Health Affairs

Three years after wellness was hailed as perhaps the only truly bipartisan component of the Affordable Care Act, both lay and trade commentators have begun observing that the assumptions behind it were incorrect while downsides were overlooked.   As a predictable result, savings have proven elusive even in seemingly ideal baseline circumstances for health improvement.  For example, a wellness program at BJC HealthCare in St. Louis reduced hospitalizations for wellness-sensitive medical events, but the savings were limited (and offset by other cost increases) by the fact that older employees there on average were hospitalized for a wellness-sensitive medical event only once every 12 years to begin with.  (See Note 1.)

Consistent with that finding, commentators (including the authors) have noted that every vendor claiming savings from what the Affordable Care Act (ACA) terms “health contingent” wellness programs has employed obviously flawed study design (like comparing the results from active motivated participants to non-motivated non-participants, and crediting the program, rather than the obvious difference in motivation, for the savings) and/or has simply made up or  misinterpreted their own outcomes .

One reason for the absence of savings is that the biometric screenings themselves on which wellness economics are based cost far more money than they can conceivably save, due to both the likelihood of overdiagnosis and the marginal benefit of taking frequent measurements in generally healthy adults.  Routine screening lacks an evidence basis and is eschewed by the medical community. For example, the federal government recommends lipid screening only once every five years. Read the rest of this entry »

April 2013 has been a quiet month for new Affordable Care Act rules and guidance. Activity to implement the ACA, of course, is moving full speed ahead at the federal level as efforts continue to implement the federal exchange and to gear up for federal enforcement of the market reforms in a number of states. The Centers for Medicare and Medicaid Services (CMS) is in the process of holding stakeholder calls in every state where a federal exchange (now called a “marketplace”) will be established. It is also locating navigator programs, signing up insurers, and preparing for the October 1, 2013 beginning of open enrollment. The states have also been very active, either trying to implement their own state exchanges and the 2014 ACA market reforms or doing everything they can dream up to keep implementation from moving ahead.

Final rules have been issued governing the exchanges, the 2014 market reforms, the premium tax credits, and the premium stabilization programs, while guidance has been issued on the federal exchanges and the navigator program. Final rules on Medicaid eligibility and appeals are expected shortly. A public hearing was held on April 23, 2013 regarding the proposed employer responsibility regulations, while another will be held on May 29, 2013 reviewing proposed individual responsibility regulations. Final rules will follow in due course. In sum, implementation is progressing, although a lot of ground must be covered between now and 2014. Read the rest of this entry »

There is a growing consensus that the regulatory system for research is in need of reform. Established 21 years ago by the Common Rule, it has functioned via a rigorous environment to assure that risk in research is dealt with and transparency maintained.

The trigger for these regulations is a definition of research as a “systematic investigation…designed to develop or contribute to “generalizable knowledge.“  When this definition is satisfied, an intensive set of requirements ensues including review, approval, and continued oversight by an Institutional Review Board (IRB); reporting requirements;, the necessity for informed consent (often highly complex); and other administrative components. If projects are not “generalizable,” (e.g., local hospital programmatic or quality review), they fall strictly under healthcare system purview rather than under Common Rule regulatory oversight.

The current system has a strong moral imperative and has been critical to mitigating risk for research subjects and providing transparency.  However, it is burdensome and fails to take into account the considerable progress made in both the research and clinical enterprises over the last few decades:  in research, technological advances in generating data on routine care, and in healthcare, much more stringent oversight. Read the rest of this entry »

This commentary is in response to the March 5, 2013 Health Affairs article, “Wellness Incentives in the Workplace: Cost Savings through Cost Shifting to Unhealthy Lifestyles.”  In that article, Jill Horwitz and coauthors express concerns about new rules governing workplace health promotion (wellness) programs due to take effect in 2014 as part of the Patient Protection and Affordable Care Act of 2011, Public Law 111-148 (“ACA”).  In addition to increasing access to health care services for all Americans, the ACA aims to place greater emphasis on health promotion and disease prevention and to encourage employer adoption of workplace wellness programs.

As I discuss below, some of the concerns raised by Horwitz et al. are legitimate points that I agree with. However, I believe that Horwitz and her colleagues go too far when they appear to question the basic idea that employees with modifiable health risks cost more than those without such risks, calling into question the entire concept of workplace wellness programs and indeed of prevention in general. In this post, I explain how well-designed wellness programs can benefit both employers and employees, and I offer some suggestions to ensure that such programs are both effective and fair.

A specific provision of the ACA (Section 2705), which is at the heart of the controversy addressed by Horwitz et al., will allow employers to design incentive-based wellness programs that reward not only participation in health promotion programs but also “outcomes” related to having healthy habits and managing biometric values within “normal” ranges.  Under the new rules, financial incentives (e.g., different health plan designs, payment terms, premiums levels, deductibles, co-insurance or co-payments) could be offered to workers who are nonsmokers, are at a given weight or BMI, or are effectively controlling their blood pressure, total cholesterol, and blood glucose.  Rewards or incentives would also be made available to employees who eat a healthy diet or are physically active. Read the rest of this entry »

More than two-thirds of Medicare beneficiaries have multiple chronic conditions, such as heart disease and diabetes, and that number is projected to rise significantly in the U.S., given our aging population. The Chronic Conditions Dashboard, recently launched by the Centers for Medicare & Medicaid Services (CMS), is the first in a series of planned web-based enhanced data analytic and visualization tools.

Use of the data available from the Dashboard can help policymakers, local health leaders, and health systems improve care coordination and health outcomes, and can help slow the increase in expenditures for Medicare beneficiaries living with multiple chronic conditions. The Dashboard was developed to be user-friendly and incorporated strong health information privacy protections, as individually-identifiable information cannot be accessed. The release of the Chronic Conditions dashboard supports the Administration’s Health Data Initiative that seeks to release more health-related data in more usable formats to support health promotion and care innovation. Read the rest of this entry »

Editor’s note: The February issue of Health Affairs was a thematic issue focused on patient engagement. In conjunction with the Patient-Centered Outcomes Research Institute (PCORI), the journal launched a new initiative inviting questions from patients and others via Facebook for Health Affairs authors on patient-centeredness and patient engagement. Questions are then answered on Health Affairs Blog.

Below, Benjamin Moulton, the senior legal adviser at the Foundation for Informed Medical Decision Making, answers a question from a reader. In the February issue (writing with Jamie King) and at the issue release event, Moulton described the results of the Group Health Demonstration Project; under a Washington State legislative mandate, Group Health studied the costs and benefits of integrating shared decision making and decision aids into clinical practice across a range of conditions for which multiple treatment options are available. Previously, Ming Tai-Seale, Jessie Gruman and Rachael Fleurence answered questions from readers.

Joan DeClaire: Thanks for a great description of how shared decision making is working within Group Health Cooperative, an integrated health system. Do you think it will take off in other kinds of health care settings? And if so, what will be the catalyst? Read the rest of this entry »

Does the United States have at its disposal a method for predictably controlling the cost and improving the quality of our health care? Can we begin by budgeting or Indexing Health Care expenditures in the Medicare HMO program now called Medicare Advantage (MA) to grow at the same rate or more slowly than the gross domestic product (GDP)?

The Indexed Health Care proposal that I outline below builds on the success of MA, but it also calls for important reforms in that program. After indexing MA costs to GDP growth, the next steps should be to progressively convert Medicare from fee-for-service to prepaid capitated payments, and to index Medicare and all federal health care expenditures – including tax expenditures – to GDP growth. The private health care sector must be persuaded to move from FFS to capitated payments. Read the rest of this entry »

Poorly manufactured and fraudulent medicines kill thousands of people around the world each year. For infectious diseases like malaria and HIV, shoddy medicines also accelerate drug resistance and dramatically alter the course of epidemics. With few new drugs under development, recent progress against these major killers in the poorest countries is precarious.

Bad drugs have become a big problem for one major infectious disease in particular: tuberculosis. If we don’t solve this issue, we may see the gains we’ve made against TB slip away.

According to the World Health Organization, global TB cases continued on a slow downward trend in 2011. While this is good news, the disease still claimed 1.4 million lives that year—more than any other infectious disease except HIV/AIDS. Meanwhile, multidrug-resistant TB cases rose to 630,000 worldwide. Resistant TB is deadly and costs significantly more to treat. For example, curing a single case of it in the United States can cost more than $200,000. Treatment takes two years, and the side effects can be severe, including nausea, vomiting, joint pain, and even hearing loss. Read the rest of this entry »

Editor’s note: The February issue of Health Affairs was a thematic issue focused on patient engagement. In conjunction with the Patient-Centered Outcomes Research Institute (PCORI), the journal launched a new initiative inviting questions from patients and others via Facebook for Health Affairs authors on patient-centeredness and patient engagement. Questions are then answered on Health Affairs Blog.

Below, Ming Tai-Seale of the Palo Alto Medical Foundation Research Institute answers a reader query; previously, Jessie Gruman and Rachael Fleurence answered questions. Watch for a Health Affairs Facebook post tomorrow inviting questions for Benjamin Moulton of the Foundation For Informed Medical Decision Making.

Paul Gionfriddo: Ming, you’ve concluded both that we need a better system of communication between clinicians and patients with less variation in clinicians’ responses and that clinicians appear to be out of their comfort zone communicating with patients about mental health concerns. Would you argue that more universal use of screening tools like the PHQ-9, coupled with better training of primary care clinicians about how to interpret results, respond to patients, and refer (via collaboration to or integration with) behavioral health professionals would create more effective give-and-take with patients and address some of the issues you raised in your paper?

Ming Tai-Seale: Thank you, Paul, for your thoughtful question. Indeed, the United States Preventive Services Task Force (USPSTF) has recommended that screening adults for depression be done in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up. Read the rest of this entry »

On April 9, 2013, the Centers for Medicare and Medicaid Services of the Department of Health and Human Services announced the availability of $54 million to fund navigator programs in states that have federally facilitated or partnership exchanges.  This funding is not available for states that operate their own exchanges, which must pay for their own navigator programs.

Since federal establishment grants cannot be used to fund state navigator programs, it is possible that some states with state exchanges will not have navigator programs up and running until after their exchanges open and begin to generate their own revenue.  It is hoped, however, that the gap in these states will be filled by consumer in-person assisters, who can be paid from establishment grants and should become available this year.

Each state will qualify for at least $600,000 in funds, with states with larger uninsured populations qualifying for larger amounts.  Texas, for example, will qualify for $8,181.185 in grants; Florida for $5,851,072.  Thirteen states will qualify for the minimum $600,000. (Curiously, the list of federal exchanges includes Utah, which earlier received contingent approval to establish a state exchange).  If all the funds allocated to any state are not awarded within that state, any remaining funds will be awarded to grant applicants from other states based on their meeting the funding criteria.  Applications are due June 7, 2013, and awards will be made on August 15, 2013.  Funds will be provided through cooperative agreements rather than grants, the distinction turning on the greater federal programmatic involvement under cooperative agreements. Read the rest of this entry »