From The Staff

Health Affairs Forum: Graduate Medical Education Governance And Financing


August 29th, 2014

Please join us on Wednesday, September 10, for a Health Affairs forum to discuss, Graduate Medical Education That Meets the Nation’s Health Needs, a recent report from the Institute of Medicine (IOM) Committee on the Governance and Financing of Graduate Medical Education (GME). Health Affairs Founding Editor John Iglehart will host the event.

For the past two years, the committee – co-chaired by former CMS and HCFA administrators Donald Berwick and Gail Wilensky – conducted an independent review of the governing and financing of the GME system, and the report is a roadmap for policymakers for repairing and improving its deficiencies. The Health Affairs forum is one of the first opportunities interested parties will have to gather in a public setting to discuss and debate the committee’s proposals.

WHEN
Wednesday, September 10, 2014
9:00 a.m. – 12:00 p.m.

WHERE
National Press Club
529 14th Street NW
Washington, DC, 13th Floor

REGISTER NOW

Follow Live Tweets from the briefing @Health_Affairs, and join in the conversation with #HA_GME. Read the rest of this entry »

Exhibit Of The Month: Income-Related Disparities Associated With Negative Health Outcomes


August 29th, 2014

Editor’s note: This post is part of an ongoing “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.

Much is known about income-related disparities when it comes to preventative care and chronic conditions, but less so about the associations between poverty and negative health outcomes.

In “Geographic Clustering Of Diabetic Lower-Extremity Amputations In Low-Income Regions Of California,” published in the August issue of Health Affairs, authors Carl Stevens et al. identify diabetic amputation “hot spots” in low-income urban and rural areas of California (Exhibit 2).

Based on California data from 2009, they isolated 7,973 lower-extremity amputations in 6,828 adults with diabetes. They compare this to a corresponding map of poverty rates in the same region based on households who reported incomes below 200 percent of the poverty level (Exhibit 3). Read the rest of this entry »

Health Policy Brief: The Relative Contribution Of Multiple Determinants To Health Outcomes


August 22nd, 2014

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) examines factors that can contribute to health status. In the United States, less than 9 percent of health expenditures go to disease prevention, and there is little support for social services, such as programs for older adults, housing, and employment programs.

This brief focuses on “multiple determinant” studies that seek to quantify the relative influence of some of these factors on health. It is part of a larger project, supported by the Robert Wood Johnson Foundation, which aims to create a structure for conducting analyses that demonstrate the value of investments in nonclinical primary prevention and their impact on health care costs.

Read the rest of this entry »

Health Affairs Briefing: Advancing Global Health Policy


August 22nd, 2014

Please join us on Monday, September 8, when Health Affairs Editor-in-Chief Alan Weil will host a briefing to discuss our September 2014 thematic issue, “Advancing Global Health Policy.”  In an expansion of last year’s theme, “The ‘Triple Aim’ Goes Global,” we explore how developing and industrialized countries around the world are confronting challenges and learning from each other on three aims: cost, quality, and population health.

A highlight of the event will be a discussion of international health policy—led by Weil—featuring former CMS and FDA administrator and current Brookings Institution Senior Fellow Mark McClellan and Lord Ara Darzi, surgeon, scholar, and former UK Health Minister. Additional panels will look at how countries are transforming chronic care, lowering costs, and redesigning delivery systems.

WHEN: 
Monday, September 8, 2014
9:00 a.m. – 12:30 p.m.

WHERE: 
National Press Club
529 14th Street NW
Washington, DC, 13th Floor

REGISTER NOW!

Follow Live Tweets from the briefing @Health_Affairs, and join in the conversation with #HA_GlobalHealth. Read the rest of this entry »

The Latest Health Wonk Review


August 15th, 2014

At Wright on Health, Brad Wright offers some health policy insight in his August recess edition of the Health Wonk Review. Brad highlights the Health Affairs Blog post by Jon Kingsdale and Julia Lerche on the “one-two punch” threatening the ACA’s second open enrollment period, as well as a variety of other great posts.  Read the rest of this entry »

Health Affairs Web First: Small Medical Practices Had Fewer Preventable Hospital Admissions


August 14th, 2014

The Affordable Care Act and other federal policy initiatives have created incentives for smaller practices to consolidate into larger medical groups or be acquired by hospitals. It is often assumed that larger practices provide better care. However, a new study, recently released as a Web First by Health Affairs, showed unexpected results: Practices with 1-2 physicians had 33 percent fewer preventable hospital admissions than practices with 10-19 physicians.

This study, which used data from the National Study of Small and Medium-Sized Physician Practices (NSSMPP) and surveyed 1,745 physician practices between July 2007 and March 2009, is believed to be the first of its kind in the United States. The study sample was limited to practices where at least 60 percent of the physicians were primary care providers, cardiologists, endocrinologists, and pulmonologists. Read the rest of this entry »

New Health Policy Brief: Interoperability


August 13th, 2014

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) looks at the issue of health information exchange. The Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law at the very beginning of the Obama administration, bringing with it significant investments in health information technology (IT)—$26 billion to date.

While the adoption of electronic health records (EHRs) has increased considerably since 2009, there is very little electronic information sharing among clinicians, hospitals, and other providers. New models of care delivery, designed to improve quality and reduce costs, require both interoperable EHRs and electronic information sharing to be effective. This Health Policy Brief looks at the efforts the federal government has made to improve interoperability and increase the level of electronic information sharing, as well as the barriers to achieving these goals.

Topics covered in this brief include: Read the rest of this entry »

Health Affairs Web Firsts: Two Studies Find Mixed Results On EHR Adoption


August 11th, 2014

Since the Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted in 2009, Health Affairs has published many articles about the promise of health information technology and the challenges of promoting broad adoption and “meaningful use.”

Last week, on August 7, the journal released two new Web First studies, “More Than Half Of US Hospitals Have At Least A Basic EHR, But Stage 2 Criteria Remain Challenging For Most” and “Despite Substantial Progress In EHR Adoption, Health Information Exchange And Patient Engagement Remain Low In Office Settings.” These studies focus on the latest trends in health information technology adoption among U.S. physicians and hospitals. Both studies, which will also appear in the September issue of Health Affairs, show that while basic electronic health record (EHR) adoption plans have moved forward, more significant implementation remains a daunting challenge for many providers and institutions. Read the rest of this entry »

Narrative Matters: How Acute Care Training Is Failing Patients With Chronic Disease


August 8th, 2014

In the August Health Affairs Narrative Matters essay, a doctor questions how well acute care medical training serves those with chronic disease while watching the decline of two patients with kidney failure, one healthier and one frail. Dena Rifkin’s article is freely available to all readers, or you can listen to the podcast. Read the rest of this entry »

Posts On ACA Legal Challenges Lead Health Affairs Blog July Top Ten


August 7th, 2014

Two posts regarding legal challenges to the Affordable Care Act were the most-read Health Affairs Blog posts in July. In the top spot: Tim Jost’s discussion of Supreme Court actions that were arguably at odds with the Court’s Hobby Lobby decision. Next on the list: another post by Jost analyzing two federal appellate court decisions taking conflicting positions on whether consumers may receive premium tax credits under the ACA in states using the federally facilitated exchange.

Number three on the July top-ten list is Suzanne Delbanco’s post on bundled payment, part of her ongoing series on payment reform; Jennifer DeCubellis and Leon Evans’ post on investing in care coordination is next.

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

Contributing Voices

Reading Piketty In DC: Does Income Inequality Squeeze Health Spending?


September 16th, 2014

In the past year, an element of mystery and suspense has crept quietly into the long-running saga of health care spending growth, in most times a dreary tale of predictability and frustration.

The Congressional Budget Office (CBO)’s August forecast of significant reductions in Medicare spending growth in the next decade will help stoke a running debate about whether the spending slowdown that has outlasted the 2008-2010 recession is merely a delayed effect of the slump or a symptom of structural changes with a life of their own.

The mystery and suspense come from month-to-month uncertainties and inscrutable data about which way the trend lines are bending, and why.

Health Spending and Employment

A useful slant on the puzzle is offered in an August Health Affairs analysis by Dave Dranove and colleagues that examines small area variations in spending growth and correlates them with employment data. Dranove et al. found that relatively higher health spending occurred where employment levels were relatively high, and high unemployment translated into less spending on health. So whether it’s copays, deductibles, insurance contributions, or some other cost associated with obtaining care, personal income is a factor in spending levels, just as health costs are a factor in personal income. Read the rest of this entry »

Early Observations Show Safety-Net ACOs Hold Promise To Achieve The Triple Aim And Promote Health Equity


September 15th, 2014

Safety-net accountable care organizations (ACOs) have the potential to deliver cost-effective, patient-centered care that engages patients and contributes to achieving the Triple Aim in Medicaid. Safety-net ACOs are playing increasingly important roles in delivering care for vulnerable populations. Active ACO formation is occurring in at least 18 state Medicaid programs with considerable variability across states, although they have been slower to develop than ACOs serving Medicare or commercial populations.

This post will outline five key observations regarding emerging safety-net ACOs and suggest broad policy implications. We are defining safety-net ACOs as collaborative entities of providers and sometimes payers that are 1) accountable for managing the health of their population, 2) assuming upside and/or downside financial risk, and 3) serving predominantly Medicaid (including dual eligibles) and uninsured patients. Read the rest of this entry »

Taos Pueblo: A Sovereign Nation Sees Positive Public Health Results


September 15th, 2014

Editor’s note: This post is part of an ongoing series written for Health Affairs Blog by local leaders from communities honored with the annual Robert Wood Johnson Foundation Culture of Health Prize. In 2014, six winning communities were selected by RWJF from more than 250 applicants and celebrated for placing a priority on health and creating powerful partnerships to drive change. Interested communities are encouraged to apply for the 2015 RWJF Culture of Health Prize. Applications are due September 17, 2014.

The Taos Pueblo in New Mexico is a National Historic Landmark and one of a handful of places around the world designated a World Heritage Site by the United Nations. Native Americans have continuously lived in this ancient tribal community, with its remarkable multi-story adobe buildings, for more than 1,000 years. Today, the Taos Pueblo tribe has about 1,350 people living on some more than 100,000 acres, just outside the artist community of Taos.

The pueblo has its share of poverty and unemployment, along with troubling rates of diabetes, obesity, and alcoholism. Data from the Indian Health Service clinic at the pueblo show that about 47 percent of pueblo youth under age 20 are overweight or obese. And 21 percent of the adults have diabetes. Many pueblo residents live below the poverty level, which is not surprising as their economy is based on tourism, crafts, and a small casino. Read the rest of this entry »

Same Care No Matter Where She Gives Birth: Addressing Variation In Obstetric Care Through Standardization


September 12th, 2014

In August, Health Affairs published a study highlighting an alarming fact in maternal health: The incidence of childbirth complications varies significantly from hospital to hospital across the United States. The study – led by Laurent Glance and colleagues at the University of Rochester – found that “women delivering vaginally at a low-performing hospital had twice the rate of any major complications than women delivering vaginally at a high-performing hospital.” The difference in these complication rates for cesareans was five-fold.

It is well known that variation in care contributes to higher rates of mortality and morbidity in all areas of health care, explaining the push toward checklists and other quality improvement tools and interdisciplinary collaboration. Identifying the primary reasons for variation in obstetric complication rates – why women giving birth in high-performing hospitals have lower complications rates – could be critical to understanding the reasons behind the increasing rates of maternal mortality and morbidity in the U.S. This study, along with other disturbing statistics, underscores the significant need for improvements in maternity care. Read the rest of this entry »

Mortality Rate Increases With Emergency Department Closures


September 11th, 2014

The Health Affairs article, “California Emergency Department Closures Are Associated With Increased Inpatient Mortality At Nearby Hospitals,” by Charles Liu, Tanja Srebotnjak, and Renee Y. Hsia, recently published in the August issue, presents an important, timely, and well-conceived analysis, especially given the number of emergency department (ED) closures in the last 10-15 years, the concomitant rise in ED visits during the same period, and the likelihood of further closures due to increased hospital consolidation across the country since the study took place.

The article focuses on mortality rates and finds that hospitals in close proximity to an ED that had closed had 5 percent higher odds of inpatient mortality than admissions to hospitals not occurring near a closure, and that this effect disproportionately affected minority, Medicaid, and low-income patients, further exacerbating existing disparities in health care and health outcomes. This finding adds to Hsia’s body of work that calls attention to the disproportionate impact of institutional closures on health outcomes for vulnerable populations. Read the rest of this entry »

Year Zero: Leaders At Oregon’s CCOs Share Lessons From The Early Days


September 11th, 2014

Oregon is one of the first states to implement a version of accountable care organizations statewide across its Medicaid program; insights from those who were “on the ground” during the early days of this experiment may prove useful to other states contemplating a similar model.

Oregon’s Big Bet

Facing a massive gap in funding for Medicaid, a team of legislators, business leaders, and health care leaders in Oregon developed a plan to redesign Oregon’s Medicaid delivery system with Coordinated Care Organizations (CCOs), regional public-private partnerships that accept a single global budget and are accountable for the physical, mental, and dental health care of their local Medicaid population. Oregon secured a federal investment of $1.9 billion over five years to support the costs of transitioning to the CCO model; if savings do not materialize, Oregon will have to pay the money back.

CCOs are designed to incorporate all who care for a regional Medicaid population. This includes payers who compete for commercial contracts, providers who compete for business, and county public health departments who have not traditionally shared their systems or structures. CCOs include health systems with separate EHRs, for-profit and not-for-profit entities, and community-based organizations with a fraction of the operating budgets of other partners. CCOs had to grow fast: applications were due to the state just a few months after the enabling legislation passed. Read the rest of this entry »

Birth Control Pills Should Be Available Over The Counter, But That’s No Substitute For Contraceptive Coverage


September 10th, 2014

In recent weeks, some opponents of the Affordable Care Act’s (ACA) contraceptive coverage guarantee have promoted the idea that oral contraceptive pills should be available to adult women without a prescription. Sens. Kelly Ayotte (R-NH) and Mitch McConnell (R-KY), for example, recently introduced the so-called Preserving Religious Freedom and a Woman’s Access to Contraception Act, a bill that would urge the Food and Drug Administration (FDA) to study whether to make contraceptives over the counter (OTC) — though for adults only.

Making birth control pills available over the counter, if done right, would meaningfully improve access for some groups of women. However, such a change is no substitute for public and private insurance coverage of contraceptives — let alone justification for rolling back coverage of all contraceptive methods and related services for the millions of women who currently have it. Read the rest of this entry »

A First Look At How The Affordable Care Act Is Affecting Coverage Among Parents And Children


September 9th, 2014

Following the implementation of the major coverage provisions of the Affordable Care Act (ACA) in 2014, the question arises: “How is the health law affecting uninsured children and their families?” Today, the Urban Institute released two new briefs using the Health Reform Monitoring Survey (HRMS) to begin to answer that question.

The bottom line is that between September 2013 and June of 2014, coverage increased for parents, particularly in states that have expanded Medicaid under the ACA, but no coverage changes were yet apparent for children. This early look suggests that the ACA is contributing to coverage gains for parents, which in turn should be beneficial to both them and their children.

Children’s Coverage

The report on children’s coverage from The Urban Institute and the Georgetown University Center for Children and Families found that the uninsured rate for children remained at historically low levels—close to 7 percent—but did not decline further for children under age 18 between September 2013 and June 2014. However, this national snapshot does not capture all of the fluctuations in children’s coverage that may be occurring across the country in particular states; we will have to wait for data from federal sources to have a definitive assessment of how coverage is changing at the state level. Read the rest of this entry »

Improving Access To High Quality Hospice Care: What Is The Optimal Path?


September 9th, 2014

Editor’s note: This post is part of 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.

High quality hospice care is consistent with the country’s stated health care reform goals: hospice is person-centered, improves clinical outcomes such as pain and satisfaction, is provided by a multidisciplinary care team, is coordinated across care settings, reduces unnecessary hospitalizations, and saves health care dollars. Studies have consistently shown that hospice improves quality for patients and families by reducing symptom distress, improving caregiver outcomes, and reducing hospitalizations near the end of life, including emergency department visits and intensive care unit stays and hospital death.

But what about access? Fortunately, hospice care in the United States is growing rapidly and there is much to celebrate in terms of the increase in the number of hospice agencies, the number of patients and families served by hospice, and the breadth of conditions and diagnoses of patients receiving hospice care. In 2011 there were more than 3,500 hospice providers — an increase of 53 percent from 2000 — caring for 1.2 million Medicare beneficiaries. Read the rest of this entry »

Implementing Health Reform: Medicaid Eligibility, 2015 Navigator Grants, And FAQs (Updated)


September 8th, 2014

Update, September 13.  The Centers for Medicare and Medicaid Services issued more new and revised guidance during the second week of September, 2014.  First, CMS released a series of slides describing the streamlined application process that it is phasing in for the 2015 open enrollment period.  Under this system, all applicants (including for now special enrollment period applicants) will be asked a series of initial screening question.

Those who are identified as having a simple household situation will be directed to a streamlined process with fewer screens and clicks. For example, an early question about income range will help individuals who are unlikely to get financial assistance to decide whether or not to apply for financial assistance, and avoid further financial assistance questions if they decide not to request assistance. Those with more complex situations will be directed to the traditional process.  The streamlined process is also only available to first time applicants, not to individuals reporting a change, who will use the traditional application.

The new process is not only shorter, but also has backward navigation capability and is optimized for mobile users.  CMS expects 70 percent of applicants to use the streamlined application; 30 percent the traditional.  The new process is being phased in beginning the first week of September and will be fully rolled out for the 2015 open enrollment period in November.

CMS also, on September 12, released revised versions of Guidance Bulletin 10 on grace periods when individuals are terminated for non-payment of premiums and their enrollment through the federally facilitated marketplace spans two benefit years, and Guidance Bulletin 11 dealing with individuals terminated because of data matching errors.  The original versions of Bulletin 10, issued on July 16, and Bulletin 11, issued on August 13  were discussed in earlier posts.

In general, an individual terminated from coverage through the federal exchange for non-payment of premiums is closed out of coverage until the next open enrollment period unless he or she qualifies for a special enrollment period.  The individual may enroll in coverage for the next coverage year, however, if he or she reenrolls and pays the first month’s premium.  Any premiums paid for coverage for the next year are credited to that year and cannot be claimed by the insurer to cover premiums owing for the previous year.

This much is clear. But problems arise when the three-month grace period that an individual is afforded to catch up on unpaid premiums spans two years; for example, the individual ceased paying premiums in November and is either auto-enrolled or chooses a plan for 2015 but is not caught up with paying premiums by the end of December.  The Bulletin works through a number of possible situations that can arise involving grace periods that span two years or that end on December 31.  The revised Bulletin is generally consistent with the original bulletin, but clarifies what transactions are classified as renewals and how the grace period interacts with enrollment transactions that meet the definition of renewal.

Bulletin 11 deals with individuals who are terminated from federally facilitated exchange coverage because they fail to produce documentation to resolve inconsistencies involving their citizenship or lawful alien status. Individuals affected by data matching issues had until September 5 to submit required documentation, and will be terminated from coverage on September 30 if they failed to do so.  Under the original Bulletin 11, individuals who attested that they had in fact submitted documentation before September 5 that did in fact resolve the inconsistency could qualify for a special enrollment period and retroactive coverage even if that documentation was not received.  Individuals who submitted required documentation that resolved inconsistencies within 60 days after termination would qualify for a special enrollment period, but only for prospective coverage, with a likely gap in coverage.

Under the revised Bulletin 11, any individual terminated because of data matching issues may re-enroll in coverage by producing sufficient documentation to resolve the inconsistency.  If found eligible, the individual’s coverage may be reinstated retroactively to avoid gaps in coverage.  Alternatively, the individual may request prospective coverage.  If the individual selects the same coverage that he or she had previously, any amounts paid out-of-pocket will be credited toward deductibles or out-of-pocket limits.  This change effectively allows any individual terminated from coverage for data matching issues to resume coverage if the individual provides appropriate documentation.

Original post.  The decision of the full D.C. Circuit to review the panel decision in Halbig v. Burwell en banc was clearly the big Affordable Care Act (ACA) court decision of the first week in September, but a September 2 decision of the federal district court of the Middle District of Tennessee, Gordon v. Wilson, is also worthy of note.

The Medicaid law has long required state Medicaid programs to determine eligibility for Medicaid with “reasonable promptness,” defined by the regulations to mean within 90 days for applicants with disabilities and 45 days for everyone else. Applicants whose applications are not determined reasonably promptly are entitled by the Medicaid law and by the Due Process Clause of the Constitution to a fair hearing.

Medicaid Eligibility and Tennessee

Tennessee, like all states, was required by the ACA to begin calculating Medicaid eligibility for most recipients using modified adjusted gross income, or MAGI as of January 1, 2014. Tennessee attempted to establish a new computer system for doing this, but when it was not ready by January 1, Tennessee asked the federal exchange to determine Medicaid eligibility until it could get its system operational. Read the rest of this entry »

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