From The Staff

Health Affairs Web First: How Do Health Policy Researchers Use Social Media?


June 6th, 2014

As the United States moves forward with health reform, conveying complex information to the public becomes increasingly important. Social media represent an expanding opportunity for health policy researchers to communicate with the public and policy makers – but its use among these researchers appears to be low, according to a new study released today as a Web First by Health Affairs.

Authors David Grande, Sarah Gollust, Maximilian Pany, Jame Seymour, Adeline Goss, Austin Kilaru, and Zachary Meisel surveyed a sample of 325 health policy researchers who had registered for the 2013 Academy Health Annual Research Meeting.

The survey found small minorities using social media: 14 percent of participants reported tweeting, and 21 percent noted blogging about their research in the past year. Survey participants expressed reluctance to use social media, fearing it is incompatible with research, creates professional risks, and is not respected by their peers or their academic institutions. Read the rest of this entry »

Request For Abstracts: Health Affairs Health Care And Medical Innovation Theme Issue


June 5th, 2014

Health Affairs is planning a theme issue on health care and medical innovation in early-2015. The issue will span the fields of medical technology and also cover public policy and private sector innovations that promote improvements in the delivery of care, lower costs, increased efficiency, etc. 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.

We invite interested authors to submit abstracts for consideration for this issue. To be considered, abstracts must be submitted by June 25, 2014. We regret that we will not be able to consider any abstracts submitted after that date. Editors will review the abstracts and, for those that best fit our vision and goals, invite authors to submit papers for consideration for the issue. Invited papers will be due at the journal by September 2, 2014.

More information on topics and themes for this issue, as well as process guidelines and timetables, is available below and on the Health Affairs website. Read the rest of this entry »

Health Affairs June Issue: Where Can We Find Savings In Health Care?


June 2nd, 2014

The June issue of Health Affairsreleased today, features various approaches to cost-savings in the U.S. health care system. A variety of articles analyze the effects of potential policy solutions on the Medicare and Medicaid programs and their impact on the health of beneficiaries and tax payer wallets.

Federal approaches to reduce obesity and Type 2 diabetes rates by improving nutrition could work—but the how matters. Sanjay Basu of the Stanford University School of Medicine and coauthors modeled the effects of two policy approaches to reforming the Supplemental Nutrition Assistance Program (SNAP), which serves one in seven Americans. They found that ending a subsidy for sugar-sweetened beverage purchases with SNAP dollars would result in a decrease in obesity of 281,000 adults and 141,000 children, through a 15.4 percent reduction in calories by the lowering of purchases of this source. They also found that a $0.30 credit back on every dollar spent on qualifying fruits and vegetables could more than double the number of SNAP participants who meet federal guidelines for fruit and vegetable consumption.

With more than forty-six million people receiving SNAP food stamp benefits, the authors suggest that policy makers closely examine the implications of such proposals at the population level to determine which will benefit people’s health the most and prove most cost-effective.

If you’re between ages 15–39 when you are diagnosed with cancer, the implications later in life extend well beyond your health. Gery P. Guy Jr. of the Centers for Disease Control and Prevention and coauthors examined Medical Expenditure Panel Survey data and determined that survivors of adolescent and young adult cancers had annual per person medical expenditures of $7,417, compared to $4,247 for adults without a cancer history. They also found an annual per capita lost productivity of $4,564 per cancer survivor — because of employment disability, missed workdays, and an increased number of additional days spent in bed as a result of poor health — compared to $2,314 for adults without a cancer history.

The authors suggest that the disparities are associated with ongoing medical care needs and employment challenges connected to cancer survivorship, and that having health insurance alone is not enough to close the gap. They stress the importance of access to lifelong follow-up care and education to help lessen the economic burden of this important population of cancer survivors.

Optional Medicaid policies can help pregnant women quit smoking, but do they result in healthier babies? Marian Jarlenski of the Johns Hopkins Bloomberg School of Public Health and coauthors analyzed the effects in nineteen states of Medicaid presumptive eligibility (coverage while an application is pending) and the unborn-child option (coverage without documentation of citizenship or residency) and found that neither approach significantly improved rates of preterm birth or babies born small for their gestational age. However, they did find that presumptive eligibility resulted in a 7.7 percentage-point increase in smoking cessation among low-income pregnant women eligible for Medicaid, whose smoking rates are almost twice as high as in the general population of pregnant women. The authors recommend presumptive eligibility enrollment for consideration as a mechanism to promote both smoking cessation and earlier prenatal care, but point out that multiple, concurrent interventions may be necessary to ultimately affect birth outcomes.
Read the rest of this entry »

The Latest Health Wonk Review


May 28th, 2014

Hank Stern offers the latest edition of the Health Wonk Review at InsureBlog. His “Life’s a Beach” edition features many interesting reads on health care polity and policy.  Read the rest of this entry »

Narrative Matters Site Gets A New Look


May 28th, 2014

As visitors to the Health Affairs website may have noticed, the Narrative Matters page looks a bit different these days. That’s because we’ve redesigned the site to be more dynamic and user-friendly, making it easier to read or listen to recent essays, or search the Archives for old favorites.

In other new features, the Podcasts tab allows visitors to easily access the rich archive of Narrative Matters essay podcasts, most of them read by the author, including a recording of the moving essay “‘I Don’t Want Jenny To Think I’m Abandoning Her’: Views On Overtreatment,” published in the May issue of Health Affairs, as read by the author, Diane E. Meier. Read the rest of this entry »

Exhibit Of The Month: Racial Disparities In Clinical Studies


May 27th, 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.

This month’s exhibit, published in the May issue of Health Affairs, illustrates losses to follow-up among black men in clinical studies due to incarceration. The findings, based on certain National Heart, Lung and Blood Institute cohort studies, raise concerns regarding the generalizability of clinical research. Read the rest of this entry »

Health Policy Research And Disparities: A Health Affairs Conversation With Lisa Simpson And Darrell Gaskin


May 22nd, 2014

Earlier this year, AcademyHealth held its 2014 National Health Policy Conference; Health Affairs was a media partner for the NHPC. In a new installment of our Health Affairs Conversations Podcast series, we talk about the conference, as well as the challenges and opportunities facing the health services and health policy research communities, with AcademyHealth president and CEO Lisa Simpson. Before taking the helm of AcademyHealth, Dr. Simpson was director of the Child Policy Research Center at Cincinnati Children’s Hospital Medical Center and professor of pediatrics in the Department of Pediatrics, University of Cincinnati. She served as the Deputy Director of the Agency for Healthcare Research and Quality from 1996 to 2002.

We also take a close look at one of the NHPC sessions: “Community Health and Disparity: Moving Beyond Description.” (The disparities session is freely available to all readers.) Darrel Gaskin, who led the panel discussion, joins us as well. He is Deputy Director of the Johns Hopkins Center for Health Disparities Solutions and Vice Chair of AcademyHealth’s Board of Directors. Read the rest of this entry »

Health Affairs Web Firsts: Provider Consolidation In Health Care


May 19th, 2014

The clinical and economic virtues of provider consolidation have long been recognized by policy experts, but in recent years, research has shown that large provider organizations may use market power to obtain relatively high prices from payers without necessarily delivering superior quality. Four articles, being released as Web Firsts by Health Affairs, examine the issue from diverse perspectives.

A study from Paul Ginsburg and Gregory Pawlson serves as an issue overview. With continued consolidation likely, the article examines strategies that purchasers and payers can pursue to combat the rising prices that may result from growing provider leverage.

Ginsburg is the Norman Topping/National Medical Enterprises Chair in Medicine and Public Policy at the Sol Price School of Public Policy and the Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California in Los Angeles; Pawlson is a senior medical consultant at the law firm Stevens and Lee in Lancaster, Pennsylvania.

“The success of the private- and public-sector initiatives,” they conclude, “will determine whether governments shift from supporting competition to directly regulating payment rates.”

Looking broadly at the drivers of competitive outcomes, a study from William Sage, the James R. Dougherty Chair for Faculty Excellence, School of Law at the University of Texas at Austin suggests that the health care system’s long history of regulation and subsidy has not only distorted prices but has also altered the nature of the products that the system buys and sells. Read the rest of this entry »

New Health Policy Brief: Breakthrough Therapy Designation


May 16th, 2014

The latest Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation describes a new expedited drug development pathway designed to speed up the Food and Drug Administration’s (FDA’s) premarketing approval process for drugs and devices that treat serious or life-threatening conditions.

Created under a 2012 law, the Food and Drug Administration Safety and Innovation Act (FDASIA), a drug may be designated a “breakthrough therapy” if it shows far more promise over comparable treatments already on the market. At that point, the FDA will initiate a special rapid approval process.

The pharmaceutical industry has responded positively to this law, and as of last month the FDA has received 178 requests for this designation. The law, whose full impact will not be known for several years, carries significant implications for approaches to clinical development, patient access to new drugs, and the drug regulations process itself.

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

Reminder: Health Affairs May 19 Event On Provider Consolidation In Health Care


May 15th, 2014

The clinical and economic virtues of provider consolidation have long been recognized by policy experts, but in recent years, research has shown that large provider organizations may use market power to obtain relatively high prices from payers without necessarily delivering superior quality. On May 19, Health Affairs will release a package of “Web First” papers examining questions regarding provider consolidation.

We invite you to a Health Affairs Briefing at the National Press Club in Washington, DC, where the authors will discuss their findings and  engage in a discussion with a panel of expert responders and the audience.  The papers and the briefing are supported by a generous grant from The Commonwealth Fund.

When:
Monday, May 19, 2014
9:00 a.m. – 10:30 a.m.

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

REGISTER NOW!

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

Contributing Voices

New Drug And Device Approval: What Is Sufficient Evidence?


July 1st, 2014

Editor’s note: In addition to Jonathan Darrow, this post is also coauthored by Aaron Kesselheim. 

The federal Food, Drug, and Cosmetic Act gives the Food and Drug Administration (FDA) the authority to evaluate all prescription drugs and high-risk medical devices before they can be marketed to physicians and patients to ensure that they are safe and effective.

However, there is growing pressure to lessen the traditional standards for defining “safe and effective” for particularly promising therapies and accelerate patient access to these products.

A recent national health policy conference in Washington, D.C., explored the nature of the evidence needed for the regulatory approval of new therapeutics and the implications for patient care. The conference was organized by the Program On Regulation, Therapeutics, And Law (PORTAL) at Brigham and Women’s Hospital/Harvard Medical School, the National Center for Health Research, and the American Association for the Advancement of Science (AAAS). Read the rest of this entry »

The Supreme Court And The Contraception Mandate: A Temporary Setback For Contraception Coverage


June 30th, 2014

Editor’s note: See Health Affairs Blog for more coverage of the Supreme Court’s Hobby Lobby decision.

Today, the United States Supreme Court ruled that for-profit companies may avoid providing contraception coverage to employees if the companies sincerely object on religious grounds. At its narrowest interpretation, this decision is a significant but remediable setback for women’s reproductive health. At its broadest (but least likely interpretation), the decision has the potential to wreak havoc on public health regulation.

The legal challenges to the Affordable Care Act’s (ACA’s) contraception mandate have been well described in three previous Health Affairs Blog posts. To briefly recap, though, the ACA requires preventive services to be covered without copayments or other cost sharing in most employer-supported health plans. To implement this requirement, the Department of Health and Human Services (HHS) issued regulations that include all FDA-approved contraceptives, and a company that does not provide no-cost coverage of contraception is subject to substantial penalties.

Three groups of employers are exempt from the mandate: small businesses with less than 50 employees, purely religious employers, and “grandfathered” plans that have not changed meaningfully since the ACA was passed. Additionally, religiously affiliated non-profits (such as universities and hospitals) received a special accommodation from HHS by which women can receive contraception from third-party insurers at no extra cost to employees or the organization if the organization objects to covering contraception and identifies an alternate insurer. Read the rest of this entry »

Implementing Health Reform: The Supreme Court Rules on Contraception Coverage (Updated)


June 30th, 2014

Stay tuned to Health Affairs Blog in the days ahead for more commentary about today’s Supreme Court decision.

Note: This post was updated on July 1, 2014, to discuss ongoing challenges to potential accommodations for employers that object to covering contraception.

UpdateIn its Hobby Lobby decision the Supreme Court majority concluded that the implementing agencies could not require the plaintiffs to cover contraceptive services for their employees because there was a less restrictive alternative that the agencies could use to achieve their presumably compelling interest in ensuring women access to contraceptives without cost-sharing.  The alternative specifically referred to by the majority was the accommodation that the agencies had already offered non-profit organizations.

Under that accommodation, non-profit organizations may certify to their insurer or third-party administrator that they are conscientiously opposed to providing coverage for contraception.  Once they do so, the insurer or third party administrator is responsible for covering contraception, with insurers using the funds they save by not covering pregnancies and third party administrators using payments they can recover from insurers who will pay them from funds that the insurers would otherwise pay to exchanges for exchange participation.

About 50 non-profit organizations are currently suing challenging that accommodation.  The lawsuits raise a host of claims, but basically the organizations claim that the certification that they must make to their insurers and TPAs impermissibly entangles them in the obligation of the insurers and TPAs to offer coverage in violation of RFRA and the First Amendment.  They also claim that a provision of the regulation prohibiting them from interfering with coverage of contraceptives by their insurers and TPAs violates their First Amendment freedom of expression rights.

So far over two dozen courts have entered temporary injunctions protecting the non-profits from complying with the accommodation.  But a half dozen courts have refused injunctions, including the 6th and 7th circuits, rejecting all of the plaintiff’s claims as unlikely to prevail on the merits.  The Supreme Court’s Hobby Lobby majority opinion, and in particular Justice Kennedy’s concurrence seemed to approve of the non-profit accommodation, although the Court made it clear in footnotes 9 and 40 that it was not conclusively deciding the question of the permissibility of the non-profit accommodation, which was not before it.

Surprisingly, therefore, later in the day on June 30 the Supreme Court issued a very temporary injunction barring the enforcement of the accommodation pending appeal in one of the non-profit cases, Wheaton College v. Burwell. In Wheaton College the district court had denied an injunction, relying on the 7th Circuit authority. The Supreme Court injunction only lasts until the Court can consider the government’s response, due July 2 by 10 a.m., and the college’s reply, due by 5 p.m. the same day, but signals that the Court may be prepared to resolve the issue, or at least address it, soon.  Justices Breyer and Sotomayor dissented from the Court’s order. 

Read the rest of this entry »

Implementing Health Reform: Exchange Eligibility Redeterminations; Small Employer Tax Credit


June 27th, 2014

While it seems like the 2014 open enrollment period just ended, the 2015 open enrollment period, which begins on November 15, is in fact only four and a half months away. On June 26, 2014, the Department of Health and Human Services released a proposed rule addressing eligibility redeterminations for 2015. Together with the proposed rule, HHS issued a guidance describing how the federally facilitated exchange intends to redetermine eligibility, as well as draft standard notices for health plans to use when discontinuing or renewing plans in the individual and small group market and instructions for completing those notices.

On the same date, the Internal Revenue Service released final rules governing the small employer tax credit program. This post will discuss these rules and guidances, as well as another court decision rejecting a challenge to the individual mandate and another spate of FAQs on the SHOP exchange program. Read the rest of this entry »

Do Insurance Marketplace Consumers Need More Doctor Choices In-Network, Or Just Better Information?


June 26th, 2014

Media outlets have focused extensively on consumer complaints about “limited networks” and not being able to find a doctor under qualified health plans (QHPs) offered through the Health Insurance Marketplaces (HIMs). In response, the Obama administration released new standards which will require all QHPs to contract with a larger proportion of essential community providers within its service area. This means that health plans will be forced to accept more health care providers within their network, which may potentially increase costs for consumers.

At the heart of the recent changes lies a fundamental question worth exploring: Is consumer satisfaction with, and perceptions of health plan “network adequacy” grounded in the number of choices for doctors within network, or is it something different? Read the rest of this entry »

Correcting The Blind Spot In Accountability: The Role Of Pharmacy Care


June 25th, 2014

Editor’s note: In addition to William Shrank, this post is also coauthored by Andrew Sussman, Patrick Gilligan, and Troyen Brennan.

The Centers for Medicare and Medicaid Services (CMS) recently issued a Request for Information (RFI) to solicit suggestions about how to improve the Accountable Care Organization (ACO) programs. CMS stated that they seek recommendations about how the ACO program might evolve to “encourage greater care integration and financial accountability.”

The RFI explicitly stated that they seek information about how to better integrate Part D expenditures into ACO cost calculations to make pharmaceuticals part of the approach to care delivery and health care transformation.

The deadline for comments about encouraging Part D integration in ACOs has now passed. But the issue extends beyond ACOs. In addition, bundled payments and patient-centered medical home programs target hospitals and primary care providers to promote higher quality and lower cost care. All these programs have largely excluded prescription drug costs in their calculus, and offer no direct incentives for Part D plans to participate in and improve care.

Nonetheless, retail pharmacies and Part D plans have developed a number of strategies to participate. As CMS and policymakers reconsider ACO regulations to stimulate greater integration of prescription drug use in delivery system reform, we thought it important to offer a description of the marketplace response to payment reform activities at large. Read the rest of this entry »

Behind The Numbers: Slight Rise In Health Care Spending Growth Projected


June 24th, 2014

PwC’s Health Research Institute (HRI) released its ninth annual Medical Cost Trend: Behind the Numbers report today. This forward-looking report is based on interviews with industry executives, health policy experts, and health plan actuaries whose companies cover a combined 93 million members. Findings from PwC’s Health and Well-being Touchstone Survey of 1,200 employers from 35 industries are also included.

HRI projects that after a five-year contraction in spending growth in the employer-sponsored market, the growth rate will rise to 6.8 percent in 2015, up from the 6.5 percent projected last year.

What are the biggest drivers of the growth in health care costs? We identify four cost inflators in this report, and I would like to highlight two. First, the economy. More than five years after the end of the Great Recession, the improved economy is finally translating into greater medical spending. Consumers are now addressing health issues they ignored or postponed previously.

Secondly, the high cost of specialty drugs. While only four percent of patients use specialty drugs, those medications account for 25 percent of total U.S. drug spending. And estimates are that U.S. specialty drug spending will quadruple by 2020. Read the rest of this entry »

Implementing Health Reform: Employer Orientation Periods; Risk Corridor Payments


June 21st, 2014

It has long been apparent to those of us who follow Affordable Care Act regulatory activity that the implementing agencies have a penchant for releasing rules on Friday afternoons in the 4:15 Federal Register post. True to form, at 4:15 on June 20, the Departments of Labor, Treasury, and Health and Human Services released a final rule clarifying the effect of orientation periods on a provision of the ACA that prohibits employer-sponsored health plans from imposing a waiting period of more than 90 days before the beginning of coverage for full-time employees.

Section 2708 of the Public Health Services Act, enacted through the ACA, forbids group health plans and insurers that cover groups from imposing waiting periods on new enrollees that exceed 90 days. The provision, enforced by all three agencies, is incorporated by the ACA into ERISA and the Internal Revenue Code and thus applies to all employers; it does not apply to individual plans. The agencies had released a guidance on waiting periods in 2012 and and published a final rule in 2014 The penalty for violating this prohibition is $100 per employee per day of violation.

The earlier final rule clarified that a “waiting period” is the period that may elapse before an employer must cover an employee or dependent who is otherwise eligible to enroll under the terms of a group health plan. To be otherwise eligible to enroll the employee must meet the plan’s substantive eligibility conditions (for example, being in an eligible job classification, achieving job-related licensure requirements specified in the plan’s terms, or being a full-time employee), but such requirements cannot be mere subterfuges for the passage of time. One such legitimate requirement specified in the final rule is completing a reasonable and bona fide employment-based orientation period. Read the rest of this entry »

Course Correction: Better Preparing Today’s Nurses For 21st Century Health Care Service


June 20th, 2014

Nursing has always been considered a highly established profession with solid job security for many, even in the midst of troubling economic conditions. In fact, a recent US News and World Report’s list of the Best 100 Jobs shows both nurse and nurse practitioner in the Top 10.  And it’s a respected profession as well: A 2013 Gallup poll showed 82 percent of Americans rate the ethical and honesty standards of nurses as “high or very high,” the highest of all professions.

Yet despite talk of an impending nursing shortage over the next few years, some believe there is an even bigger crisis looming, one that stems from the very heart of the career — education.  Quite simply, nursing students are not as prepared as they should be for the “real world” of nursing and patient care.

This skills deficit is all-encompassing. There is a lack of the basic technical skills, such as physical assessment and emergency response. But the equal lack of “soft skills,” such as critical thinking, problem recognition, prioritization and recognition of urgency, and communication with physicians, is just as alarming. Read the rest of this entry »

The Role Of Sales Representatives In Driving Physicians’ Off-Label Prescription Habits


June 19th, 2014

Off-label prescribing is widespread in Canada and the United States. One in nine prescriptions for Canadian adults are for off-label uses with the highest percentages coming from anticonvulsants (66.6 percent), antipsychotics (43.8 percent), and antidepressants (33.4 percent). Overall, 79 percent of the off-label prescriptions lacked strong scientific evidence for their use.

For 160 drugs commonly prescribed to U.S. adults and children, 21 percent were for off-label indications totaling 150 million prescriptions. In this case, 73 percent had little to no scientific backing and once again psychoactive drugs such as gabapentin had the highest level of off-label use.

Moreover, doctors do not seem to know what are and are not approved FDA use for many of the drugs that they prescribe. Now an article published in the June issue of Health Affairs by Ian Larkin and colleagues points to active promotion by sales representatives as one reason for the widespread off-label use of antipsychotics and antidepressants in children. Read the rest of this entry »

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