, being released today as a Web First by Health Affairs, used simulation methods to compare nondisabled adults enrolled in Medicaid before the ACA with newly eligible adults and those previously eligible but not enrolled in the program.

According to the study’s analysis, both the newly eligible and those not previously enrolled were healthier than the pre-ACA Medicaid enrollees. Authors Steven Hill, Salam Abdus, Julie Hudson, and Thomas Selden found that the pattern of results was similar for physical and mental health. They also determined that in states not expanding Medicaid under the ACA, adults in the income range for the law’s Medicaid expansion were healthier than pre-ACA enrollees. Read the rest of this entry »

New Health Policy Brief: Transitioning To ICD-10


March 20th, 2014
by Tracy Gnadinger

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

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

The Latest Health Wonk Review


March 14th, 2014
by Chris Fleming

Brad Wright at Wright on Health offers this week’s edition of the Health Wonk Review. His “Mud Season Edition” is an entertaining read and includes a Health Affairs Blog post by Suzanne Delbanco on pay-for-performance. Read the rest of this entry »

Health Affairs Web First: Medicaid/Marketplace ‘Churning’ State-By-State


March 12th, 2014
by Tracy Gnadinger

The Affordable Care Act (ACA) requires almost all Americans to have health insurance. For most lower-income Americans, this means coverage through Medicaid, employer-sponsored insurance, or health exchanges, depending on their income and state of residence. Approximately half of all low-income, non-elderly Americans experience a change of income or family circumstance in a given year, which may result in an involuntary shift in how they are covered from health insurance purchased through an exchange to Medicaid — or vice versa. This process, called “churning,” could lead to both gaps in coverage and disruptions in the continuity of care.

A new study released today as a Web First by Health Affairs provides state-by-state estimates of churning. Using data from two Census Bureau sources — its 2008 Survey of Income and Program Participation, and American Community Surveys from 2009–2011 — Benjamin Sommers, John Graves, Katherine Swartz, and Sara Rosenbaum found that every state is likely to have significant numbers of residents whose eligibility changes over time: at least 40 percent of eligible adults over the course of twelve months. They observed that higher-income states and states with more generous Medicaid eligibility criteria in place before the ACA’s expansion experienced a higher rate of churning, although differences between states were small. (The authors’ analysis assumes that all states had expanded Medicaid under health reform. At the moment, twenty-five states and the District of Columbia have done so.) Read the rest of this entry »

Howard Koh To Keynote Health Affairs Briefing Tomorrow On ACA And HIV/AIDS


March 10th, 2014
by Chris Fleming

One of the least explored yet most important parts of the Affordable Care Act (ACA) are provisions that hold promise for addressing serious health care challenges facing the 1.1  million Americans who are living with HIV/AIDS — and others like them — most of whom are impoverished and uninsured.

Please join Health Affairs Founding Editor John Iglehart on Tuesday, March 11, in Washington, DC, for a Health Affairs briefing on our March issue where we will spotlight topics related to the ACA and people with HIV/AIDS. The briefing will be keynoted by Howard Koh, Assistant Secretary for Health, U.S. Department of Health and Human Services.

WHEN:
Tuesday, March 11, 2014
9:00 a.m. – Noon

WHERE:
National Press Club
529 14th Street NW, Washington, DC, 13th Floor (Metro Center)

REGISTER ONLINE

Follow live Tweets from the briefing @HA_Events, and join in the conversation with the hashtag #HA_HIVAIDS Read the rest of this entry »

New Health Policy Brief: Geographic Variation In Medicare Spending


March 6th, 2014
by Tracy Gnadinger

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation describes geographic variation in Medicare spending. Data from the Centers for Medicare and Medicaid Services (CMS) show that in 2012 Medicare spent an average of $9,503 nationally per beneficiary, ranging from $15,957 in Miami, Florida, to $6,569 in Grand Junction, Colorado.

This brief looks at the factors that may be driving these variations, including the amount Medicare pays for services, the health status of beneficiaries, the types of services provided to a region’s population, and whether the local spending patterns are consistent with the spending on patients with private insurance.

As policy makers continue to find ways to improve quality in health care and eliminate unnecessary spending, a better understanding of geographic variation in Medicare spending has the potential to help achieve the so-called Triple Aim: better health, better health care, and lower costs. Read the rest of this entry »

New Health Affairs: ACA’s Impact On Americans With HIV/AIDS And Jail-Involved Individuals


March 3rd, 2014
by Chris Fleming

Health Affairs’  March issue, released today, explores how the Affordable Care Act (ACA) could affect two key sectors of the population with unique public health needs—those living with HIV/AIDS and people who have recently cycled through local jails.

When it comes to HIV treatment, timing is everything. Dana Goldman of the University of Southern California and coauthors modeled HIV transmission and prevention based on when HIV-positive individuals started combination antiretroviral treatment (cART). They estimate that from 1996-2009, early treatment initiation in the US prevented 188,700 HIV cases and avoided $128 billion in life expectancy losses.

The authors highlight treatment at “very early” stages (when CD4 white blood cell counts are greater than 500, consistent with current treatment guidelines in the US) as responsible for four-fifths of prevented cases. Early treatment both reduces morbidity and mortality in people living with HIV/AIDS, and decreases the transmission of the disease to the uninfected. Goldman and coauthors conclude that early treatment has clear value for both HIV-positive and HIV-negative populations in the US. Read the rest of this entry »

Contributing Voices

Medicare Advantage Rolls On


April 11th, 2014
by Billy Wynne

Monday afternoon, the Centers for Medicare and Medicaid Services (CMS) released the final rates and other reimbursement policies for Medicare Advantage (MA) plans, referred to as the Final Call Letter. Once again, the Administration took pains to ameliorate planned cuts to MA, demonstrating the program’s increasing popularity with seniors and, by extension, its robust political strength.

For my money, we’ll look back at this year as the final hurdle the program jumped on its path to dominating the Medicare benefit for a generation to come. It’s already well on its way, covering 30 percent of Medicare beneficiaries and growing. So let’s take a quick tour of the MA program’s initially volatile history and the winning streak it’s been on of late, culminating with the breaks the Administration cut it this go round.

The past. First there was the growth and then precipitous decline of managed care in the 90s, a wave that the program – then called Medicare+Choice – rode alongside the commercial sector. Read the rest of this entry »

It’s Always Too Soon Until It’s Too Late: Advanced Care Planning With Alzheimer’s


April 10th, 2014
by Ellen Goodman

Editor’s note: This post is published in conjunction with the April issue of Health Affairs, which features a series of articles on Alzheimer’s disease.

I cannot write about Alzheimer’s disease without writing about my sister. For that matter, it is probably best to begin with the building where the word was first said to her. After all, my sister Jane was an architecture critic and buildings mattered to her, as did the urbanscape, and her whole vision of a people-centered city.

The building where she’d been diagnosed with “mild cognitive impairment” was a former military base now recycled into a labyrinth of medical offices, including the department where the people who clocked and studied—but could not curtail—the decline of her memory were lodged with their pencils and papers.

To get to the office, we had to drive into the imposing parking garage, take an elevator to the only floor where there was a bridge to the medical building, cross that bridge, then take a second elevator downstairs to register, get an electronic key, then ride upstairs again and find our way through a mysterious series of halls to the right door and unlock it.

This elaborate rite of passage never failed to strike me as a bizarre test in itself. Who designed this? What memory-impaired patient could remotely navigate this journey? Was this some sort of black humor, a way to triage those with or without the “executive function” to get there? Those with or without a caregiver who could lead her? Read the rest of this entry »

What’s Past Is Prologue: Making The Case For PET Beta-Amyloid Imaging Coverage


April 9th, 2014
by Dora Hughes

Editor’s note: This post is published in conjunction with the April issue of Health Affairs, which features a series of articles on Alzheimer’s disease.

In September of 2013, CMS issued its final decision memo that concluded positron emission tomography- amyloid beta (PET Aβ) imaging is “not reasonable or necessary”, finding “insufficient evidence” that use of this diagnostic tool would improve health outcomes for patients with dementia or neurodegenerative disease. As such, PET Aβ imaging to help diagnose Alzheimer’s disease (AD) is not a covered service for Medicare beneficiaries except for those enrolled in CMS-approved clinical trials.

CMS’ final decision underscores the emerging new paradigm for coverage decision-making, requiring innovators not only to demonstrate to FDA’s satisfaction that their products are effective, but also to prove to CMS and other payors that their use will improve clinical outcomes.  This paradigm will increase confidence in the value and health benefit of new technologies, although it will make the path to coverage more difficult and uncertain for diagnostic developers. Read the rest of this entry »

Accelerating Medicines Partnership: A New Public-Private Collaboration For Drug Discovery


April 8th, 2014
 
by Aaron Kesselheim and Yongtian Tan

Editor’s note: This post is published in conjunction with the April issue of Health Affairs, which explores the many subjects raised by Alzheimer’s disease including a new public-private research collaboration designed to produce improved treatments.

Earlier this year, the National Institutes of Health joined forces with ten major pharmaceutical companies and several nonprofit disease interest groups to create the Accelerating Medicines Partnership (AMP). With an integrated governance structure consisting of representatives from all partners, the AMP venture aims to combine public-private expertise and pooled resources to reduce the time and cost of developing biomarkers for therapeutic targets.

The initial capitalization is reported to be $230 million.  The AMP is the first national cross-sector partnership of its size and scale, and is the latest initiative in the drug development market to embrace open data exchange, encouraging collaboration over competition as pathways for promoting innovation.

The AMP management chose to focus on four diseases—Alzheimer’s disease, type 2 diabetes mellitus, rheumatoid arthritis, and systemic lupus erythematosus—in which there was solid knowledge about the underlying pathophysiology, a sufficient level of potential therapeutic targets open to pursuit, and a lack of substantial individual manufacturer commitment.  The latter criterion explains why more prevalent diseases such as cancer did not make the list. Read the rest of this entry »

Implementing Health Reform: Medicaid & CHIP February 2014 Report


April 5th, 2014
by Timothy Jost

On April 4, 2014, the Centers for Medicare and Medicaid Services released their Medicaid & CHIP February 2014 Monthly Applications, Eligibility Determinations, and Enrollment Report.   (Blog post here.)  For the first time, the February monthly report provides meaningful data on enrollment.

Like previous reports, the report gives the total number of applications received by all reporting state agencies (2,207,513) and total number of individuals determined eligible for Medicaid and CHIP by state agencies (2,249,120). For comparison, the numbers of applications is down from initial January reports (2,266,778), but the number of determinations is up (2,436,879).

As with previous reports, however, these numbers are subject to so many qualifications as to be little use for determining growth of the Medicaid program.  The data do not include numbers from New York and Washington, while Tennessee only reported CHIP data.  They are also very preliminary — the January determinations figure was revised upwards by about a fifth in February. Read the rest of this entry »

What The Affordable Care Act Means For Pregnant Inmates


April 4th, 2014
 
by Katy Kozhimannil and Rebecca Shlafer

Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health.

The Affordable Care Act (ACA) is anticipated to expand coverage to 44 million Americans. As John Iglehart noted in his introduction to the March issue of Health Affairs, expansion of Medicaid through the ACA will open an important door for a particularly vulnerable population – those who are cycling in and out of the criminal justice system.

Although Medicaid does not cover standard health care for inmates during incarceration, expansion of Medicaid to single and childless adults has meant that prisons and jails can start enrolling inmates (a substantial portion whom meet these criteria) so they are covered upon release.

The ACA also allows Medicaid to pay for inmates’ care for hospital stays longer than 24 hours. Such changes have important implications for a group of inmates that is not often the focus of health policy dialogue – incarcerated pregnant women.

A Particularly Vulnerable and Costly Group: Pregnant Prisoners

Nationwide, 75 percent of incarcerated women are of reproductive age, and about 6-10 percent of female prisoners are pregnant during their incarceration. Incarcerated women fare worse than incarcerated men, and their reproductive health care needs, including access to contraception and abortion services, often go unmet. Inmates who are pregnant face additional risks. Compared with similar women that are not incarcerated, pregnant inmates have more risk factors and worse birth outcomes, for both mothers and babies. Read the rest of this entry »

The Role Of Remote Care Management In Population Health


April 4th, 2014
by Alan Snell

Editor’s note: For more on this topic, see the February issue of Health Affairs, which features a series of articles on connected health. 

Remote care management (RCM) programs use telehealth technology to facilitate clinically driven, remote monitoring, care, and education of patients and are an absolute necessity for providers and payers striving to implement an effective population health management strategy. Historically, RCM programs have been viewed through a fee-for-service lens and, as a consequence, overlooked, because physicians would not be reimbursed for the time to monitor these patients outside the confines of their offices.

Yet the current shift to value-based care presents an imperative for health care providers to avoid costs by better managing the health of people with chronic conditions. This change will require more hands-on, effective support for patients that result in lasting behavior change.

Providers are working to keep the health of an individual from rapidly deteriorating once they develop a chronic condition(s). Two prominent barriers to providers’ efforts to keep their patients healthy are the providers’ intermittent contact with patients and limited access to clinical data. Remote care management addresses these barriers. Read the rest of this entry »

Clinical Nuance: Benefit Design Meets Behavioral Economics


April 3rd, 2014

On Capitol Hill, there’s a growing chorus of support from both sides of the aisle to move the focus of health care payment incentives from volume to value. Earlier this month, legislators introduced proposals that would have fixed the sustainable growth rate in Medicare, as well as made other changes, including allowing for clinical nuance in Medicare benefit designs. The Centers for Medicare and Medicaid Services, too, is embracing this trend, recently asking for partners in a demonstration project to used value-based arrangements in benefit design. These efforts of policymakers and agencies to innovate Medicare’s benefit design are crucial both for the health of seniors and to ensure value in the Medicare program.

The concept of clinical nuance, implemented using value-based insurance design (V-BID), is a key innovation already widely implemented in the private and public payers. It recognizes two important facts about the provision of medical care:  1) medical services differ in the amount of health produced, and 2) the clinical benefit derived from a medical service depends on who is using it, who is delivering the service, and where it is being delivered.

Today’s Medicare beneficiaries face little clinical nuance in their benefit structure. Medicare largely uses a “one-size-fits-all” structure that does not recognize that some treatments, drugs or tests are more important to health than others. Not only does it create inefficiencies in the health system, it can actually harm the health of beneficiaries. Read the rest of this entry »

The Manifest Destinies Of Managed Care And Palliative Care


April 2nd, 2014
 
by Richard Bernstein and Karol DiBello

Editor’s Note: This post is the sixth in a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on an upcoming volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.

Two unremitting forces are shaping changes in the U.S. health care system: (1) the graying of America or “silver tsunami,” in which 10,000 individuals are now turning age 65 each day and (2) the cost trends associated with caring for seniors and those with multiple chronic and often life-limiting conditions. Health care experts have identified palliative care and managed care as essential ways to address the special needs of an aging population and for providing care that can lower the rate of national health expenditures.

The complex set of clinical demands of this growing wave of Medicare members includes multimorbidity, frailty as well as functional and cognitive decline.  To effectively and cost-efficiently manage the needs of this population, Managed Care Organizations (MCOs) as well as other risk assuming entities must address the quality and cost of the most expensive segment of this group of seniors. Read the rest of this entry »

The Payment Reform Landscape: Price Transparency


April 2nd, 2014
by Suzanne Delbanco

Editor’s note: This is the third post in a Health Affairs Blog series on payment reform by Catalyst for Payment Reform Executive Director Suzanne Delbanco. The first two posts are available here and here.

Last week Catalyst for Payment Reform (CPR) and our partners at the Healthcare Incentives Improvement Institute (HCI3) released our second annual Report Card on State Price Transparency Laws. This year, we decided not to grade states on a curve and to place greater emphasis on the price information actually available to consumers—not just what is written in the law.

Forty-five states received an F in this year’s Report Card, but there were a couple of notable exceptions: Massachusetts and Maine. Each month in this blog, I’ve been sharing insights about payment reform and which models are proving to work, so this naturally raises the question: what is the relationship between payment reform and the success of state price transparency efforts?

At CPR, we like to say price transparency is one of the core building blocks of payment reform and a higher-value health care system. Purchasers and consumers need transparency for three primary reasons: (1) to help contain health care costs; (2) to inform consumers’ health care decisions as they assume greater financial responsibility; and, (3) to reduce unknown and unwarranted price variation in the system. Read the rest of this entry »

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