From The Staff

How To Succeed At Payment Reform (By Really Trying)


December 18th, 2014

Editor’s note: This is part 2 of a blog post adapted by the author from his recent keynote address at the New York State Health Foundation Conference, “Payment Reform: Expanding the Playing Field.” You can watch his half-hour speech, beginning around the eight-minute mark.

In my previous post, I explained “Why I Oppose Payment Reform.” Despite the reservations I laid out in that post, I do not actually oppose payment reform.

To summarize the case for payment reform, fee-for-service payment has supported a fragmented delivery system with little accountability for cost or quality.  As there is growing consensus that we want to move from our current system toward one that maximizes the health outcomes we achieve relative to the resources we expend, alternative payment models may provide us with a path. We should remember, however, that payment reform is a tool, not an end in itself; and we should be clear about our goals and then deploy the tool where it can help us achieve those goals.

Achieving payment reform is a process.  Here are five elements that are necessary for a successful process. Read the rest of this entry »

Health Affairs Web First: The Bottom Line On Different Management Models In State Health Exchanges


December 17th, 2014

The Affordable Care Act gives states discretion as to how they design their health insurance Marketplaces. Some states run their own Marketplace; others are part of the federally facilitated exchange; and a few chose a state-federal partnership. All states have plan management responsibilities, and if a state runs its own Marketplace, it has management choices. A “clearinghouse” model of management is when all health plans meeting published criteria are accepted into the exchange.

This model is used by some state-run exchanges and all the state-federal partnerships and federally facilitated exchanges. The alternative is the “active purchasing” model, allowing a state to directly negotiate premiums, provider networks, and other details. This model has been adopted by ten of the seventeen state-run exchanges.

A new study, released today as a Web First by Health Affairs, found that in the 2013–14 open enrollment period, state-based Marketplaces using a clearinghouse model had significantly lower adjusted average premiums for all plans within each metal tier (bronze, silver, and gold) compared to state-based Marketplaces having active purchasing models. This study offers the first attempt to assess the premium differences across Marketplace models. Read the rest of this entry »

New Health Policy Brief: Physician Compare


December 16th, 2014

A new policy brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) looks at the evolution and current development plans for Physician Compare, a website mandated by the Affordable Care Act (ACA). A simple version of the site first launched in 2010.

Since then the Centers for Medicare and Medicaid Services (CMS) has slowly been adding limited sets of data listing the various physician groups participating in a number of Medicare quality improvement initiatives. In 2015 the site will expand to include more recent and extensive information about physician performance and quality of care, in a format that’s similar to the other ACA-generated websites — Hospital Compare, Nursing Home Compare, Home Health Compare, and Dialysis Facility Compare.

These sites, which encompass tens of thousands of facilities nationwide, are credited with advancing accountability and motivating improvements in care and quality. They are also faulted as poorly organized and inadequately audited when the data are submitted by facilities. Read the rest of this entry »

Narrative Matters: Shining A Light On Child Health


December 15th, 2014

Last month, a group of writers, clinicians, policy makers and other experts gathered at Airlie House in Warrenton, Virginia, for the 2014 Narrative Matters Symposium. About an hour outside the city, the scenic fall setting—rolling farm land and trees with auburn and gold leaves—was the perfect backdrop to take attendees outside of their normal day-to-day work and introduce them to others who also are deeply passionate about improving the health of vulnerable children.

The focus of this year’s symposium was “Vulnerable Children: Using Stories to Shine a Light on Child Health.” Manuel Pastor, professor of Sociology and American Studies & Ethnicity at the University of Southern California, delivered a keynote address in which he discussed the changing demographics of the United States, which by 2043 is projected to be a “majority minority” nation — driven, not by immigration itself, but by the rising number of children born in this country to immigrants. Economists have noted that inequality in the nation causes slower economic growth, Pastor pointed out, concluding that if we reduce income disparities, we are actually contributing to national prosperity. Read the rest of this entry »

Why I Oppose Payment Reform


December 12th, 2014

I recently gave the keynote address at the New York State Health Foundation Conference “Payment Reform: Expanding the Playing Field.” This blog post is adapted from those remarks (you can watch the half-hour speech beginning around the eight-minute mark).

I had my epiphany shortly after I announced my departure from the National Academy for State Health Policy (NASHP) about nine months ago. In an effort to help find my successor, I contacted some executive search firms. One firm quoted what they referred to as the “market price.” When I pressed them to tell me how much effort this price represented, they declined to do so. Ultimately, I recommended that NASHP contract with a search firm that charged by the hour.

It was then that I realized that, given the choice between capitation (a fixed fee for the outcome I desired) and fee-for-service (an hourly rate with no accountability for the outcome), I, as a purchaser, chose fee-for-service. Only a hypocrite would go around talking about the importance of payment reform, while secretly conducting business the old way!

Having given the matter some further thought, I present my five reasons for opposing payment reform: Read the rest of this entry »

The Latest Health Wonk Review


December 9th, 2014

Last week, Hank Stern at InsureBlog provided us with a “post-turkey day” edition of the Health Wonk Review. Included in Hank’s nice round-up is a Health Affairs Blog post by Suzanne Delbanco summarizing the lessons learned from her series here on payment reform.  Read the rest of this entry »

Children’s Health: Health Affairs’ December Issue


December 8th, 2014

The December issue of Health Affairs includes a number of studies examining current threats to the health and health care of America’s children, and what can be done to meet the needs of children within an ever-evolving health care system. Some of the subjects covered: the role of Medicaid in reducing early-term elective deliveries; how pediatric services are covered in the state insurance Marketplaces; Medicaid spending on children with complex medical conditions; and the effect of abuse and neglect on children’s health and school engagement.

This issue of Health Affairs is supported by The W.K. Kellogg Foundation as well as by the Children’s Hospital Association, The David and Lucile Packard Foundation, Nemours, the Annie E. Casey Foundation, and The Child and Adolescent Health Measurement Initiative. Read the rest of this entry »

Health Affairs Event Reminder: Children’s Health


December 4th, 2014

Threats to children’s health have changed dramatically over the past few generations, but America’s health care system has been slow to transform to meet children’s evolving needs. The December 2014 thematic issue of Health Affairs examines the current state of children’s health, health care delivery, and coverage.

You are invited to join us on Monday, December 8, at a forum featuring authors from the new issue at the National Press Club in Washington, DC.  Panels will cover financing, delivery, access, and the social determinants of children’s health, and spotlight innovative programs that are making a difference.

WHEN: 
Monday, December 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_ChildHealth. 

See the full agenda. Among the confirmed speakers are: Read the rest of this entry »

Health Affairs Web First: National Health Spending In 2013 Continued Pattern Of Low Growth


December 3rd, 2014

A new analysis from the Office of the Actuary at the Centers for Medicare and Medicaid Services (CMS) estimates that in 2013 health care spending in the United States grew at a rate of 3.6 percent in 2013 to $2.9 trillion, or $9,255 per person. The increase was slower than the 4.1 percent growth in 2012 and continued a pattern of low growth that has held relatively steady at between 3.6 percent and 4.1 percent annual growth for five consecutive years.

The continued low growth in health spending is consistent with the modest overall economic growth since the end of the recent severe recession and with the long-standing relationship between economic growth and health spending—particularly several years after the end of economic recessions, when health spending and overall economic growth tend to converge. As a result, health spending’s share of the nation’s gross domestic product (GDP) remained at 17.4 percent in 2013.

The study was released today by Health Affairs as a Web First and will appear in the January issue of Health Affairs. It was discussed this morning at a reporters briefing in the National Press Club.   Read the rest of this entry »

Takeaways From Health Affairs’ Twitter Chat With PCORI


November 26th, 2014

Recently, we at Health Affairs hosted our first Twitter chat with the Patient Centered Outcomes Research Institute (PCORI) on patient engagement in research. The chat was a follow-up to the Health Affairs patient engagement issue and the recent release of three videos, produced in partnership with PCORI, on the ways patients and practitioners are incorporating patient engagement in health care decisions. The videos are hosted and reported by journalist John Dimsdale.

During the Twitter chat, we moderated a question-and-answer session with PCORI’s director of patient engagement, Sue Sheridan, while many users joined in the conversation with #PatientHC. So what does patient engagement in research look like (question courtesy of the National Partnership for Women and Families)? PCORI responded with the following tweet: “Should engage early and often, but it is not one size fits all,” and then referenced their engagement rubric. Read the rest of this entry »

Contributing Voices

Reconsidering Pauly And Coauthors’ ‘Economic Framework For Preventive Care Advice’


January 12th, 2015

Editor’s note: The following blog post is an extended version of a Letter to the Editor, published in the January issue of Health Affairs. You can read both the letter and the response from Pauly and coauthors on Health Affairs.

In the November issue of Health Affairs, Mark Pauly and coauthors criticize the lack of cost-effectiveness considerations in the Affordable Care Act (ACA), which mandates that health plans include preventive care free at the point of use. The bodies critiqued, the Advisory Committee on Immunization Practices (ACIP) and the U.S. Preventive Services Task Force, convene health experts to develop recommendations for immunizations and other preventive services.

According to the authors, the task entrusted to these bodies by the ACA, of offering sound advice on preventive care without considering its cost-effectiveness, is “impossible to do well.” They propose instead an “economic framework” under which only services with “substantial external benefits” (e.g. a vaccination for contagious disease) would be mandated for coverage. We believe this position is misguided. Read the rest of this entry »

Implementing Value-Based Payment In Practice


January 7th, 2015

Editor’s note: This post is part of a series of several posts related to the 4th European Forum on Health Policy and Management: Innovation & Implementation, to be held in Berlin, Germany on January 29 and 30, 2015. For more information or to request your personal invitation contact info@centerforhealthcaremanagement.org.

Meeting the objectives of a value-based care model requires hospitals and health systems to realign operational processes, invest in targeted resources (such as physician extenders, educational initiatives and care coordination structures), educate physicians and staff, change organizational culture, and invest in capital (such as physical locations and information technology).

Within hospitals, quality measures have been evolving from purely structural-based outcomes (such as the existence of attributes or features like a hospitalist program or an electronic medical record) to process-based (the percent of surgical patients who received prophylactic antibiotics or acute myocardial infarction patients who received aspirin within 24 hours of arrival) to patient-centered outcomes (return of a patient’s functional status post-surgically or measurement of post-surgical pain). Read the rest of this entry »

Arkansas Payment Improvement Initiative: Self-Insured Participation


January 7th, 2015

Editor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. The authors of this post are part of the team evaluating the Arkansas model.

Designed and launched by the state’s Medicaid program and some of its largest private insurers, including Arkansas Blue Cross Blue Shield (BCBS) and QualChoice, the Arkansas Payment Improvement Initiative (APII) has been a multi-payer effort since its inception in 2011. As the APII has developed, participation from some of the state’s largest self-insured employers has increased its scope and impact.

While we’ve referenced self-insured participation in our previous blog posts, we provide more detail in the following blog post on its ongoing development and explore what it takes for self-insured plans to adapt to the Arkansas Payment Improvement Initiative’s payment model. What has been the response from Arkansas employers and plans? What is the effect on existing contractual relationships? What are the hurdles? Read the rest of this entry »

A (Global) Cornucopia Of Clues To Optimize Medication Use


January 6th, 2015

The most common patient care intervention, issuing a prescription, is fraught with continuing challenges for patients, their caregivers, and practitioners. Patients rely on medications across a continuum of care, with expectations for self-management; some experience unintended problems along the way. For older patients, such problems often result in emergency hospitalizations, many of which could be prevented.

Historically, integration to support safe and appropriate medicine use across the U.S. health care ecosystem has been sporadic, including within our siloed Medicare Part D benefit. Other countries, however, are well on their way to better integration.

In the following blog post, we share examples from the United Kingdom and Australia. Fortunately, U.S. practitioners who recognize optimizing medication use as an essential element of population health can look to several recent federal opportunities to support their efforts. Read the rest of this entry »

The Lame Duck Device Tax?


January 5th, 2015

In a recent Health Affairs Blog post, I explored the types of changes that might be made to the Affordable Care Act (ACA) if and when Congress decides to revisit the law in a bipartisan manner. While that day is likely still some years away, Republican control of the Senate this year does raise the probability we’ll see action on some more central elements of President Obama’s signature domestic policy achievement.

While there has been considerable scrutiny, and bipartisan concern, about the employer mandate and the manner in which full-time employees are calculated for purposes of compliance with the ACA, for example, there has arguably been no steadier drum beat for repeal of a section of the health care law than for the medical device tax.

Senators Hatch, Coburn, and Burr, for example, in their influential repeal and replace proposal, would strike the medical device tax (along with others under the new law). Perhaps more telling, however, is the fact that 34 Democrats, including Senate leadership members Schumer, Durbin, Murray, Klobuchar, and Warren, cast a nonbinding vote to repeal the policy as recently as September 2014. Read the rest of this entry »

Implementing A Care Planning System: How To Fix The Most Pervasive Errors In Health Care


January 2nd, 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.

In the course of a single life time, medical science has made unprecedented strides in managing advanced illness. As good as the United States health care system is, it is nonetheless prone to serious error. In 2000, the Institute of Medicine estimated that as many as 268 patients die each day due to preventable hospital errors.

Although many safety issues are being addressed successfully, a significant safety concern remains. We know that many of the sickest patients suffer needlessly in their final weeks and months of life because they receive treatments that offer little benefit but great burden — treatments that are not aligned with patients’ values and goals. Although the vast majority of health care professionals are well trained and compassionate, they often work in systems organized for productivity — systems that simply do not provide sufficient opportunity for health professionals to get to know a patient and develop relationship-based perspectives. Even when patients’ perspectives become known, few mechanisms exist to document and communicate them across settings of care and over time. Read the rest of this entry »

Implementing Health Reform: Open Enrollment Progress For 2015 (Updated)


December 31st, 2014

January 8, 2015 update: Tax filing requirements.  On January 8, 2014, HHS Secretary Burwell and Treasury Secretary Lew issued a joint statement regarding new tax filing requirements that are in effect under the Affordable Care Act for 2014 taxes.  Individuals who did not have qualifying health coverage for all or part of 2014 will have to file a form 8965 and either qualify for an exemption or pay a tax penalty.  Individuals who received advance premium tax credits should receive a 1095A from their marketplace and will need to file a form 8962 to reconcile the tax credits they were due and the credits they actually received.

The press release links to an IRS publication, as well as an HHS website and two HHS flyers on ACA tax issues. HHS will be reaching out to individuals who have received premium tax credits for 2014 with further information and is working with tax preparers during the tax filing season.

Latest enrollment figures.  On January 7, CMS released its enrollment report for week 7 of the 2015 open enrollment period.  Not surprisingly, because it was a holiday week with no enrollment deadlines, only 102,896 individuals selected a plan (although 246,543 submitted an application and nearly 2 million visited the healthcare.gov website).  Total plan selections through the federal marketplaces now total nearly 6.6 million.

Medicaid/CHIP coordination with exchange coverage.  One the goals of the Affordable Care Act was to create a seamless relationship between Medicaid and CHIP, which would cover the lowest-income Americans, and premium tax credits through the marketplaces, which would assist moderate-income Americans.  Working families often transition between one form of coverage and another as their income changes, but consumers have experienced some difficulties making the transition.  In particular, individuals who are enrolled in a qualified health plan have had difficulty terminating that coverage when they are found eligible for Medicaid or CHIP, thus exposing them to having to pay back premium tax credits that they were not entitled to and to pay premiums for coverage that they do not need and cannot afford.  Consumers have also experienced problems when the marketplace assesses them to be eligible for Medicaid or CHIP, and thus ineligible for premium tax credits, but the state Medicaid agency determines that they are ineligible for Medicaid or CHIP.

On December 30, 2014, CMS released a guidance providing directions for handling these situations.  The guidance provides step-by-step instructions to be followed by qualified health plan enrollees when they or some members of their family are assessed or determined by the marketplace to be eligible for Medicaid or CHIP.  Individuals assessed by the marketplace to be eligible for Medicaid or CHIP may either terminate qualified health plan coverage at that time or wait until they receive a definite eligibility determination from the state Medicaid agency.  The guidance also provides instructions for individuals to follow, if they terminate QHP coverage upon being assessed as eligible by the marketplace but are then determined ineligible for Medicaid or CHIP by the state Medicaid agency, that will permit them to reenroll in QHP coverage and receive retroactive coverage through a special enrollment period.

Original post.  On December 30, 2014, the Centers for Medicare and Medicaid Services released several reports on enrollment numbers covering the second marketplace enrollment period to date.  It released its first monthly ASPE (Assistant Secretary for Planning and Evaluation) report covering October 15 to November 15, 2014.   (press release here  )  The ASPE report for the first time includes some — very incomplete — information on enrollment in the state-operated exchanges.

CMS simultaneously released a snapshot report covering enrollment in the Federally Facilitated Marketplace (FFM) for the sixth week of open enrollment.

The bottom line is that the reports confirm what we all knew already: The first month of open enrollment is going much better than the early months of open enrollment last year.  As of December 26, 6,490,492 individuals had selected a plan through the FFM.  Only 96,446 selected a plan in Week 6, compared to 3.9 million in week 5, emphasizing again the importance of the December 15 deadline for January 1 coverage in driving enrollment. Read the rest of this entry »

What Does ‘Big Data’ Mean In The Context Of Coordinated Care?


December 30th, 2014

Editor’s note: This post is part of a series of several posts related to the 4th European Forum on Health Policy and Management: Innovation & Implementation, to be held in Berlin, Germany on January 29 and 30, 2015. For more information or to request your personal invitation contact the Center for Healthcare Management.

In economic terms, coordinated care is about vertical integration in the quest of a competitive edge. Just as IBM subjects its computer chip suppliers to rigorous monitoring to ensure a high-quality, high-price product, so too do health insurance companies impose restrictions on participating providers designed to achieve a favorable ratio of patient utility to cost and with it, a competitive ratio of the utility of policy holders to premiums.

This endeavor calls for collating information from multiple sources, which is typical of big data: When does a particular health problem arise? Why? What is the appropriate intervention? Who should provide it? How should it be carried out? Where should it be provided? Answers to these questions are necessary for the implementation of quality assurance programs. Read the rest of this entry »

Rethinking The Gruber Controversy: Americans Aren’t Stupid, But They’re Often Ignorant — And Why


December 29th, 2014

M.I.T. economist Jonathan Gruber, whom his colleagues in the profession hold in very high esteem for his prowess in economic analysis, recently appeared before the House Committee on Oversight and Government Reform. Gruber was called to explain several caustic remarks he had offered on tortured language and provisions in the Affordable Care Act (the ACA) that allegedly were designed to fool American voters into accepting the ACA.

Many of these linguistic contortions, however, were designed not so much to fool voters, but to force the Congressional Budget Office into scoring taxes as something else. But Gruber did call the American public “stupid” enough to be misled by such linguistic tricks and by other measures in the ACA — for example, taxing health insurers knowing full well that insurers would pass the tax on to the insured.

During the hearing, Gruber apologized profusely and on multiple occasions for his remarks. Although at least some economists apparently see no warrant for such an apology, I believe it was appropriate, as in hindsight Gruber does as well. “Stupid” is entirely the wrong word in this context; Gruber should have said “ignorant” instead. Read the rest of this entry »

The Challenge Of Financing Sustainable Community-Based Palliative Care Programs


December 29th, 2014

Since its publication in September 2014, there has been widespread praise for the Institute of Medicine (IOM) report, Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. It is a masterful piece of scholarship that summarizes the spectrum of issues facing palliative care.

We hope the report will influence key decision-makers in medicine and various legislatures to promote the many changes outlined in the document, enabling palliative care to further improve the quality of life for those with advanced illness.

Yet, despite the encyclopedic scope of Dying in America, the report did not make suggestions about how to achieve sustainable funding for community-based palliative care. Freestanding programs provide special value to some of the sickest members of the population who struggle with their serious illness while living in the community, outside any facility or hospice program. Read the rest of this entry »

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