August 6th, 2014
Note: In addition to Marc Berk, Claudia Schur also coauthored this post.
Recent discussion about the Affordable Care Act has intensified the media’s interest in the cost of medical care. While as health services researchers we are perhaps in the best position to provide information on complex health care topics, we may need to improve our ability to distill information into one minute sound bites.
A particularly interesting example of the disconnect between media reporting and a more nuanced analysis occurred earlier this year, on March 4, when NBC ran a story about the cost of having a baby. The story confused the very different concepts of what health care providers charge, what they are actually paid, and what consumers owe, and in so doing obscured one of the key benefits for consumers of being insured.
We were startled to hear that, according to NBC, the cost of having a baby has increased more than 300 percent in the past 10 years. According to the report, the cost of a vaginal delivery went from $7,700 to $32,000, while the cost of a cesarean birth went from $11,000 to $51,000. A small heading in the table presented by NBC cited Truven Analytics as the source of these data. Read the rest of this entry »
August 5th, 2014
Note: In addition to Suzanne Delbanco, this post is also coauthored by David Lansky.
“The accountable care organization is like a unicorn, a fantastic creature that is vested with mythical powers. But no one has actually seen one,” said former California HealthCare Foundation CEO, Mark Smith, MD, in 2010. Over the last four years, we’ve certainly seen a proliferation of unicorns and we’re now reaching the point where fantasy—at least in a handful of cases—is becoming a reality.
A growing number of large employers are piloting accountable care organizations (ACOs), working through their health plan; in some cases they are doing so directly with provider systems, such as the new Boeing arrangement with Providence Health and Services, Swedish Health Services, and University of Washington Medicine and Intel’s contracting efforts in Albuquerque, New Mexico and Portland, Oregon. The large employers and other health care purchasers with whom we work — eager, if not desperate, for solutions to contain the costs of health care and improve its quality — are watching these first movers carefully to see if ACOs prove to be a viable strategy for improving population health and bending the cost trend.
These leading purchasers intend to set the bar high. They cannot make the investment to pursue these ACO relationships if they are not assured that their populations will see meaningful, measurable gains in their health care and its affordability, as well as their health. That often means contractual commitments to lowering total costs of care and showing improved patient outcomes for targeted populations — like high risk, medically complex patients. Our purchaser colleagues who have been among the early adopters of ACO arrangements have begun to identify the features critical to successful ACOs; these are the elements other purchasers will look for when deciding if it’s worth proceeding. Read the rest of this entry »
August 5th, 2014
Note: In addition to Tom Williams, Jill Yegian also coauthored this post.
Seeing “IHA” and “Fails” together in the title of an article in the nation’s premier health policy journal was not an outcome that we anticipated when the bundled payment initiative described by M. Susan Ridgely et. al in the August issue of Health Affairs was launched.
The key objective of the Integrated Healthcare Association (IHA)’s initiative was to implement over 20 payer-provider bundled payment contracts, resulting in completion of more than 500 bundled cases within the first two years of the project. During the third year of the project, researchers were to conduct both a clinical and an economic evaluation to test how bundled payments affect the quality and cost of care, in conjunction with an implementation evaluation to determine the scalability of this approach.
Looking back, these targets seem highly optimistic; but at the pilot’s launch, both IHA and its stakeholders had a number of reasons to be confident. The pilot was well funded by a three-year grant from the Agency for Health Research and Quality (AHRQ), building on two rounds of planning and feasibility work over four years funded by the Blue Shield of California Foundation and the California HealthCare Foundation. In addition, there was a high level of interest and enthusiasm among a core group of providers and health plans that had a prior history of collaboration in a California physician pay for performance program. Read the rest of this entry »
August 4th, 2014
Note: In addition to Christopher Koller, Sabrina Corlette coauthored this post.
The rates are coming, the rates are coming.
While there seem to be fewer “latest verdicts on the ACA,” breathlessly reported in the popular press, as we move through the second half of 2014, the filing of 2015 rate requests for individual and small group products on the health insurance exchanges offer one more piece of catnip for pundits.
Who is up? Who is down? How much? Is this the dreaded death spiral for the ACA? Or its vindication?
As discussions and analysis of these increases are disseminated, it is important to remember the following points. Read the rest of this entry »
August 4th, 2014
Note: In addition to Jon Kingsdale, this post is coauthored by Julia Lerche.
Since recovering from its flawed rollout, the ACA has enjoyed a string of successes. By April, some eight million Americans managed to enroll; for 2015, some reluctant insurers, including the nation’s second largest (United), are jumping into the new ACA Marketplaces; and the New England Journal of Medicine recently published an analysis confirming the ACA’s significant reduction of the uninsured.
Approximately 87 percent of Marketplace enrollees claimed premium tax credits, of which an estimated 85 percent, or six million, actually paid premiums. (We assume a disenrollment rate of 3 percent per month since April 2014, which is conservative compared with the Massachusetts Health Connector’s experience and in line with the assumptions of several State-based Marketplaces.) Many of the original six million, plus more recent enrollees, will experience their second enrollment between November 15, 2014 and February 15, 2015. They will also file with the IRS for a premium tax credit as early as January 2015.
The two events in combination represent a huge risk. We hope the responsible agencies will act soon to mitigate the risks. Read the rest of this entry »
August 1st, 2014
On July 31, 2014, Michael Carvin, attorney for the plaintiffs in King v. Burwell, one of two parallel cases challenging an IRS rule allowing premium tax credits to be issued by federally facilitated exchange, filed a petition for a writ of certioriari in the United States Supreme Court. The petition asks the Court to review the Fourth Circuit decision affirming Judge James Spencer’s ruling rejecting their claim.
As was described here in detail last week, ACA opponents lost in the Fourth Circuit in a unanimous decision in King v. Burwell but won a split decision in the District of Columbia Circuit Court of Appeals in Halbig v. Burwell. Carvin is thus seeking Supreme Court review based on a split of authority between the circuits that must be resolved by the Supreme Court.
It is not the intent of this post to review the arguments in Carvin’s brief. Carvin argues that judges Griffith and Randolph made the right decision in Halbig, and that judges Gregory, Thacker and Davis in the Fourth Circuit and Edwards in the D.C. Circuit are wrong. There is really only one new argument in the petition that was not made below, namely that Congress’ intent to deny premium tax credits in states that failed to establish exchanges has now been conclusively established by statements made by Jon Gruber two years after the statute was adopted. This disregards the fact that Gruber neither drafted nor voted on the ACA and had earlier stated that premium tax credits were available in federally facilitated exchange states. Read the rest of this entry »
August 1st, 2014
Editor’s note: In addition to Roy Rosin, this post is also coauthored by Evan Fieldston and David Asch.
The French filmmaker Jean Renoir said, “the foundation of all civilization is loitering,” expressing the view that transformative value is created when people have time to step back and imagine a better way. Most businesses today seem to take a contrary position. Organizations in health care and beyond have spent a generation attacking slack, removing inefficiencies within processes and budgets. The narrow operating margins of health systems have led many to turn to companies such as Toyota or General Electric (GE) to learn about lean or Six Sigma techniques.
Subsequently, frontline clinicians are easy targets for attacks on slack. They are among the most expensive personnel within health systems and their productivity drives profitability. Working at the top of one’s license is set as a goal — reflecting the view that anything that can be delegated to a less expensive resource should be, and that everyone should be adding directly measurable peak value at all times. Read the rest of this entry »
July 31st, 2014
After nearly two years of deliberation, the Institute of Medicine (IOM) Committee on the Governance and Financing of Graduate Medical Education (GME) has issued its report. It presents a strong case for the need for change and a strong case for its recommendations.
The members of the Committee and the IOM are to be commended for their hard work, vision, and a high quality report. The report presents a clear path to a system that would help produce a physician workforce better aligned with the nation’s needs and a framework for a rational and defensible expenditure of nearly 15 billion dollars in public funds each year on GME.
Issues related to GME financing have been contentious for many years. In 1965, Congress included GME financing under Medicare reimbursement in what was intended to be a temporary arrangement. Nearly 50 years later, we are still trying to find a permanent and more rational way to finance and pay for the training of physicians as an alternative to the current complex, arcane formula built on Medicare inpatient days. Despite the well-documented shortcomings of the current system and numerous studies, attempts to find agreement on how to change and improve GME financing have been unsuccessful. Read the rest of this entry »
July 31st, 2014
Editor’s note: In addition to Darshak Sanghavi, Meaghan George and Sara Bencic also coauthored this post.
Individual patient expanded access, sometimes termed “compassionate use,” refers to situations where access to a drug still in the development process is granted to patients on a case-by-case basis outside of a clinical trial, prior to completion of mandated clinical trials and approval by the Food and Drug Administration (FDA). This typically involves filing a single patient or emergency investigational new drug (IND) request with the Food and Drug Administration and voluntary release of the drug by the manufacturer.
Generally, the following criteria must be met: there is reasonable expectation of meaningful benefit despite the absence of definitive clinical trial data, the patient has a serious or life-threatening condition, there are no comparable or satisfactory treatment alternatives, and there are no suitable clinical trials for the drug available to the patient. This form of expanded access, which is the focus of this paper, is different from the situation in which a drug is discharged to a large group of needy patients in the interval between successful phase 3 trials and presumed FDA approval, a strategy often termed a “treatment” IND or protocol, which was initially used in the 1980s for releasing zidovudine to patients with acquired immune deficiency syndrome.
A Call to Action: The Importance of Expanded Access Programs
The Engelberg Center for Health Care Reform at the Brookings Institution recently invited senior leaders from several pharmaceutical companies, two bioethicists, a senior FDA representative, and a patient advocate to share experiences and discuss organizational strategies related to expanded access (see acknowledgements). A driving factor for this meeting was a recent flurry of highly public cases of desperate patients seeking access to experimental drugs, which lead to social media campaigns and media coverage. Read the rest of this entry »
July 30th, 2014
Editor’s note: Otis Brawley also coauthored this post. This post is part of a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on an upcoming volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.
Racial and ethnic disparities in health care have been well documented among minority groups with respect to access to care, receipt of care, and quality of care. As a result of these disparities, minority populations are often diagnosed with late stage illness and have inferior outcomes likely leading to increased suffering.
Little is known, however, about disparities in access to and use of specialty palliative care. Palliative care is medical care aimed at relieving suffering and providing the best possible quality of life for people facing pain, symptoms, and stresses from serious illness. Palliative care is appropriate for patients at any age or illness stage and can be provided along with curative or life-prolonging therapies. Read the rest of this entry »