From The Staff

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 »

The Latest Health Wonk Review


February 28th, 2014
by Chris Fleming

David Harlow at HealthBlawg offers this week’s edition of the Health Wonk Review. All of the posts in David’s “In Like A Lion” Review reward reading, including the Health Affairs Blog post by Mark McClellan and coauthors at Brookings on how to pay for Medicare physician payment reform. Read the rest of this entry »

HA Issue Briefing: The ACA And The Future Of HIV/AIDS In America


February 28th, 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.

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 »

Exhibit Of The Month: Virtual Visits On The Rise


February 27th, 2014
by Rob Lott

At Health Affairs Blog, we’re excited to introduce a new regular feature. Each month, Health Affairs editors will review all the tables, charts, graphs and maps that have run in the latest print edition of the journal. After deliberating in a dark, but smoke-free, backroom, we’ll emerge to crown the most compelling, creative or surprising exhibit as our Exhibit of the Month!  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 exhibit shows how, within the Kaiser Permanente Northern California system, the number of virtual physician visits grew from 4.1 million in 2008 to 10.5 million in 2013. Read the rest of this entry »

HA Web First: Improved Prescribing And Reimbursement Practices In China


February 26th, 2014
by Tracy Gnadinger

Pay-for-performance—reimbursing health care providers based on the results they achieved with their patients as a way to improve quality and efficiency—has become a major component of health reforms in the United States, the United Kingdom, and other affluent countries. Although the approach has also become popular in the developing world, there has been little evaluation of its impact. A new study, released today as a Web First by Health Affairs, examines the effects of pay-for-performance, combined with capitation, in China’s largely rural Ningxia Province.

Between 2009 and 2012, authors Winnie Yip, Timothy Powell-Jackson, Wen Chen, Min Hu, Eduardo Fe, Mu Hu, Weiyan Jian, Ming Lu, Wei Han, and William C. Hsiao, in collaboration with the provincial government, conducted a matched-pair, cluster-randomized experiment to review that province’s primary care providers’ antibiotic prescribing practices, health spending, and several other factors. They found a near-15 percent reduction in antibiotic prescriptions and a small decline in total spending per visit to community clinics.

The authors note that the success of this experiment has motivated the government of Ningxia Province to expand this intervention to the entire province. “From a policy perspective, our study offers several additional valuable lessons,” they conclude. “Provider patterns of overprescribing and inappropriate prescribing cannot be changed overnight; nor can patient demand, for which antibiotics are synonymous with quality care. Provider payment reform probably needs to be accompanied by training for providers and health education for patients.” Read the rest of this entry »

Recent Health Policy Brief Updates: CO-OP Insurance and SHOP Exchanges


February 26th, 2014
by Tracy Gnadinger

The latest Health Policy Brief update from Health Affairs and the Robert Wood Johnson Foundation, published February 6, describes the new marketplaces created for small businesses to buy cheaper coverage more easily. These exchanges were created under the Affordable Care Act (ACA)’s Small Business Health Options Program (SHOP). Employers with fewer than 25 employees must purchase coverage through a SHOP if they want the small-business tax credit. This policy brief discusses the potential impact of the problems with the online exchange systems on health benefits offered by small employers.

The preceding Health Policy Brief update, published January 23, describes the current status of the Consumer Operated and Oriented Plan (CO-OP) program especially now that ACA implementation has begun. Because of funding cuts, one CO-OP was disbanded, and now 23 remain in 23 states. An updated partial list of approved CO-OPs and their sponsoring organizations is included. This policy brief discusses CO-OP funding, competency, competitive premium rates, and provision of care. Despite its early success, the next steps will be to see how many people the CO-OPs are able to enroll, whether their premium rates are sustainable, and their plans offer the same quality of care as the commercial market. Read the rest of this entry »

Mendelson: Senate GOP Reform Proposal Provides Welcome Flexibility In Benefit Design


February 26th, 2014
by Chris Fleming

A health reform proposal introduced by three Republican Senators is a positive development both substantively and politically, Dan Mendelson, CEO of Avalere Health, said in a recent interview. He said the greater flexibility in benefit design afforded by the GOP proposal could be a boon for many uninsured people dissatisfied with the choices allowed by the Affordable Care Act.

Senators Richard Burr (NC), Tom Coburn (OK), and Orrin Hatch (UT) offered the proposal, designed to replace the ACA, earlier this year. “This is the discussion that I wish had happened before the passage of the law, said Mendelson, who served as Associate Director for Health at the White House Office of Management and Budget under President Clinton. “We have here three very knowledgeable, relatively moderate Republican Senators coming together on a construct that embraces a lot of what was passed in the ACA. There’s an individual market … prohibited from discrimination on the basis of pre-existing condition; there are patient protections like the age band ratings, albeit less restrictive than the ones that were enacted in the bill.”

Mendelson noted that the Burr-Coburn-Hatch framework retains the ACA’s Medicare provisions. “Everything related to health system change stays: The Medicare Advantage Star ratings, which are very significant and far reaching policy, the Center for Medicare and Medicaid Innovation, and the like,” he said.

The Senate GOP proposal also contains some “very significant changes” from the ACA, many of which provide greater state flexibility in the individual market and Medicaid, Mendelson pointed out. On Medicaid, the proposal “really goes much closer to the block grant proposal that Republicans have felt comfortable with for quite some time. Ironically block granting might actually result in more coverage [than the ACA Medicaid provisions], given where Texas and some of the other Republican states are right now, because they would accept this,” in contrast to their rejection of Medicaid expansion under the ACA. Read the rest of this entry »

The State Of Health Reform: A Health Affairs Conversation With James Capretta, Genevieve Kenney, and Larry Levitt


February 25th, 2014
by Chris Fleming

The Obama administration touted a recent increase in the enrollment rate for young adults in the Affordable Care Act’s health insurance exchanges – how significant was this trend? What should we make of the recent Congressional Budget Office findings regarding projected decreases in hours worked by Americans as a result of the ACA? How does the recent introduction of a new health reform proposal by three Republican Senators affect the policy and political discussions around reform? And what should we expect as states continue to assess whether to expand their Medicaid programs?

In the latest edition of our Health Affairs Conversations podcast series, our guests address these and other health reform developments. James Capretta is a Senior Fellow at the Ethics and Public Policy Center and a Visiting Fellow at the American Enterprise Institute; Genevieve Kenney is Co-Director and a senior fellow in the Health Policy Center of the Urban Institute; and Larry Levitt is Senior Vice President for Special Initiatives at the Kaiser Family Foundation and Senior Advisor to the President of the Foundation.

You can access the podcast recording here. Read the rest of this entry »

Arkansas Governor Beebe Talks Private Option At Health Affairs/Kaiser Health News Newsmaker Breakfast


February 24th, 2014
by Chris Fleming

Those who have watched the debate in Washington over the increasing use of Senate filibusters will likely have considerable sympathy for Arkansas Governor Mike Beebe (D), the guest at today’s Health Affairs/Kaiser Health News Newsmaker Breakfast. At least the majority party in the Senate can break a filibuster with 60 out of 100 votes. In Arkansas, it takes 75-percent votes in both legislative Houses to pass an appropriations bill — including the funding necessary to continue operating Arkansas’s path-breaking “private option” approach to expanding Medicaid under the Affordable Care Act, in which those newly eligible for Medicaid under the ACA are insured through private plans rather than the state’s traditional Medicaid program.

The ACA requires states to expand their Medicaid program to cover all those making up to 138 percent of the federal poverty level and funds 100 percent of the state costs of the expansion, declining to 90 percent in 2020. After the ACA was passed, the Supreme Court made the Medicaid expansion optional for states. Arkansas was the first state to secure federal approval for the private option — sometimes called the “Arkansas Plan” – and this approach has since attracted attention from Republicans in other states interested in expanding coverage with federal dollars but averse to increasing the size of their traditional Medicaid programs.

The Republican-controlled Arkansas state Senate has voted to fund the private option – or “Arkansas plan,” as it is sometimes called – for its second fiscal year (beginning July 1), but several ballots last week in the 100-member state House of Representatives – also controlled by the GOP — fell a handful of “yeas” short of the needed 75 votes. The House plans to continue voting on the plan this week, and Beebe said he remains optimistic that it will pass. He said the case for approval is just “arithmetic,” referring not to counting votes but counting the dollars – all $89 million of them – that the state will need to cut from its next budget if the Arkansas does not reapprove the private option and thus loses the federal funding that goes with it, money that has already been committed to a tax cut that legislators are not about to repeal. That’s on top of the tens of millions more dollars that state businesses and hospitals would lose. Read the rest of this entry »

Jeffrey Brenner On GrantWatch: The Future For Population Health


February 21st, 2014
by Tracy Gnadinger

In a recent GrantWatch Blog post, Jeffrey Brenner raises the question, “What if Thomas Edison had to write grant proposals to invent the light bulb?” Brenner is a MacArthur fellow, medical director of the Urban Health Institute, and executive director and founder of the Camden Coalition of Healthcare Providers.

Brenner uses the Edison analogy to look at current grant funding and population health.

Since 1945 the National Institutes of Health (NIH), a federal government agency that funds medical research, has spent $547 billion dollars to cure disease and push the frontiers of medical knowledge. This spending has been supplemented by funding from private foundations. Sadly, despite all of this spending we have little understanding of how to deliver better care at lower cost to every American. At best, in the field of population health, we have a few light bulbs that stay lit for an hour or two, but we lack even basic knowledge to drive this field forward.

With 85 million baby boomers in the midst of retiring and a health care system that consumes 18 percent of our economy, it is not a small problem. We do not understand the fundamental drivers of health care utilization; the basic rules for designing and implementing effective interventions; the best ways to use data to plan, implement, manage, and evaluate interventions; nor how to train staff to run and lead these interventions. Why the lack of progress? Read the rest of this entry »

Contributing Voices

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 »

Implementing Health Reform: First Marketplace Open Enrollment Ends With More Than Seven Million Enrollees


April 2nd, 2014
by Timothy Jost

Editor’s note: This post was updated on April 3 to conclude with additional details on the special enrollment period for people who began, but were unable to complete, their enrollments by March 31.

The White House announced on Tuesday April 1, 2014 that as of the end of open enrollment, 11:59 p.m. on March 31, 2014, 7.1 million Americans had signed up for health plans under the Affordable Care Act. Tens of thousands more will be added from individuals who attempted to apply during the open enrollment period but were unable to complete their applications.  And many more will be enrolled through special enrollment periods as they undergo life changes over the coming year.

Of course, arguments will continue as to how many of those who selected a plan will pay their premiums (which they must do before they are covered); how many were previously uninsured; and whether those who enrolled are young, healthy, and male enough to offer insurers a risk pool like that they anticipated when they set their rates.  There is ample evidence that many have not yet paid, but it is reasonable to expect that the payment rate will pick up as enrollees figure out how to pay their insurers and insurers figure out who their enrollees are.  There is also evidence that many of those who signed up were previously covered.  Of course, one of the purposes of the ACA was to make insurance affordable, so if someone who was struggling to afford coverage (and might have had to drop it in the near future) can now afford it, that is also a success.  It was not a coincidence that the first example of the success of the ACA that the President gave in his Tuesday Rose Garden speech  was of a family who had been insured, but whose premiums were reduced by exchange enrollment from $30,000 to $9000 a year.  Moreover, millions of the uninsured have also signed up for Medicaid and some have also obtained coverage in the individual market outside the exchange or from their employer.  Finally, the size of the risk pool suggests that it is reasonably balanced demographically.

In any event, 7 million enrollees was the number that has constantly been held up as the unobtainable goal for the exchanges, and it has been reached–indeed surpassed.   Pictures all over the web today of long lines and full waiting rooms of people eager to enroll in coverage demonstrate that in fact people want health care coverage and the ACA is allowing them to get covered. Read the rest of this entry »

Mental Illness In America’s Jails And Prisons: Toward A Public Safety/Public Health Model


April 1st, 2014
by Dean Aufderheide

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.

Mental Illness in America’s Jails and Prisons

The United States continues to have one of the highest incarceration rates in the world, with 5 percent of the world population, but nearly 25 percent of the world’s prisoners.  Inmates are spending more time behind bars as states adopt “truth in sentencing laws,” which requires inmates to serve 85 percent of their sentence behind bars.

In 2012, about 1 in every 35 adults in the United States, or 2.9 percent of adult residents, was on probation or parole or incarcerated in prison or jail, the same rate observed in 1997.  If recent incarceration rates remain unchanged, an estimated 1 out of every 20 persons will spend time behind bars during their lifetime; and many of those caught in the net that is cast to catch the criminal offender will be suffering with mental illness.

Nearly a decade ago, I wrote an article with Patrick Brown titled “Crisis in Corrections: The Mentally Ill in America’s Prisons.”  It was about the alarming growth in the number of mentally ill individuals behind bars.  Since then, it has been shown that about 20 percent of prison inmates have a serious mental illness, 30 to 60 percent have substance abuse problems and, when including broad-based mental illnesses, the percentages increase significantly. For example, 50 percent of males and 75 percent of female inmates in state prisons, and 75 percent of females and 63 percent of male inmates in jails, will experience a mental health problem requiring mental health services in any given year. Read the rest of this entry »

Embarking On A New Journey With Health Affairs


March 31st, 2014
by Alan Weil

I am delighted to be taking on the role of editor-in-chief of Health Affairs.  This is a dynamic time in all aspects of health and health care: insurance coverage expansions, delivery system changes, and growing attention to population health.  Building upon thirty-three years of peer-reviewed scholarship, Health Affairs will continue to serve as the nation’s primary resource for the health policy community.

My goals for Health Affairs coalesce around a single theme: broadening the reach of the journal.

Health Affairs is strong in the core health policy community, but our scholarship is relevant to myriad actors in the one-sixth of the United States economy represented by health care.  My goal is to broaden our engagement with the worlds of law, finance, design, and many others. Read the rest of this entry »

Should Provider Performance Measures Be Risk-Adjusted For Sociodemographic Factors?


March 27th, 2014
by Christine Cassel

The National Quality Forum released draft recommendations on March 18 to change the way we assess the care that doctors and hospitals provide, and they are sure to cause a buzz in and beyond the health care community. That’s a good thing, because reflection and conversation are vital pieces of ‘getting it right’ when determining how measures can be used to gauge healthcare performance.

The recommendations come from a panel of 26 national experts convened by NQF at the request of the federal government. The question before them:  Should the measures we use to assess providers’ performance be risk-adjusted to account for patients who are poor, homeless, illiterate, uneducated, or have other indicators of lower socioeconomic status? The panel’s recommendations are discussed below, and we encourage you to register your views by commenting on the report by April 16 and on this post. Read the rest of this entry »

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