From The Staff

Exhibit Of The Month: California’s Hospital Fair Pricing Act Reduces Amount Paid By Uninsured


January 29th, 2015

Editor’s note: This post is part of an ongoing “Exhibit of the Monthseries. 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 January issue of Health Affairs, looks at the proportion of hospital charges to and collections from uninsured patients in California from 2003 to 2012.

In the article, “California’s Hospital Fair Pricing Act Reduced The Prices Actually Paid By Uninsured Patients,” author Ge Bai of the Williams School of Commerce, Economics, and Politics at Washington and Lee University, examines how the Hospital Fair Pricing Act affects the net price paid by uninsured patients. Read the rest of this entry »

Health Affairs Web First: Do Low-Income Consumers In Medicaid Opt-Out States Pay More Out Of Pocket?


January 28th, 2015

In the twenty-three states currently not expanding Medicaid under the Affordable Care Act (ACA), uninsured adults who would have been eligible for that program and have incomes at or above poverty are now generally eligible for subsidies to purchase health coverage in their state’s Marketplace exchange. How would out-of-pocket costs in the Marketplace compare with Medicaid coverage for this group of low-income Americans living in states not expanding Medicaid?

This study, being released by Health Affairs as a Web First, estimated these costs under two simulation scenarios: calculating out-of-pocket costs for families covered by a subsidized silver Marketplace plan and comparing that with coverage under Medicaid. Author Steven Hill found that Medicaid would more than halve these adults’ average annual family out-of-pocket spending ($938 versus $1,948). Read the rest of this entry »

New On GrantWatch Blog


January 27th, 2015

Health Affairs GrantWatch Blog brings you news and views of what foundations are funding in health policy and health care.

Here are the most recent posts: Read the rest of this entry »

New Health Policy Brief: The Two-Midnight Rule


January 23rd, 2015

A new policy brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) examines the so-called “two-midnight rule.” The rule, announced in 2013, is an effort by the Centers for Medicare and Medicaid Services (CMS) to clarify when a patient will be considered by Medicare as an inpatient for hospital billing purposes. Under this rule, only patients that a doctor expects to need two nights in the hospital would be considered inpatients for the purpose of Medicare claims.

In the past, CMS provided little guidance to hospitals on this matter. This is important because the Medicare payment structures are very different for inpatients versus outpatients: Hospitals are reimbursed with a single comprehensive payment for all care provided to an inpatient during his or her time at the hospital, but they are paid standard fees for each unique service they provide to outpatients. This brief describes the perceived need by CMS for the two-midnight rule, how it would work, the implications for Medicare payment, and the heated response to the rule by the hospital industry. Read the rest of this entry »

Health Affairs Briefing: Biomedical Innovation


January 20th, 2015

Biomedical innovation lengthens and enriches our lives through breakthroughs in medications and care, but it is has also been the leading source of health care cost growth over the past few decades. The upcoming February 2015 thematic issue of Health Affairs examines the topic from many perspectives.

You are invited to join us on Thursday, February 5, at a forum featuring authors from the new issue at the W Hotel in Washington, DC.  Panels will cover pharmaceuticals; biotechnology; medical devices; and accelerating, diffusing, and financing innovation.

WHEN: 
Thursday, February 5, 2015
9:00 a.m. – 12:30 p.m.

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

Register Now!

Follow live Tweets from the briefing @Health_Affairsand join in the conversation with #HA_BiomedInnovation. Read the rest of this entry »

Health Affairs Web First: New Medicare Per Capita Spending Shows A Rise With Age, Then A Decline After 96


January 14th, 2015

New analysis of Medicare spending from 2000–11 found that in 2011 per capita spending increased with age, from $7,566 for beneficiaries age seventy to $16,145 at age ninety-six, and then declining for even older beneficiaries. The study authors Patricia Neuman, Juliette Cubanski, and Anthony Damico also found that since 2000, the age that Medicare per capita spending peaks has increased each year: In 2000, the highest spending was found to be among those age ninety-two.

They also found that Medicare beneficiaries ages eighty and older, who comprised 24 percent of the beneficiaries, accounted for a disproportionate share (33 percent) of traditional Medicare spending in 2011. This study, being released by Health Affairs as a Web First, is part of the journal’s re-established DataWatch series, which features timely health-related data and surveys. Read the rest of this entry »

The Importance Of Zip Code In Determining One’s Health Tops 2014 GrantWatch Blog Most-Read List


January 9th, 2015

Happy New Year! We have compiled a list of the ten most-read posts on GrantWatch Blog during 2014, in case you missed any of them. Read the rest of this entry »

New Narrative Matters: A Mother’s Hope For A Natural Birth In A Cesarean Culture


January 9th, 2015

Health Affairs‘ January Narrative Matters essay features a physician and mother on giving birth in a culture that increasingly pushes women toward cesarean sections. Carla Keirns’ article is freely available to all readers, or you can listen to the podcast.

Read the rest of this entry »

Medicaid Expansion Post Leads Health Affairs Blog 2014 Top-Fifteen List


January 8th, 2015

As we begin 2015, we present the fifteen most-read Health Affairs Blog posts from 2014. Topping the list is “Opting Out Of Medicaid Expansion: The Health And Financial Impacts,” by Sam Dickman, David Himmelstein, Danny McCormick, and Steffie Woolhander. “Low-income adults in states that have opted out of Medicaid expansion will forego gains in access to care, financial well-being, physical and mental health, and longevity that would be expected with expanded Medicaid coverage,” the authors write, and they offer a state-by-state projection of these consequences.

Next on the list is Susan DeVore‘s overview of health care trends to watch in 2014, followed by David Muhlestein‘s look at the likely growth of accountable care and an examination of declining inpatient hospital utilization by Robert York, Kenneth Kaufman, and Mark Grube. The list also includes two posts from Tim Jost’s comprehensive series on implementing the Affordable Care Act, on waiting periods for employer-sponsored health insurance and Medicaid asset rules.

Stay tuned for the 2014 most-read lists for Health Affairs journal and GrantWatch Blog.

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

Health Affairs’ January Issue: Aging And Health


January 5th, 2015

The January issue of Health Affairs includes a number of studies examining issues pertaining to aging and health or health care. Other subjects covered include: the effect of Medicare’s Hospital Compare quality reports on hospital prices; how the Affordable Care Act’s provisions impact Americans shouldering high medical cost burdens; and whether California’s Hospital Fair Pricing Act has benefited uninsured patients.

Content on aging and health was supported by the John A. Hartford Foundation. Read the rest of this entry »

Contributing Voices

Moving In Reverse? Potential Coverage Impacts For Children Of King v. Burwell, Medicaid And CHIP Eligibility Changes


March 17th, 2015

Over the last three decades, the US has taken important steps to reduce financial barriers to health insurance coverage for low and moderate-income children. These steps began with the Medicaid expansions for children in the 1980s and early 1990s, which were followed by the creation of the Children’s Health Insurance Program (CHIP) in 1997. Most recently, Congress reauthorized CHIP in 2009 and enacted the Affordable Care Act (ACA) in 2010.

This commitment to children has resulted in substantial increases in coverage. The uninsured rate among children decreased from 15.0 percent in 1989 to 6.6 percent in 2012 (Exhibit 1).

Read the rest of this entry »

Implementing Health Reform: Wraparound Benefits Final Rule; Coverage Report (Revised)


March 17th, 2015

Correction: My March 17 post on the wraparound coverage rule (below) was based on a misunderstanding of how the Multi-State Plan program wrap works.  In fact, employer coverage would not wrap around MSP SHOP coverage but rather around individual MSP coverage.  Under prior guidance the employer would still not be able to pay for the primary individual MSP coverage, but would only pay for the wrap.

The employer could offer some categories of employees comprehensive coverage and other categories of employees only wrap coverage, as long as coverage offers did not discriminate on the basis of preexisting conditions or health status or in favor of highly compensated employees.  Alternatively, the employer might offer all emloyees the option of either comprehensive coverage or wrap coverage, in which case employees who opted for wrap coverage would not qualify for premium tax credits unless employer coverage was in fact inadequate or unaffordable.

Employers would in any event be required to continue to make a total aggregate contribution toward primary and wrap coverage for all employees that was “substantially the same” as the amount contributed for coverage of all full-time employees for plan years that began in 2013 and 2014.  The employer could be liable for the employer mandate penalty if the employer failed to offer adequate and affordable coverage to some employees that resulted in those employees receiving premium tax credits through the marketplace.

With open enrollment closed for 2015 and the Departments having finalized the Benefit and Payment Parameters Rule and Letter to Issuers for 2016, we have entered the Spring Affordable Care Act regulatory doldrums.  Reports, minor regulations, guidances, and court decisions continue to appear, however.  Two appeared on March 16.  This post addresses the final wraparound coverage excepted benefits rule, and a report on health insurance coverage and the ACA (technical appendix here), both released on March 16, 2015.

The wraparound coverage rule creates a new category of excepted benefits.  The concept of excepted benefits was created by the Health Insurance Portability and Accountability Act of 1996 and is carried forward in the ACA.  Excepted benefits plans provide benefits that resemble in some way the health benefits that have been regulated by HIPAA and are now regulated by the ACA, but are more limited or are more tangential to medical care.  These include benefits that are not generally medical benefits but do afford some medical coverage (auto liability, workers’ compensation); health coverage that is not medical coverage (dental, vision, long-term care); benefits that are not coordinated with medical benefits (specific disease coverage, fixed dollar indemnity coverage); and coverage that is supplemental to medical coverage (such as Medicare supplement policies).  Additional specific conditions must be met for some of these benefits to qualify as excepted benefits.

Excepted benefits are generally not subject to Affordable Care Act requirements, such as the ban on dollar coverage limits or preexisting conditions clauses.  But excepted benefit coverage explicitly does not qualify as minimum essential coverage.  An individual who has only excepted benefit coverage and does not qualify for a shared responsibility requirement exception must still pay the individual mandate penalty.  Large employers that offer only excepted benefits may have to pay the employer responsibility penalty, but individuals offered only excepted benefits by their employers are not disqualified from receiving premium tax credits to purchase individual coverage through the marketplaces. Read the rest of this entry »

Can Safety-Net Hospital Systems Redesign Themselves To Achieve Financial Viability?


March 16th, 2015

Safety-net hospital systems have long played a special role in the nation’s health care system by serving low-income, medically, and socially vulnerable patients regardless of their ability to pay. Beyond caring for people regardless of insurance coverage, safety-net systems provide comprehensive care to meet the needs of their diverse, complex patient populations, including culturally-responsive health and social services that other hospital systems do not.

As providers of last resort, some safety-net systems, especially public hospitals, are expected by their communities and by state and local governments to offer needed but unprofitable services, regardless of whether adequate revenue streams exist to support these services.

In recognition of that role, national, state, and local government agencies historically have provided supplemental funding to these systems to offset unreimbursed and under-reimbursed care. Under the Affordable Care Act, however, that is changing. With the expectation that most people will be insured under the new law, policy makers have planned to reduce much of this supplemental funding. In this view, safety-net systems will either become financially independent or close. Read the rest of this entry »

Should Health Lawyers Pay Attention To The Administration’s Privacy Bill?


March 13th, 2015

Health care lawyers justifiably ignored the 2012 Obama administration consumer privacy framework because it expressly and broadly exempted entities subject to HIPAA, stating “To avoid creating duplicative regulatory burdens, the Administration supports exempting companies from consumer data privacy legislation to the extent that their activities are subject to existing Federal data privacy laws.”

In contrast, the administration’s 2015 draft bill, the Consumer Privacy Bill of Rights Act, though based on that framework, substantially affects health care entities, including those subject to HIPAA, and so demands more attention in the health law community.

The “HIPAA clause” in the draft bill is subtly different (and noticeably narrower than its preemption of state law clause): “If a covered entity is subject to a provision of this Act and a comparable provision of a Federal privacy or security law [the list includes HIPAA] such provision of this Act shall not apply to such person to the extent that such provision of Federal privacy or security law applies to such person.”

The “provision” wording is key; most of the key substantive provisions in the draft bill—those going to consent, withdrawal of consent, context, and data minimization—do not crosswalk to any comparable provisions in HIPAA. For HIPAA mavens this has the potential of “more stringent than” all over again, but at a higher stakes table. (For nonmavens, this refers to questions raised by HIPAA’s language leaving intact state laws “more stringent than” HIPAA’s privacy protections.) Read the rest of this entry »

Physician Aid In Dying: Whither Legalization After Brittany Maynard?


March 12th, 2015

Editor’s note: This post is part of a series stemming from the Third Annual Health Law Year in P/Review event held at Harvard Law School on Friday, January 30, 2015. The conference brought together leading experts to review major developments in health law over the previous year, and preview what is to come. A full agenda and links to video recordings of the panels are here.

Brittany Maynard’s highly publicized decision to end her life under Oregon’s Death With Dignity law has given a new face to the American right to die movement. It is that of a young, attractive, athletic newlywed, who would not have considered herself as having a stake in the movement until the day she learned a brain tumor was the cause of her severe headaches. She was terminally ill and faced a future of six months of increasing pain, debilitation, and severe seizures before dying.

A video of Maynard’s story produced by the non-profit advocacy organization Compassion and Choices has reached many millions of viewers. Extended coverage of her decision-making process by People Magazine resulted in record numbers of hits to the publication’s website. During her illness, Maynard moved from California to Oregon and on November 1, 2014 took barbiturates to end her life. In her memory, her husband and mother have become prominent activists in the effort to legalize physician aid-in-dying (PAD).

Is all of this likely to advance the PAD movement and, if so, through what legal processes? Read the rest of this entry »

Implementing Health Reform: March Enrollment Report Provides Income Data (Updated)


March 11th, 2015

Update: In another ACA development, the IRS has just clarified that an immigrant present in the United States under the Deferred Action for Childhood Arrivals (DACA) program is not considered lawfully present, and is thus eligible for the exemption from the individual responsibility requirement that applies to individuals not lawfully present in the United States.  It has long been clear that DACA program immigrants are not eligible for Medicaid and CHIP.

Original post: On March 10, 2015, the HHS Assistant Secretary for Planning and Evaluation (ASPE) released the Health Insurance Marketplaces 2015 Open Enrollment Period March Enrollment Report.  The report covers open enrollment activity through February 22, 2015; it contains a wealth of data on 2015 marketplace enrollment, including for the first time enrollee income data that provides some useful insights (discussed in more detail below).

The headlines of the report are old news.  Nearly 11.7 million Americans selected or were automatically enrolled in health plans through the marketplaces during the 2015 open enrollment period, including 8.84 million through the exchanges that use healthcare.gov.  Of these, 4.6 million were new consumers, 2.2 million actively reenrolled , and nearly 2 million were automatically reenrolled.  Nearly 2.85 million people selected plans or were automatically enrolled through state exchanges that used their own marketplace platforms. Read the rest of this entry »

Reconciling Prevention And Value In The Health Care System


March 11th, 2015

The term ‘value’ (commonly defined as health improvements attained per dollar spent) has become ubiquitous in discussions around improving the health care system. Increasingly, payers are adopting value-based purchasing programs (paying more for higher value care) and providing benefits that follow the principles of value-based insurance design (aligning patient cost-sharing with the value of the service). These programs typically focus on services widely regarded as relatively low-cost and clinically effective, such as beta-blockers prescribed for patients following a myocardial infarction (i.e. heart attack).

Simultaneously, there is widespread enthusiasm for the increased use of preventive services. The Patient Protection and Affordable Act (ACA) mandates the elimination of consumer cost sharing for selected preventive services in marketplace plans and many other individual health plans. A particular subset of plans, High-Deductible Health Plans with Health Savings Accounts (HSA-HDHPs) can cover certain preventive services—but not other services—before the deductible, a minimum of $1,250 for an individual and $2,500 for a family, is met.

Generally, policies supporting prevention and value are consistent. Many (not all) preventive services do provide considerable value. Yet as with value, there are nuances in the definition of prevention that can lead to suboptimal policy choices. Specifically, most policy related to prevention defines preventive services as those delivered to asymptomatic individuals. Read the rest of this entry »

Price Transparency: Removing The Blindfold


March 11th, 2015

Shopping for health care is like shopping blindfolded in Macy’s, says noted health care economist Uwe Reinhardt — consumers don’t know what they are buying or how much it will cost until they have paid and gone home. Moreover, consumers are not the only ones affected by the lack of information; employers as purchasers of insurance, government policy makers, and insurers are all frustrated by the lack of price and quality information that would allow consumers to shop for value in their care.

We hope that 2015 will be the year of transparency and the first year in an era of higher value health care. This blog post discusses our observations from the Health Care Cost Institute’s (HCCI) perspective of developing guroo.com, a transparency website: the impetus for transparency, the magnitude of the data needed, the challenges in summarizing and presenting the data, and finally realistic expectations for transparency tools. Read the rest of this entry »

Implementing Health Reform: Supreme Court Remands Contraceptive Case; ACA Cost Estimates Go Lower


March 10th, 2015

On March 9, 2015, the Supreme Court waded once again into the waters of the Affordable Care Act, or at least got its toes wet.  The Supreme Court granted certiorari in Notre Dame v. Burwell, vacated the decision of the federal Court of Appeals for the Seventh Circuit, and remanded the case for reconsideration in light of Hobby Lobby v. Burwell.  Both Hobby Lobby and Notre Dame, of course, involve the regulations that require health plans and insurers to provide contraceptive services to female employees and students.

Also on March 9, 2015, the Congressional Budget Office issued its March, 2015 baseline report.  The CBO and the Joint Committee on Taxation (JCT) now project that the major insurance provisions of the ACA will cost $1.2 trillion over the period 2016-2025, $144 billion less than it projected in January, 2015.  Current projections for the years 2015-2019 are over $200 billion less than costs projected in 2010 when the law was adopted, while projected costs for 2019 are $56 billion, or 33 percent, lower.  The CBO also projects, however, that the ACA will reduce the number of uninsured by 25 million by 2025 rather than the 27 million it had projected in January. Read the rest of this entry »

Effective Public Engagement To Improve Palliative Care For Serious Illness


March 10th, 2015

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 a recent 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.

Public engagement is necessary to improve care for individuals suffering with serious illness. Fortunately, several drivers of potential change exist for advocacy. In the following blog post, we outline some areas for change and specify advocacy efforts we can undertake to improve the overall face of palliative care.

First, palliative care here is defined as being a type of specialized medical care for people with serious illness. Its goal is to improve quality of life for both person and family. It is provided by a team of doctors, nurses, and other specialists who work with the patient’s other providers to provide an extra layer of support. Although some people think palliative care is only for those at the end of life, it is actually appropriate at any age and at any stage in a serious illness and can be provided together with curative or disease-modifying treatment. Read the rest of this entry »

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