Health Affairs

On May 9, 2012, the Center for Medicare and Medicaid Services released proposed regulations to implement section 1202 of the Health Care and Education Reform Act of 2010. Section 1202 increases Medicaid payments made to primary care physicians for primary care services during the years 2013 and 2014 to Medicare payment rates, with the additional cost covered by the federal government.

State Medicaid programs almost universally pay physicians lower rates than does Medicare (and much lower rates than private insurers).  In one recent year, state Medicaid payments to primary care physicians averaged 2/3 of Medicare rates, with some states paying as little as 36 percent of Medicare rates.  Many primary care physicians refuse to accept new Medicaid patients (or indeed any Medicaid patients), and low payment rates are undoubtedly one of the reasons why.

The Affordable Care Act’s expansion of Medicaid coverage to all adults with incomes below 138 percent of the poverty level, however, is going to dramatically increase the need for primary care physicians willing to accept Medicaid patients.  Congress increased Medicaid primary care payment rates temporarily for 2013 and 2014 to address this need. Read the rest of this entry »

If one were to try and identify what issue has most roiled the biomedical community in the past few months it is surely the effort to censor two papers describing genetic modifications of the H5N1 flu virus.

Background.  Last December, the U.S. National Science Advisory Board for Biosecurity (NSABB) was asked by the U.S. National Institutes of Health to look at two NIH-funded studies.  Both involved experiments in which scientists in the U.S. and the Netherlands showed that a form of the potentially deadly H5N1 influenza virus could be genetically tweaked so as to create a nastier, more lethal version, and one that could more easily cause airborne transmission between ferrets.  The ferret is an animal beloved of vaccine researchers partly for historical reasons but mainly because it sneezes; most vaccine experts agree that what can be transmitted through particles in the air between ferrets is very, very likely to be transmissible among humans.  High transmissibility between humans of a nasty version of pandemic flu could mean that someone could, alerted to the techniques used by the American and the Dutch research groups, create a highly contagious and lethal form of flu and put it to terroristic purposes. Read the rest of this entry »

A recent spate of commentaries on the continuing health spending moderation raise an important policy question:  If the cost curve is well and truly bent, why are we investing so much of our policy energy on bending it further, when the more pressing problem is the declining percentage of Americans that can afford our health system’s astronomical costs?

Health spending the past two reported years (2009 and 2010) have grown in the high 3 percent range, the lowest growth rates since Dwight Eisenhower’s last year in office (1960), five years before Medicare. Medicare’s actuaries have pointed to the recession as a root cause.  Yet even Medicare spending growth has subsided to about 5 percent in 2010, a development hard to attribute to recession since so few Medicare patients have first-dollar cost exposure. This analyst’s extensive industry contacts suggest no spending rebound in 2011 and 2012, despite an aging population and fee-for-service’s pernicious volume-increasing incentives in full force. Read the rest of this entry »

In this post, we put forth a social compact intended to define the reciprocal obligations of health care professionals, patients and society that are necessary to achieve truly patient-centered, team-based care.  The compact and recommendations were developed from a working group formed at the March 2010 invitational conference co-sponsored by the American Board of Internal Medicine Foundation (ABIMF) and the American Academy of Nursing (AAN).  These groups and the conference invitees represent constituencies crucial to implementing team-based care.  The recommended compact moves beyond most of the writings about team-based care by the explicit inclusion of principles related to the patient and family as central members of the team.

Interprofessional team-based care is gaining momentum as a strategy to improve outcomes, continuity and effectiveness of health care from primary care to acute, hospital-based tertiary settings.  This renewed interest and emphasis on interprofessional collaboration has its roots in several documents from an earlier era of health care reform.  Over a decade ago, the Tavistock Group put forth shared ethical principles for health care that emphasized rights and responsibilities of both health care professionals and patients in shaping care.  Shortly thereafter, the Institute of Medicine challenged the health professions to put patients at the center and in control of their health care.

More recently, the World Health Organization (WHO) reaffirmed its support for team-based care that puts patients in the center of care in order to achieve true primary health care in any nation.  WHO further asserts that every health care worker should be prepared to participate as a full member of teams, a position affirmed by the Interprofessional Education Collaborative Expert Panel. Despite this growing momentum for team-based, patient-centered care, we have not achieved it, nor have we achieved true control by patients of their health care. Read the rest of this entry »

Editor’s note: For more on Rick Brown’s life and work, see Chris Hafner-Eaton’s Health Affairs Blog post and Lee-Lee Prina’s post on Health Affairs’ GrantWatch Blog.

E. Richard (Rick) Brown, a nationally recognized public health leader who advocated for health care reform and pioneered the collection and broad dissemination of health survey data to influence policy, died Friday, April 20. Rick was 70 at the time of his death, and passed away shortly after moderating a session at the Keeneland Conference Center in Kentucky on the critical role of state and local health surveys. Throughout his life, Rick looked for ways to build bridges between the most underserved Americans and the people who were supposed to help them – lawmakers, academics, and advocates. For Rick, helping people was always a deeply personal mission.

As a past president of the American Public Health Association, a member of dozens of health advisory committees and boards, and through his work for two U.S. Presidents – Clinton and Obama – and several U.S. Senators — Bob Kerrey, Bill Bradley, Paul Wellstone, and Al Franken — Rick forged a reputation for his intense determination to make health care services more accessible and more affordable to all Americans. He was a tireless advocate for the uninsured, and promoted the development of health data surveys to both dispel persistent myths about the uninsured and document the devastating consequences of the chronic lack of health insurance for millions of Americans.

Rick’s career was based in academia, and he achieved significant success within the academic community. He received his bachelor’s, master’s, and doctoral degrees at UC Berkeley, and was a professor in the Departments of Health Services and Community Health Sciences in the UCLA Fielding School of Public Health for the past 33 years. He was the founding director of the UCLA Center for Health Policy Research, which he established in 1994 to translate academic research into practical evidence that policy audiences and community health organization could use in their work.  Central to this vision was the concept of credible and comprehensive data that could make a non-partisan case for policies and programs that could improve the health and well-being of all Californians and the nation. Read the rest of this entry »

Editor’s note: For more on Rick Brown’s life and work, see Gerald Kominski’s Health Affairs Blog post and Lee-Lee Prina’s post on Health Affairs’ GrantWatch Blog.

I humbly write what cathartically emanates from me regarding UCLA’s Dr. E. Richard Brown, who passed away on April 20, 2012. Rick Brown, as he was known to most of us, expressed truly important, yet difficult social justice concepts in way that almost soothed the soul with heartfelt logic…leaving one with seedlings of ideas that each person could nurture, own and embrace as change for the betterment of humankind.

What can one say about a person who profoundly and fundamentally shaped a young person into a professional? Moreover, what right does one person, an early mentee nonetheless, have to even attempt this when the mentor was such a visionary and giving, yet principled and strong entity who touched not just hundreds, or thousands, but perhaps millions of lives?

Hopefully, my sharing will bring forth sides that others are feeling. To hold Rick in our hearts and propel our Public Health purpose forward, I write this at the request of several who stated that they wanted to be able to hold these stories that brought tears of joy to their eyes as I retold just a few of many moments with Rick Brown. It is my intent to honestly honor not only a great man, but his family, of blood relatives and those who became part of the Public Health family to which he committed his life. Read the rest of this entry »

Planned and unplanned disruptions in production of drugs are behind an overwhelming share of drug shortages.  Stockpiling the finished product has been proposed as a solution for preventing future shortages.  The general idea is that the federal government would purchase and stockpile select drugs, just as it does with vaccines and anti-bioterrorism agents.  This would counterbalance the relatively low inventory levels currently in distribution channels.  In contrast to how Medicare participates in the sterile injectable drug market, where it pays providers rather than manufacturers, here the government would purchase the drugs directly from manufacturers.

Presumably a stockpile could permanently lift the demand for these drugs if the government were to pay prices higher than the going market rate and/or the government were to buy additional drugs above and beyond those purchased by healthcare providers and patients.  By increasing demand for the target drugs, a stockpile would theoretically increase incentives for manufacturers to expand production capacity, thereby reducing the likelihood of a shortage.  And if a drug shortage were to occur, the federal government would release the stockpiled drug for use by the general public.

This concept is appealing for its presumed simplicity and also for the fact that it builds on an existing and well-accepted blueprint with the existing federal government’s Strategic National Stockpile of vaccines and bioterrorism agents.  However, setting up a stockpile that will effectively help address future drug shortages is not feasible in the current fiscal and political environment.  Here’s why. Read the rest of this entry »

If, as suggested in the April Health Affairs article by Andrew Ryan and coauthors, the Premier/Medicare Hospital Quality Incentive Demonstration (HQID) program failed to achieve its goals, we can only hope that all subsequent demonstration projects fail so successfully.

The fact is HQID showed that the combination of rewarding performance improvement and providing transparency of results drives improvement further and faster. Implying otherwise is misleading.

HQID, which ran from 2003-2009, was designed to test whether incentives would improve care processes and a limited number of outcomes in hospitals beyond what was possible with public reporting alone. Based on dramatic improvements documented in exhibits 1-3 of the article, even the authors would have to admit HQID achieved this goal. Read the rest of this entry »

Whether Medicare Advantage plans should be paid more than traditional Medicare has long been an issue of debate. In the Patient Protection and Affordable Care Act of 2010, Congress voted to narrow the difference in payments between the two programs from 2012-2017, with some offsets based on quality bonuses for plans with higher quality scores. The Administration used its demonstration authority to expand and move forward quality incentives, providing particularly large offsets to payment reductions in 2012.

In an article last week anticipating the release of a GAO report critical of the demonstration, the New York Times termed the $8 billion spent on it “costly waste”.  The Medicare Payment Advisory Commission, a nonpartisan body advising Congress and a critic of using demonstration authority so broadly, says that the bonus program will apply to plans with 93 percent of MA enrollees, versus 25 percent under the legislated program.

Despite GAO’s recommendation to the contrary, CMS’s quality bonuses are part of the 2012 Medicare Advantage marketplace, where they are embedded in Medicare Advantage contracts that are negotiated far in advance and define the benefits and premiums available to Medicare Advantage enrollees. Even if reversal were possible in 2012, such change seems unlikely, as this would be highly disruptive for the program and beneficiaries even though, according to GAO, 2012 is when the extra funding has the largest effect on rates. Certainly the amount of funding the demonstration made available got the attention of firms that now factor quality scores into their Medicare Advantage strategy. Read the rest of this entry »

Editor’s note: You can hear Amy Berman discuss her April Health Affairs Narrative Matters essay at the recent release event for the April issue. You can also join Amy tomorrow (May 1) at noon for live online chat hosted by the Washington Post, which will also be publishing an abridged version of her essay. In addition, Amy appeared with Diane Meier, the author of this blog post, on a recent edition of the Diane Rehm show.

Amy Berman’s story in Narrative Matters describes the experience of a perfectly healthy professional faced with a new diagnosis of inflammatory breast cancer. Inflammatory breast cancer is a rare subtype, and, as a result, there are few studies to guide treatment. Amy has Stage 4 inflammatory breast cancer that has spread to her bones — a feared diagnosis with no great treatment options.

Because Amy is a medical professional she knows the consequences of toxic chemotherapy, surgery, and radiation, and she knows that there is a good probability that none of these therapies will make much difference to her long-term survival outcomes. They will, however, make her quite sick and miserable.  So she made a logical and common-sense decision to preserve her quality of life, while at the same time pursuing disease-modifying options (hormone therapy and bisphosphonates to protect her skeleton) with tolerable side-effect profiles.

Eighteen months after diagnosis, Amy looks great, feels great, and is working full time. Her tumor markers are normal, and flat. There is nothing wrong with this picture. The oddest thing about Amy Berman’s story is that it is unusual.  So why is Amy’s decision so rare? Read the rest of this entry »