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Burden of Depressive Disorders

Reviewer and Curator: Larry H Bernstein, MD, FCAP

 

This article is an important contribution to the literature on depression, substantiation the cardiovascular burden of depression on cardiovascular disease.

Burden of Depressive Disorders by Country, Sex, Age, and Year:Findings from the Global Burden of Disease Study 2010

AJ Ferrar*,FJ Charlson,RE Norman,SB Patten, G Freedman, CJL.Murray,T Vos

1Universityof Queensland, School of Population Health,Herston, Queensland, Au
2Queensland Centre for Mental Health Research, Wacol, Queensland, Au
3University of Queensland, Queensland Children’s Medical Research Institute,Herston,Queensland, Au
4Universityof Calgary, Department of Community Health Sciences,Calgary, Alberta, Ca
5University of Washington,Institute for Health Metrics and Evaluation, Seattle, Wash

Abstract

Background

Depressive disorders were a leading cause of burden in the Global Burden of Disease (GBD) 1990 and 2000  studies. Here, we analyze the burden of depressive disorders in GBD 2010 and present severity proportions ,burden by country, region, age, sex, and year, as well as burden of depressive disorders as a risk factor fo rsuicide and ischemic heart disease.

Methods and Findings

Burden was calculated for major depressive disorder (MDD) and dysthymia. A systematic review of  epidemiological data was conducted. The data were pooled using a Bayesian meta-regression. Disability weights from population survey data

  • quantified the severity of health loss from depressive disorders.

These weights were used to calculate

  • years lived with disability (YLDs) and
  • disability adjusted life-years (DALYs).

Separate DALYs were estimated for

  • suicide and
  • ischemic heart disease

attributable to depressive disorders. Depressive disorders were the second leading cause of YLDs in 2010.

  • MDD accounted for 8.2% (5.9%–10.8%) of global YLDs and
  • dysthymia for 1.4% (0.9%–2.0%).

Depressive disorders were a leading cause of DALYs even though no mortality was attributed to them as the underlying cause.

  • MDD accounted for 2.5% (1.9%–3.2%) of global DALYs and
  • dysthymia for 0.5% (0.3%–0.6%).

There was more regional variation in burden for MDD than for dysthymia; with

  • higher estimates in females, and
  • adults of working age.

Whilst burden increased by 37.5% between 1990 and 2010, this was due to population growth and ageing. MDD explained

  • 16 million  suicide DALYs and
  • almost 4 million ischemic heart disease DALYs.

This attributable burden would increase the overall burden of depressive disorders from 3.0% (2.2%–3.8%) to 3.8% (3.0%–4.7%) of global DALYs.

Conclusions

GBD 2010 identified depressive disorders as a leading cause of burden. MDD was also a contributor of burden

  • allocated to suicide and ischemic heart disease.

These findings emphasize the importance of including depressive disorders as a public-health priority and

  • implementing cost-effective interventions to reduce its burden.

Please see later in the article for the Editors’ Summary.

Citation:Ferrari AJ, Charlson FJ, Norman RE, Patten SB, Freedman G,etal.(2013) Burden of Depressive Disorders by Country, Sex, Age, and Year: Findings from the Global Burden of Disease Study 2010. PLoS Med 10(11):e1001547. http://dx.doi.org/10.1371/journal.pmed.1001547

Abbreviations: CRA, comparative risk assessment; DALY, disability adjusted life years; DSM, Diagnostic and Statistical Manual of Mental Disorders; GBD, global burden of disease; ICD, International Classification of Diseases; MDD, major depressive disorder; MEPS, US Medical Expenditure Panel Survey; NESARC, US National Epidemiological Survey on Alcohol and Related Conditions 2000–2001 and 2004–2005; NSMHWB, Australian National Survey of Mental Health and Well being of Adults 1997; RR, relative risk; YLD, years lived with disability;YLL,years of life lost.

Figure1.YLDs by age and sex for MDD and dysthymia in 1990 and 2010.  http://dx.doi.org/10.1371/journal.pmed.1001547.g001

Figure1.YLDsbyageandsexforMDDanddysthymiain1990and2010.

Figure2.YLD rates (per100,000) by region for MDD and dysthymia in 1990 and 2010. 95%UI, 95% uncertainty interval; AP-HI, Asia Pacific, high income; As-C, Asia Central; AS-E, Asia East; AS-S, Asia South;A-SE, Asia Southeast; Aus, Australasia; Caribb, Caribbean; Eur-C, Europe Central; Eur-E, Europe Eastern; Eur-W, Europe Western; LA-An, LatinAmerica, Andean; LA-C, Latin America, Central; LA-Sth, LatinAmerica, Southern; LA-Trop, Latin America, Tropical; Nafr-ME, NorthAfrica/MiddleEast; Nam-HI, North America, high income; Oc, Oceania; SSA-C, Sub-Saharan Africa, Central; SSA-E, Sub-Saharan Africa, East; SSA-S, Sub-Saharan Africa Southern; SSA-W, Sub-Saharan Africa,West.  http://dx.doi.org/10.1371/journal.pmed.1001547.g002

Figure2. YLD rates (per100,000) by region for MDD and dysthymia in 1990 and 2010

Plot 1  age dtandardized YLD rates

Editors’ Summary

Background.

Depressive disorders are common mental disorders that occur in people of all ages across all world regions. Depression—an overwhelming feeling of sadness and hopelessness that can last for months or years—can make people feel that life is no longer worth living. People affected by depression lose interest in the activities they used to enjoy and can also be affected by physical symptoms such as disturbed sleep. Major depressive disorder (MDD, also known as clinical depression) is

  • an episodic disorder with a chronic (long-term) outcome and increased risk of death.

It involves at least one major depressive episode in which the affected individual experiences

  • a depressed mood almost all day, every day for at least 2 weeks.

Dysthymia is a milder, chronic form of depression that lasts for at least 2 years. People with dysthymia are often described as constantly unhappy. Both these subtypes of depression (and others such as that experienced in bipolar disorder) can be treated with antidepressant drugs and with talking therapies.

Why Was This Study Done? Depressive disorders were a  leading cause of disease burden in the 1990 and 2000 Global Burden of Disease (GBD) studies, collaborative scientific efforts that quantify the health loss attributable to

  • diseases and injuries in terms of disability adjusted life years (DALYs; one DALY represents the loss of a healthy year of life).

DALYs are calculated by adding together the years of life lived with a disability (YLD, a measure that includes a disability weight factor reflecting disease severity) and the years of life lost because of disorder-specific premature death. The GBD initiative aims

  • to provide data that can be used to improve public-health policy.

Thus, knowing that depressive disorders are a leading cause of disease burden worldwide has helped to prioritize depressive disorders in global public-health agendas. Here, the researchers analyze the burden of MDD and dysthymia in GBD 2010 by country, region, age, and sex, and

  • calculate the burden of suicide and ischemic heart disease attributable to depressive disorders (depression is a risk factor for suicide and ischemic heart disease).

GBD 2010 is broader in scope than previous GBD studies and quantifies the direct burden of 291 diseases and injuries and the  burden attributable to 67 risk factors across 187 countries.

What Did the Researchers Do and Find? The researchers collected data on

  • the prevalence, incidence, remission rates, and duration of MDD and dysthymia and on deaths caused by these disorders from published articles.

They pooled these data using a statistical method called Bayesian meta-regression and calculated YLDs for MDD  and dysthymia using disability weights collected in population surveys. MDD accounted for 8.2% of global YLDs in 2010, making it the second leading cause of YLDs. Dysthymia accounted for 1.4% of global YLDs. MDD and dysthymia were also leading causes of DALYs, accounting for 2.5% and 0.5% of global DALYs, respectively. The regional variation in the burden was greater for MDD than for dysthymia, the  burden of depressive disorders was higher in women than men, the largest proportion of YLDs from depressive  disorders occurred among adults of working age, and the  global burden of depressive disorders increased by 37.5%  between 1990 and 2010 because of population growth and ageing. Finally, MDD explained an additional 16 million  DALYs and 4 million DALYs when it was considered as a risk factor for suicide and ischemic heart disease, respectively.  This ‘‘attributable’’ burden increased the overall burden of depressive disorders to 3.8% of global DALYs.

What Do These Findings Mean? These findings update and extend the information available from GBD 1990 and  2000 on the global burden of depressive disorders. They confirm that

  • depressive disorders are a leading direct cause of the global disease burden and show that
  • MDD also contributes to the burden allocated to suicide and ischemic heart disease.

The estimates of the global burden of depressive disorders reported in GBD 2010 are likely to be more accurate than those in previous GBD studies but are  limited by factors such as the sparseness of data on depressive disorders from developing countries and, consequently,

  • the validity of the disability weights used to calculate YLDs.

Even so, these findings reinforce the importance of treating  depressive disorders as a public-health priority and

  • of implementing cost-effective interventions to reduce their  ubiquitous burden.

Additional Information. Please access these websites via  the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001547.

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Patient Protection and Affordable Care Act Featured at RAND

Reporter: Aviva Lev-Ari, PhD, RN

Below the reader will find a compilation of all the articles related to Affordable Care Act Featured at RAND

The Patient Protection and Affordable Care Act (ACA)—the sweeping health care reform sometimes known as “Obamacare”—was enacted in 2010. The law aims to expand access to health coverage for uninsured Americans.

The ACA does this through several provisions: an individual mandate requiring adults to have health insurance or pay a fine; an employer mandate requiring firms with 50 or more employees to offer coverage or pay a fine; a requirement that each state establish a health insurance exchange or accept a federally established exchange in which individuals and small businesses can buy coverage; an expansion of Medicaid eligibility to cover greater numbers of lower-income people. (A 2012Supreme Court decision held that states could not be required to expand Medicaid, thus leaving expansion up to the states.)

In addition, the ACA makes changes to Medicare intended to cut costs, shore up the program’s fiscal solvency, and improve delivery of care.

What’s Next for the ACA

With most of the ACA’s provisions taking full effect in 2014, the complex process of implementing the law is underway across the country. RAND research is tracking the progress of implementation and assessing the potential consequences of choices facing decisionmakers at many levels: federal and state governments, employers, families, and individuals.Our recent work has examined the likely impact of the ACA in four key policy areas:

Patient Protection and Affordable Care Act
Through a number of provisions — such as individual and employer mandates, health insurance exchanges, and the expansion of Medicaid — the Patient Protection and Affordable Care Act (ACA) aims to expand access to health care for uninsured Americans. RAND has examined implementation challenges, cost and coverage implications, Medicaid expansion, state health insurance exchanges, and reforms to both care delivery and payment.

Featured at RAND

The RAND Health Reform Opinion Study

group opinionsThe RAND Health Reform Opinion Study tracks public opinion of the Affordable Care Act by surveying the same people over time. This allows us to observe true changes in public opinion, rather than changes based on who was surveyed randomly.

The Affordable Care Act: Four Key Policy Areas

Obama signing the ACAWith the complex process of implementing the ACA underway, RAND research is tracking the progress of implementation and assessing the potential consequences of choices facing federal and state governments, employers, families, and individuals.

All Items (123)

Fotolia_52964211_Subscription_Monthly_XXLThe latest data from the RAND Health Reform Opinion Study indicates that positive opinion of the ACA continues to increase. The overall favorable rating is now as high as it was in late September, prior to the opening of the health insurance exchanges.

BLOG

RAND Health Reform Opinion Study Update: Positive Opinion on ACA Grows, Negative Opinion Stabilizes— Dec 23, 2013

President Barack Obama and First Lady Michelle Obama discuss the Affordable Care Act with mothersLast week we introduced the RAND Health Reform Opinion Study, a new way to measure public opinion of the Affordable Care Act. Negative opinion about the ACA seems to be stabilizing, while positive opinion is increasing. Those undecided about the ACA are decreasing.

COMMENTARY

A New Way to Measure Public Opinion of Health Reform — Dec 18, 2013

Obama healthcare law supporters rally during the third and final day of legal arguments over the Patient Protection and Affordable Care Act at the Supreme Court in Washington, March 28, 2012Whether the public will begin to settle on an overall positive or negative perception of the Affordable Care Act (ACA) is very much an open question. But understanding how opinion of the law evolves over time could offer valuable insight into Americans’ appetite both for the ACA and for health reform more broadly.

RESEARCH BRIEF

Will the Affordable Care Act Make Health Care More Affordable? — Dec 11, 2013

Fotolia_48436515_Subscription_Monthly_XLFor most lower-income people who obtain coverage as a result of the Affordable Care Act, health care spending will fall. But spending by some newly insured higher-income people will increase because they will be now paying insurance premiums.

COMMENTARY

Is There Really a Physician Shortage? — Dec 5, 2013

Fotolia_51436665_Subscription_Monthly_XLLarge coverage expansions under the ACA have reignited concerns about physician shortages. These estimates result from models that forecast future supply and demand for physicians based on past trends and current practice. While useful exercises, they do not necessarily imply that intervening to boost physician supply would be worth the investment.

PERIODICAL

Ramifications of Health Reform — Nov 26, 2013

doctor listens to a heartbeat of a 5-year-old patient 2014 will be an important year for the Patient Protection and Affordable Care Act. Health insurance exchanges will offer people new ways to buy insurance. Medicaid will expand in many states. And people without “minimum essential coverage” may have to pay a fee.

COMMENTARY

Employer-Provided Health Insurance: Why Does It Persist, and Will It Continue after 2014? — Nov 25, 2013

health insurance claim form, pen, calculatorAs the ACA is implemented, policy makers should be attuned to potential inefficiencies and inequities created by a system with different regulatory and tax rules for small employers, large employers, and individual health plans. Attempts to equalize the playing field may be difficult.

COMMENTARY

Can the Affordable Care Act Help Asthma Sufferers Breathe Easier? — Nov 20, 2013

Fotolia_52973064_Subscription_Monthly_XLACA reforms can potentially address barriers that get in the way of individuals with asthma getting the care they need. At the population level, the law has the potential to improve outcomes and efficiency and equity of services for chronic conditions such as asthma for which cost-effective preventive treatments exist.

COMMENTARY

Four Questions on Canceled Insurance Policy Fix — Nov 14, 2013

U.S. President Barack Obama talks about the Affordable Care Act in the Brady Press Briefing Room at the White House in Washington, November 14, 2013David Mastio, Forum editor at USA TODAY, asked RAND’s Christine Eibner four questions about President Obama’s plan to fix the problem with people getting their insurance canceled.

BLOG

The Future of the Health Care Workforce: RAND Researchers Well Represented in Health Affairs Special Issue— Nov 7, 2013

Fotolia_52420884_Subscription_Monthly_XXLIn “Redesigning the Health Care Workforce,” a new special issue of the journal Health Affairs, RAND researchers contribute to several timely examinations of challenges, opportunities, and potential solutions relating to the future of health care staffing in the U.S. and abroad.

COMMENTARY

Quick Takes: Health Literacy and ACA Enrollment — Nov 7, 2013

Fotolia_44089855_Subscription_Monthly_XXLThe Affordable Care Act (ACA) expands coverage to millions of Americans. But the newly eligible may face challenges enrolling if they lack understanding of how the health care system itself works. Laurie Martin explains the role of health literacy in determining how successful the ACA will be in providing coverage for America’s uninsured.

COMMENTARY

Quick Takes: The Math of Medicaid Expansion — Oct 21, 2013

blonde boy getting checkupExpanding Medicaid under the Affordable Care Act (ACA) is both contentious and complicated. RAND mathematician Carter Price has been using the COMPARE model to help those making decisions understand what their choices mean for their budgets and population health.

COMMENTARY

Medicaid Access for the Formerly Incarcerated Under the ACA: Helping the Oft-Forgotten — Oct 3, 2013

male patient wearing white shirt talking to psychiatristAmerica’s prison population tends to be sicker than the general population. While Medicaid eligibility under the ACA offers an historic opportunity, enrolling the formerly incarcerated into the health exchanges or Medicaid will be neither simple nor straightforward.

COMMENTARY

Understanding the Affordable Care Act — Oct 2, 2013

Fotolia_54387258_Subscription_Monthly_XLOne of the chief aims of the Affordable Care Act (ACA) is the expansion of insurance coverage to individuals who at present either cannot afford it or choose not to purchase it. Unfortunately, many Americans lack the financial literacy needed to navigate the numerous and complex options thrust upon them by the ACA.

COMMENTARY

Will the Affordable Care Act Make Health Care More Affordable? — Oct 1, 2013

Fotolia_49599013_Subscription_Monthly_XXLOut-of-pocket spending on health care will decrease for both the newly insured as well as for those changing their source of insurance. These decreases will be largest for those who would otherwise be uninsured.

BLOG

Ask Me Anything: Carter Price on the Affordable Care Act — Oct 1, 2013

Fotolia_56040470_Subscription_Monthly_XLAs of October 1, many Americans can now shop for health insurance through state exchanges created as part of the Affordable Care Act (ACA)—the sweeping health care reform often referred to as “Obamacare.” To provide some insight into the ACA, RAND’s Carter Price hosted an “Ask Me Anything” session on Reddit today.

NEWS RELEASE

Affordable Care Act Will Reduce Out-of-Pocket Medical Spending for Many Americans — Oct 1, 2013

The Affordable Care Act will have a varied impact on health spending by individuals and families, depending primarily on their income and whether they would have been uninsured in 2016 without the program.

REPORT

Affordable Care Act Will Reduce Out-of-Pocket Medical Spending for Many Americans — Oct 1, 2013

a middle aged woman checking out at a medical reception counterThe Affordable Care Act will have a varied impact on health spending by individuals and families, depending primarily on their income and whether they would have been uninsured in 2016 without the program.

Patient Protection and Affordable Care Act

Through a number of provisions — such as individual and employer mandates, health insurance exchanges, and the expansion of Medicaid — the Patient Protection and Affordable Care Act (ACA) aims to expand access to health care for uninsured Americans. RAND has examined implementation challenges, cost and coverage implications, Medicaid expansion, state health insurance exchanges, and reforms to both care delivery and payment.

Featured at RAND

The RAND Health Reform Opinion Study

group opinionsThe RAND Health Reform Opinion Study tracks public opinion of the Affordable Care Act by surveying the same people over time. This allows us to observe true changes in public opinion, rather than changes based on who was surveyed randomly.

The Affordable Care Act: Four Key Policy Areas

Obama signing the ACAWith the complex process of implementing the ACA underway, RAND research is tracking the progress of implementation and assessing the potential consequences of choices facing federal and state governments, employers, families, and individuals.

All Items (123)

Will ACA Implementation Lead to a Spike in Demand for Care? — Sep 26, 2013

Fotolia_48335019_Subscription_Monthly_XXLThe growing number of Americans newly-insured under the ACA will undoubtedly lead to a surge in demand for care, whether through Medicaid or insurance exchanges. But, if predictions hold, the increase won’t be as dramatic as some may fear, writes David I. Auerbach.

COMMENTARY

Data Points: Why Delay of the Employer Mandate May Not Actually Mean That Much — Aug 29, 2013

health insurance policy and reading glassesThe bottom line is that the employer mandate does not provide a large inducement for firms to change their health insurance offerings, but it does raise a substantial amount of money to pay for the ACA’s coverage provisions over time.

REPORT

No Widespread Increase in Cost of Individual Health Insurance Policies Under Affordable Care Act— Aug 29, 2013

calculator, pills, and stethoscopeAn analysis of 10 states and the United States overall predicts that there will be no widespread premium increase in the individual health insurance market under the ACA. However, the cost of policies will vary among states and will be influenced by individual factors such as a person’s age and whether they smoke.

NEWS RELEASE

No Widespread Increase in Cost of Individual Health Insurance Policies Under Affordable Care Act— Aug 29, 2013

An analysis of 10 states and the United States overall predicts that there will be no widespread premium increase in the individual health insurance market under the ACA. However, the cost of policies will vary among states and will be influenced by individual factors such as a person’s age and whether they smoke.

NEWS RELEASE

Delay of Employer Insurance Mandate Will Not Cause Major Problems for Affordable Care Act — Aug 19, 2013

A one-year delay in requiring large employers to provide health insurance to their workers will not significantly hurt the goals of the Affordable Care Act, but a repeal of the requirement would seriously undermine financial support for the law.

REPORT

Delay of Employer Insurance Mandate Will Not Cause Major Problems for Affordable Care Act — Aug 19, 2013

stethoscope and clockA one-year delay in requiring large employers to provide health insurance to their workers will not significantly hurt the goals of the Affordable Care Act, but a repeal of the requirement would seriously undermine financial support for the law.

MULTIMEDIA

The Math of State Medicaid Expansion — Jul 17, 2013

Carter PriceMathematician Carter Price discusses the potential impacts to low-income populations and local economies in states that choose not to expand Medicaid under the Affordable Care Act.

COMMENTARY

Health Care Spending: What’s in Store? — Jul 16, 2013

illustration of weighing medical costsResolving the question of whether or not the U.S. has finally gotten a handle on health care spending is vitally important, because the choices we make going forward will have profound implications for our economy, the financial wellbeing of millions of American families, and ultimately America’s standing in the world.

REPORT

Helping Decisionmakers Implement the ACA’s Medicaid Provisions — Jun 26, 2013

A stethoscope atop a United States flagThe Affordable Care Act (ACA) contains many Medicaid-related provisions. RAND is working closely with decisionmakers at the federal and state levels to help resolve challenges associated with implementing the ACA’s sweeping reforms.

CONTENT

The Impact of RAND’s Work for the Centers for Medicare & Medicaid Services (CMS) — Jun 26, 2013

stethoscope on American flagRAND’s work for the Centers for Medicare & Medicaid Services reflects the diverse, widespread nature of CMS’s programs. Major topics examined by our health policy experts include improving Medicare payment policies, implementation of the ACA’s Medicaid provisions, Medicare demonstration projects, measuring quality of care, and assessing patients experience.

JOURNAL ARTICLE

How Well Do Medicare’s Pay-for-Performance (P4P) Programs Match Desirable P4P Design Criteria?— Jun 25, 2013

ear exam on senior patientAlignment with best P4P practices varies across Medicare programs; the program for Medicare Advantage aligns most strongly. It is unclear which P4P design elements are critical for quality improvement. Unintended consequences of design features are poorly understood.

REPORT

Revenue, Spending Reductions Will Offset Costs of Expanding Medicaid in PA — Jun 24, 2013

Harrisburg, Pennsylvania panoramaWhile the expansion of Medicaid under the Affordable Care Act will require additional spending by the Commonwealth of Pennsylvania, these costs will be more than offset by additional revenue or reductions in other spending in the 2014-2020 timeframe.

COMMENTARY

Will Small Firms Self-Insure After Jan. 1, 2014? — Jun 17, 2013

 Doctor with young womanBecause of the ACA’s regulations, some smaller employers with young and healthy workers are considering avoiding the purchase of health care coverage in the regulated market, opting instead to self-insure their employees.

RESEARCH BRIEF

The Math of State Medicaid Expansion — Jun 7, 2013

Fotolia_45672516_Subscription_Monthly_XXLRAND researchers have analyzed how opting out of Medicaid expansion would affect insurance coverage and spending and whether alternative policy options—such as partial Medicaid expansion—could cover as many people at lower costs to states.

BLOG

Covering Emergency Care for Young Adults: Is the ACA Doing Its Job? — Jun 5, 2013

A woman is wheeled through an emergency department on a gurney.The dependent coverage provision of the Affordable Care Act is working as intended, say Andrew Mulcahy and Katherine Harris. In 2011, it spared individuals and hospitals from $147 million in emergency room costs.

CONTENT

Should States Expand Medicaid Under the ACA? — Jun 3, 2013

U.S. state map with stethoscopeSome governors have stated publicly that their states will not participate in Medicaid expansion. A recent RAND study explores how this could affect government costs and coverage.

NEWS RELEASE

Expanding Medicaid Is Best Financial Option for States — Jun 3, 2013

States that choose not to expand Medicaid under federal health care reform will leave millions of their residents without health insurance and increase spending on the cost of treating uninsured residents, at least in the short term.

JOURNAL ARTICLE

Expanding Medicaid Is Best Financial Option for States — Jun 3, 2013

Nuns On The Bus rally and Texas Capitol visit about MedicaidStates that choose not to expand Medicaid under federal health care reform will leave millions of their residents without health insurance and increase spending on the cost of treating uninsured residents, at least in the short term.

REPORT

Labor Market Outcomes of Health Shocks and Dependent Coverage Expansions — Jun 1, 2013

machine_shop_workerA series of studies on sources of variation in individual valuation of employer-provided group health care found that the effects of bundling health insurance with employment in the U.S. can vary significantly within different population groups.

NEWS RELEASE

Health Reform Shields Young Adults from Emergency Medical Costs — May 29, 2013

A new federal law allowing young adults to remain on their parents’ medical insurance through age 25 has shielded them, their families, and hospitals from the full financial consequences of serious medical emergencies.

Through a number of provisions — such as individual and employer mandates, health insurance exchanges, and the expansion of Medicaid — the Patient Protection and Affordable Care Act (ACA) aims to expand access to health care for uninsured Americans. RAND has examined implementation challenges, cost and coverage implications, Medicaid expansion, state health insurance exchanges, and reforms to both care delivery and payment.

Featured at RAND

The RAND Health Reform Opinion Study

group opinionsThe RAND Health Reform Opinion Study tracks public opinion of the Affordable Care Act by surveying the same people over time. This allows us to observe true changes in public opinion, rather than changes based on who was surveyed randomly.

The Affordable Care Act: Four Key Policy Areas

Obama signing the ACAWith the complex process of implementing the ACA underway, RAND research is tracking the progress of implementation and assessing the potential consequences of choices facing federal and state governments, employers, families, and individuals.

Infographic: How Pennsylvania May Fare Under the ACA — May 15, 2013

Pennsylvania capitol buildingThis infographic presents findings from a RAND analysis of the economic and other effects of Medicaid expansion on the commonwealth of Pennsylvania.

COMMENTARY

Governors Missing the Point on Medicaid — Apr 29, 2013

6170068425_b192a9d867_bWhile a governor or legislator may disagree with Medicaid expansion for philosophical reasons, the claims that the expansion will be a burden on states’ economies seem misguided given the full range of projected economic impacts on the states, writes Carter C. Price.

RESEARCH BRIEF

Infographic: How Arkansas May Fare Under the Affordable Care Act — Apr 8, 2013

Arkansas state quarterThis infographic presents findings from a RAND analysis of the economic and other effects of the Affordable Care Act on the state of Arkansas.

COMMENTARY

Helping Obama—and Other Americans—Weigh Which Health Insurance Exchange to Pick — Apr 1, 2013

a health insurance claim form and a silver penMultistate plans are most likely to appeal to out-of-state students, interstate migrants, out-of-state workers, seasonal movers (e.g., “snowbirds”), and similar groups that require improved access to health care across state lines.

NEWS RELEASE

Expanding Medicaid in Pennsylvania Would Sharply Increase Federal Revenue to State — Mar 28, 2013

Expanding Medicaid in Pennsylvania under the Affordable Care Act would boost federal revenue to the state by more than $2 billion annually and provide 340,000 residents with health insurance.

REPORT

The Economic Impact of Medicaid Expansion on Pennsylvania — Mar 28, 2013

Pennsylvania state flagIf Pennsylvania opts into Medicaid expansion under the Affordable Care Act, more residents would have health coverage and the state would enjoy a positive economic effect. However, benefits would have a long-term cost, with uneven regional results.

REPORT

Multistate Health Plans in the ACA’s State Insurance Exchanges — Mar 20, 2013

blue and pink pillsThe ACA requires the government to work with insurance issuers to establish at least two multistate plans (MSPs) in each state’s health insurance exchange. MSPs may be especially attractive to those interested in issuers that operate in multiple states, such as out-of-state students or temporary workers.

REPORT

Efforts to Reform Physician Payment by Tying Payment to Performance — Feb 14, 2013

pediatrician with patient and motherPublic and private sector purchasers are actively working to design value-based payment programs to achieve the goals of improved quality and more efficient use of health care resources. How these programs are designed is a complex undertaking and one that will determine the likelihood of their success.

BLOG

In Brief: Amelia M. Haviland on Consumer-Directed Health Plans — Jan 23, 2013

In this video, Amelia Haviland presents the results of several new RAND studies on cost and quality in consumer-directed health plans, and explores how switching plans affects the quality of care.

BLOG

Modeling the Effects of the Affordable Care Act in Arkansas — Jan 7, 2013

patients sitting in waiting roomThe Medicaid expansion under the ACA will result in about 400,000 people newly insured in Arkansas by 2016. Of these, about 190,000 would be newly enrolled in Medicaid and the rest would be newly insured through the new insurance exchanges. The state is likely to save about $67 million for reduced uncompensated care costs for the uninsured.

REPORT

The Economic Impact of the ACA on Arkansas — Jan 3, 2013

Arkansas flagFor Arkansas, the Affordable Care Act will result in an increase in GDP of around $550 million and the creation of about 6,200 jobs. The new law will also increase health insurance coverage by 400,000 newly insured individuals.

JOURNAL ARTICLE

Implications of New Insurance Coverage for Access to Care, Cost-Sharing, and Reimbursement — Jan 1, 2013

Many physician practices will face a set of critical decisions in the coming years that may contribute to the ultimate success or failure of the ACA.

CONTENT

Four Strategies to Contain America’s Growing Health Care Spending — Nov 15, 2012

pills and coinsIn its second term, the Obama Administration can restrain further health care spending growth—without compromising quality—by employing four broad strategies: fostering efficient and accountable providers, engaging and empowering consumers, promoting population health, and facilitating high-value innovation.

COMMENTARY

Health Care Costs Must Be Curbed, No Matter Who Wins — Oct 16, 2012

money and pillsRegardless of which candidate wins in November, and regardless of whether “Obamacare” is repealed, amended, or defended by the next Congress, the next president will have to contend with the spiraling cost of health care in the United States—a problem that is growing more acute with each passing year, writes Arthur Kellermann.

COMMENTARY

California Improves on Affordable Care Act by Letting RNs Dispense Birth Control — Oct 8, 2012

birth control pillsAs we look for ways to provide efficient, high-quality and cost-effective healthcare to more Americans, states may study California as a potential model for how to do more to deliver on what the Affordable Care Act has to offer women, while saving money at the same time, writes Chloe Bird.

PERIODICAL

The Fate of ACA Is a Major Issue in Upcoming Congressional and Presidential Elections — Sep 21, 2012

stethoscope on 50 dollar billsWhether the Affordable Care Act is repealed, defended, or weakened will hinge on who holds the balance of power next January. Regardless of what happens with the ACA, the spiraling cost of health care in the United States will remain a huge challenge.

CONTENT

Retail Clinics Play Growing Role in Health Care Marketplace — Sep 11, 2012

man getting his arm wrappedRetail health care clinics provide treatment for acute conditions like bronchitis as well as vaccinations and other preventive care. With the role of retail clinics expanding and U.S. health care entering a dynamic period of change, it is important to consider what we know about this emerging health care setting.

COMMENTARY

Supporting Comprehensive Healthcare for Women Makes Dollars, and Sense — Sep 5, 2012

As we look for ways to provide efficient, high-quality, and cost-effective health care to more Americans, we can’t afford to ignore women’s health issues, including reproductive health care and the cost savings that contraceptive access provides, writes Chloe Bird.

JOURNAL ARTICLE

Medicare Postacute Care Payment Reforms Have Potential To Improve Efficiency Of Care, But May Need Changes To Cut Costs — Sep 1, 2012

ACA-mandated payment reforms need to achieve more than a one-time cost saving.

COMMENTARY

Will More Employers Drop Coverage Under the ACA? Don’t Bet on It — Jul 27, 2012

A problem with using surveys to predict behavior is that they measure employer sentiment toward the ACA today, rather than the economic decisions employers typically make when the time comes, writes Art Kellermann.

COMMENTARY

Time to Focus on Healthcare Costs — Jun 29, 2012

The bottom line is this: With or without the Affordable Care Act, the nation can no longer kick the can down the road on costs, writes Arthur Kellermann.

CONTENT

Supreme Court Upholds the Affordable Care Act: What the Experts Are Saying — Jun 28, 2012

Supreme Court pillarsNow that the Supreme Court has upheld key provisions of the Affordable Care Act, what lies ahead for health care in America? RAND experts sound off in the wake of this momentous decision.

COMMENTARY

Time to Shift Talk to Health Care Costs — Jun 28, 2012

The U.S. Supreme Court’s ruling on the Affordable Care Act is unquestionably historic, but there is a critical aspect of health care reform that still needs to be fixed. The nation needs to take decisive action to address the rising costs of health care, writes Arthur Kellermann.

RESEARCH BRIEF

Consumer-Directed Plans Could Cut Health Costs Sharply, but Also Discourage Preventive Care — Jun 28, 2012

pills and moneySwitching to a consumer-directed health plan (CDHP) could save families 20 percent or more on their health care costs. Families with CDHPs initiate less episodes of care and spend less per episode, however, they also tend to scale back on high-value preventive care, such as child vaccinations.

PERIODICAL

Eliminating Individual Mandate Would Decrease Coverage, Increase Spending — May 11, 2012

If the individual mandate requiring all Americans to have health insurance were eliminated, it would sharply reduce the number of people gaining coverage and slightly increase the cost for those who do buy policies through the new insurance exchanges.

JOURNAL ARTICLE

Expanding Consumer-Directed Health Plans Could Help Cut Overall Health Care Spending — May 7, 2012

If consumer-directed health plans grow to account for half of all employer-sponsored insurance in the United States, health costs could drop by $57 billion annually—about 4 percent of all health care spending among the nonelderly.

BLOG

Would the Affordable Care Act Lead to Reductions in Employer-Sponsored Coverage? — May 4, 2012

As the U.S. Supreme Court considers the constitutionality of the Affordable Care Act’s (ACA) individual mandate, one of the questions being debated is what effect the mandate would have on employer-sponsored health insurance coverage. A factor to consider in this is the effect the ACA would have on small businesses, which employ the majority of America’s private-sector workforce.

COMMENTARY

What Happens Without the Individual Mandate? — Mar 21, 2012

If the individual mandate were ruled unconstitutional, subsidies and the age structure of premiums should keep enough healthy people in the insurance exchanges to prevent huge spikes in premiums, write Carter C. Price and Christine Eibner.

PAST EVENT

The Affordable Care Act’s Individual Mandate in Play — Mar 20, 2012

RAND economist Christine Eibner spoke at a Bloomberg Government and RAND Corporation event in Washington, D.C. Eibner briefed the attendees on the results of her recent study, How Would Eliminating the Individual Mandate Affect Health Coverage and Premium Costs?

PROJECT

Will Health Care Reform Impact Applications for Disability Benefits? — Mar 12, 2012

As the Affordable Care Act expands health insurance coverage in the U.S., the “cost” of applying for SSDI will decline for many. Studying the effect of Massachusetts health care reform in 2006 may provide insights into the impact the ACA may have on SSDI applications and awards.

NEWS RELEASE

Ending Individual Mandate Would Cut Health Coverage, but Not Dramatically Hike Insurance Price— Feb 16, 2012

Eliminating a key part of health care reform that requires all Americans to have health insurance would sharply lower the number of people gaining coverage, but would not dramatically increase the cost of buying policies through new insurance exchanges.

RESEARCH BRIEF

How Would Eliminating the Individual Mandate Affect Health Coverage and Premium Costs? — Feb 16, 2012

An analysis of the effects of implementing the Affordable Care Act without an individual mandate found that over 12 million people who would have otherwise signed up for coverage will be uninsured and premium prices will increase by 2.4 percent.

REPORT

Ending Individual Mandate Would Cut Health Coverage, but Not Dramatically Hike Insurance Price— Feb 16, 2012

Eliminating a key part of health care reform that requires all Americans to have health insurance would sharply lower the number of people gaining coverage, but would not dramatically increase the cost of buying policies through new insurance exchanges.

CONTENT

How Will Eliminating the Individual Mandate Affect Health Coverage and Premium Costs? — Feb 15, 2012

doctor showing patient xrayThe individual mandate of the Patient Protection and Affordable Care Act of 2010 (ACA) requires that most Americans either obtain health coverage or pay an annual fine. How much will overturning the individual mandate affect costs and coverage?

JOURNAL ARTICLE

Rules Allowing Small Businesses to Opt Out of Health Reform Should Have Minor Impact on Insurance Cost— Feb 8, 2012

health insurance formRules that allow some small employers to avoid regulation under the federal Affordable Care Act are unlikely to have a major impact on the future cost of health insurance unless those rules are relaxed to allow more businesses to opt out.

NEWS RELEASE

Rules Allowing Small Businesses to Opt Out of Health Reform Should Have Minor Impact on Insurance Cost— Feb 8, 2012

Rules that allow some small employers to avoid regulation under the federal Affordable Care Act are unlikely to have a major impact on the future cost of health insurance unless those rules are relaxed to allow more businesses to opt out.

COMMENTARY

How Will the Effects of the Affordable Care Act Be Monitored? — Jan 4, 2012

Most will agree with the undeniable fact that a new era in US medicine and US health care begins in less than two years. The key question is what potential measures should be monitored to determine both anticipated and unanticipated effects of the new law on the health of the US population, writes Robert H. Brook.

OURNAL ARTICLE

Two Years and Counting: How Will the Effects of the Affordable Care Act Be Monitored? — Jan 1, 2012

The Affordable Care Act marks a new era in US health care and US medicine. This commentary suggests ways to monitor the act’s effect on the health of the US population.

RESEARCH BRIEF

How Does Health Reform Affect the Health Care Workforce? Lessons from Massachusetts — Dec 13, 2011

Since Massachusetts enacted health reform legislation in 2006, health care employment in the state has grown more rapidly than in the rest of the United States, primarily in administrative positions.

CONTENT

What Are the Public Health Implications of Prisoner Reentry in California? — Dec 1, 2011

Fotolia_54591532_Subscription_Monthly_XXLCalifornia, the state with the nation’s largest prison population, is releasing increased numbers of inmates under its 2011 Public Safety Realignment Plan. RAND was asked to study the public health implications of returning prisoners for the communities they return to and has found both challenges and opportunities.

REPORT

Addressing Medicare Payment Differentials Across Ambulatory Settings — Oct 12, 2011

bill payment calculatorMedicare’s payment for physician work and malpractice liability expenses is the same regardless of where a service is provided, but payments differ for facility-related components of care.

REPORT

Power to the People: The Role of Consumer-Controlled Personal Health Management Systems in the Evolution of Employer-Based Health Care Benefits — Sep 13, 2011

The Patient Protection and Affordable Care Act has piqued employers’ interest in new benefit designs. This paper reviews consumer-controlled personal health management systems that could help individuals control and manage their health care.

JOURNAL ARTICLE

Health Care Reform and the Health Care Workforce — The Massachusetts Experience — Sep 1, 2011

Analysis of the Massachusetts Health Care Reform Plan suggests national health care reform may require larger numbers of support personnel, rather than requiring greater numbers of physicians and nurses themselves.

PROJECT

Comprehensive Assessment of Reform Efforts (COMPARE) — Jul 20, 2011

thermometer graphPolicymakers are facing new challenges as they implement the Patient Protection and Affordable Care Act (ACA). RAND COMPARE is a modeling tool that simulates the impact of implementation decisions on insurance coverage, premiums, and health care spending.

REPORT

Employer Self-Insurance Decisions and the Implications of the Patient Protection and Affordable Care Act as Modified by the Health Care and Education Reconciliation Act of 2010 (ACA) — May 25, 2011

Implications of the Patient Protection and Affordable Care Act of 2010 (as Modified by the Health Care and Education Reconciliation Act) for small firms’ decisions to offer self-insured health plans and consequences of self-insurance for enrollees.

REPORT

How Community and Faith-Based Organizations Can Help Improve Community Well-Being — May 9, 2011

Content for a toolkit was designed to help community and faith-based organizations take advantage of opportunities presented in the Patient Protection and Affordable Care Act and engage leaders in promoting health in their communities.

NEWS RELEASE

How National Health Reform Will Affect a Variety of States — Apr 5, 2011

A series of new reports by the RAND Corporation outlines the impact that national health care reform will have on individual states, estimating the increased costs and coverage that are expected in five diverse states once reform is fully implemented in 2016.

NEWS RELEASE

Health Reform Will Add Coverage for 6 Million Californians; State Health Spending to Grow by 7 Percent— Apr 5, 2011

National health care reform will help 6 million California residents obtain health insurance and increase health care spending by state government by about 7 percent when it is fully implemented in 2016.

NEWS RELEASE

Health Reform Will Add Coverage for 170,000 in Connecticut; State Health Spending to Drop by 10 Percent— Apr 5, 2011

National health care reform will help 170,000 Connecticut residents obtain health insurance and decrease health care spending by state government by about 10 percent when it is fully implemented in 2016.

NEWS RELEASE

Health Reform Will Add Coverage for 1.3 Million in Illinois; State Health Spending to Grow by 10 Percent— Apr 5, 2011

National health care reform will help 1.3 million Illinois residents obtain health insurance and increase health care spending by state government by about 10 percent when it is fully implemented in 2016.

NEWS RELEASE

Health Reform Will Add Coverage for 125,000 in Montana; State Health Spending to Grow by 3 Percent— Apr 5, 2011

National health care reform will help 125,000 Montana residents obtain health insurance and increase health care spending by state government by about 3 percent when it is fully implemented in 2016.

NEWS RELEASE

Health Reform Will Add Coverage for 5 Million in Texas; State Health Spending to Grow by 10 Percent— Apr 5, 2011

National health care reform will help 5 million Texas residents obtain health insurance and increase health care spending by state government by about 10 percent when it is fully implemented in 2016.

RESEARCH BRIEF

High-Deductible Health Plans Cut Spending but Also Reduce Preventive Care — Apr 5, 2011

High-deductible plans significantly reduce health care spending but also lead consumers to cut back on their use of preventive health care — even though high-deductible plans waive the deductible for such care.

RESEARCH BRIEF

How Will Health Care Reform Affect Costs and Coverage? Examples from Five States — Apr 1, 2011

Projects how the coverage-related provisions of the Patient Protection and Affordable Care Act will affect health insurance coverage and state government spending on health care in five states.

REPORT

The Impact of the Coverage-Related Provisions of the Patient Protection and Affordable Care Act on Insurance Coverage and State Health Care Expenditures in Illinois: An Analysis from RAND COMPARE — Apr 1, 2011

Projects how the coverage-related provisions of the Patient Protection and Affordable Care Act will affect health insurance coverage and state government spending on health care in Illinois through 2020.

REPORT

The Impact of the Coverage-Related Provisions of the Patient Protection and Affordable Care Act on Insurance Coverage and State Health Care Expenditures in Texas: An Analysis from RAND COMPARE — Apr 1, 2011

Projects how the coverage-related provisions of the Patient Protection and Affordable Care Act will affect health insurance coverage and state government spending on health care in Texas through 2020.

REPORT

The Impact of the Coverage-Related Provisions of the Patient Protection and Affordable Care Act on Insurance Coverage and State Health Care Expenditures in California: An Analysis from RAND COMPARE — Apr 1, 2011

Projects how the coverage-related provisions of the Patient Protection and Affordable Care Act will affect health insurance coverage and state government spending on health care in California through 2020.

REPORT

The Impact of the Coverage-Related Provisions of the Patient Protection and Affordable Care Act on Insurance Coverage and State Health Care Expenditures in Montana: An Analysis from RAND COMPARE — Apr 1, 2011

Projects how the coverage-related provisions of the Patient Protection and Affordable Care Act will affect health insurance coverage and state government spending on health care in Montana through 2020.

REPORT

The Impact of the Coverage-Related Provisions of the Patient Protection and Affordable Care Act on Insurance Coverage and State Health Care Expenditures in Connecticut: An Analysis from RAND COMPARE — Apr 1, 2011

Projects how the coverage-related provisions of the Patient Protection and Affordable Care Act will affect health insurance coverage and state government spending on health care in Connecticut through 2020.

REPORT

Investment in New Health Care Quality Measures Needed as Cost-Cutting Strategies Grow — Feb 23, 2011

stethoscope chartHealth care spending reforms should be met with new efforts to develop and refine quality of care and other performance measures in order to assure that any changes will improve medical care and not harm patients.

JOURNAL ARTICLE

Small Firms’ Actions in Two Areas, and Exchange Premium and Enrollment Impact — Feb 1, 2011

An analysis of two rules that allow small businesses to avoid participating in health reform concludes they will have only a minor impact because relatively few businesses are likely to take advantage of the options.

RESEARCH BRIEF

How Will the Affordable Care Act Affect Employee Health Coverage at Small Businesses? — Sep 8, 2010

Finds that the Affordable Care Act will increase the percentage of employers that offer health coverage to workers: from 57 percent to 80 percent for firms with 50 or fewer workers, and from 90 percent to 98 percent for firms with 51 to 100 workers.

JOURNAL ARTICLE

The Effects of the Affordable Care Act on Workers’ Health Insurance Coverage — Sep 1, 2010

The nature of employer-sponsored coverage may change substantially after implementation of the Patient Protection and Affordable Care Act, with an increase in the number of workers offered coverage through the health insurance exchanges.

REPORT

Establishing State Health Insurance Exchanges: Implications for Health Insurance Enrollment, Spending, and Small Businesses — Aug 11, 2010

The Patient Protection and Affordable Care Act will increase insurance offer rates at small businesses. By 2016, rates would increase from 53 to 77 percent at firms with ten or fewer workers and from 71 to 90 percent at firms with 11 to 25 workers.

REPORT

Grandfathering in the Small Group Market Under the Patient Protection and Affordable Care Act: Effects on Offer Rates, Premiums, and Coverage — Jun 2, 2010

To avoid changes in current health coverage, the Patient Protection and Affordable Care Act exempts existing plans from some regulations. These exemptions may lead to higher employer-sponsored insurance enrollment and lower government spending.

JOURNAL ARTICLE

Patient Protection and Affordable Care Act: Laying the Infrastructure for National Health Reform — Jun 1, 2010

This article discusses the range of health information technology initiatives included in the 2009 economic stimulus legislation that collectively are known as the Health Information Technology for Economic and Clinical Health (HITECH) initiative; these include proposed regulations on

RESEARCH BRIEF

RAND COMPARE Analysis of President Obama’s Proposal for Health Reform — Mar 3, 2010

Compares President Obama’s Proposal for Health Reform, the U.S. House and Senate health care reform bills, and the status quo on changes in number of uninsured and government and national costs, as estimated by the RAND COMPARE microsimulation model.

RESEARCH BRIEF

Coverage, Spending, and Consumer Financial Risk: How Do the Recent House and Senate Health Care Bills Compare? — Feb 12, 2010

Compares how two health care reform bills, HR. 3962 and H.R. 3590, passed by the U.S. House and Senate, respectively, in late 2009 compare on a variety of projections made using the RAND COMPARE microsimulation model.

RESEARCH BRIEF

Analysis of the Patient Protection and Affordable Care Act (H.R. 3590) — Feb 11, 2010

Using the COMPARE microsimulation model, estimates the effects of the Patient Protection and Affordable Care Act (H.R. 3590) on the number of uninsured, the costs to the federal government and the nation, and consumers’ health care spending.

NEWS RELEASE

The Potential Impact of House Health Reform Legislation — Jan 8, 2010

Health reform as set forth in legislation passed by the U.S. House of Representatives in November would cut the number of uninsured Americans to 24 million by 2019 (a 56 percent decrease) and increase personal spending on health care by about 3.3 percent cumulatively between 2013 and 2019.

RESEARCH BRIEF

Analysis of the Affordable Health Care for America Act (H.R. 3962) — Jan 7, 2010

Using the COMPARE microsimulation model, estimates proposed health care reform legislation’s effects on the number of uninsured, the costs to the federal government and the nation, revenues from penalty payments, and consumers’ health care spending.

JOURNAL ARTICLE

Bending the Curve Through Health Reform Implementation — Jan 1, 2010

Cost savings can be achieved while improving health care quality by speeding payment reforms, implementing insurance reforms, and reforming coverage.

JOURNAL ARTICLE

Could We Have Covered More People at Less Cost? Technically, Yes; Politically, Probably Not — Jan 1, 2010

Using the COMPARE (Comprehensive Assessment of Reform Efforts) microsimulation model, this study evaluated how the recently enacted health reform law performed compared with alternative designs on measures of effectiveness and efficiency and found that only a few different approaches would cover more individuals at a lower cost to the government; however, these appeared politically untenable because they included substantially higher penalties, lower subsidies, or less generous Medicaid expansion.

JOURNAL ARTICLE

The Science of Health Care Reform — Jun 17, 2009

Another health policy window has opened; through it will stream proposals to reform the US health care system. President Obama has demanded that reform proposals improve both coverage and quality of care and make health care more affordable for all Americans. Extending coverage without worrying about costs would be relatively easy. Improving quality of care without worrying about costs might also be achievable. But extending coverage and improving quality while also making coverage more affordable will be difficult.

PEOPLE

David I. Auerbach

Policy Researcher; Professor, Pardee RAND Graduate School
Ph.D. in health economics, Harvard University; M.S. in environmental science & policy, MIT; M.S. in chemistry, University of California, Berkeley; B.S. in chemistry, MIT

PEOPLE

Christine Eibner

Economist
Ph.D. in economics, University of Maryland, College Park

PEOPLE

Peter S. Hussey

Policy Researcher; Professor, Pardee RAND Graduate School
Ph.D. in health policy and management, Johns Hopkins Bloomberg School of Public Health

PEOPLE

Sarah A. Nowak

Associate Physical Scientist; Professor, Pardee RAND Graduate School
Ph.D. and M.S. in biomathematics, University of California, Los Angeles; B.S. in physics, MIT

PEOPLE

Jeanne S. Ringel

Director, Public Health Systems and Preparedness Initiative, RAND Health; Senior Economist; Professor, Pardee RAND Graduate School
Ph.D. in economics, University of Maryland, College Park; M.A. in economics, University of Maryland, College Park

PEOPLE

Kristin R. Van Busum

Project Associate, Behavioral & Policy Sciences
M.P.A. in health policy analysis, New York University; B.A., Butler University

SOURCE

http://www.rand.org/topics/patient-protection-and-affordable-care-act.all.0.html

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Curation, HealthCare System in the US, and Calcium Signaling Effects on Cardiac Contraction, Heart Failure, and Atrial Fibrillation, and the Relationship of Calcium Release at the Myoneural Junction to Beta Adrenergic Release


Curation, HealthCare System in the US, and Calcium Signaling Effects on Cardiac Contraction, Heart Failure, and Atrial Fibrillation, and the Relationship of Calcium Release at the Myoneural Junction to Beta Adrenergic Release

Curator and e-book Contributor: Larry H. Bernstein, MD, FCAP
Curator and BioMedicine e-Series Editor-in-Chief: Aviva Lev Ari, PhD, RN

and 

Content Consultant to Six-Volume e-SERIES A: Cardiovascular Diseases: Justin Pearlman, MD, PhD, FACC

This portion summarises what we have covered and is now familiar to the reader.  There are three related topics, and an extension of this embraces other volumes and chapters before and after this reading.  This approach to the document has advantages over the multiple authored textbooks that are and have been pervasive as a result of the traditional publication technology.  It has been stated by the founder of ScoopIt, that amount of time involved is considerably less than required for the original publications used, but the organization and construction is a separate creative process.  In these curations we amassed on average five articles in one curation, to which, two or three curators contributed their views.  There were surprises, and there were unfulfilled answers along the way.  The greatest problem that is being envisioned is the building a vision that bridges and unmasks the hidden “dark matter” between the now declared “OMICS”, to get a more real perspective on what is conjecture and what is actionable.  This is in some respects unavoidable because the genome is an alphabet that is matched to the mino acid sequences of proteins, which themselves are three dimensional drivers of sequences of metabolic reactions that can be altered by the accumulation of substrates in critical placements, and in addition, the proteome has functional proteins whose activity is a regulatory function and not easily identified.  In the end, we have to have a practical conception, recognizing the breadth of evolutionary change, and make sense of what we have, while searching for more.

We introduced the content as follows:

1. We introduce the concept of curation in the digital context, and it’s application to medicine and related scientific discovery.

Topics were chosen were used to illustrate this process in the form of a pattern, which is mostly curation, but is significantly creative, as it emerges in the context of this e-book.

  • Alternative solutions in Treatment of Heart Failure (HF), medical devices, biomarkers and agent efficacy is handled all in one chapter.
  • PCI for valves vs Open heart Valve replacement
  • PDA and Complications of Surgery — only curation could create the picture of this unique combination of debate, as exemplified of Endarterectomy (CEA) vs Stenting the Carotid Artery (CAS), ischemic leg, renal artery stenosis.

2. The etiology, or causes, of cardiovascular diseases consist of mechanistic explanations for dysfunction relating to the heart or vascular system. Every one of a long list of abnormalities has a path that explains the deviation from normal. With the completion of the analysis of the human genome, in principle all of the genetic basis for function and dysfunction are delineated. While all genes are identified, and the genes code for all the gene products that constitute body functions, there remains more unknown than known.

3. Human genome, and in combination with improved imaging methods, genomics offers great promise in changing the course of disease and aging.

4. If we tie together Part 1 and Part 2, there is ample room for considering clinical outcomes based on individual and organizational factors for best performance. This can really only be realized with considerable improvement in information infrastructure, which has miles to go.

Curation

Curation is an active filtering of the web’s  and peer reviewed literature found by such means – immense amount of relevant and irrelevant content. As a result content may be disruptive. However, in doing good curation, one does more than simply assign value by presentation of creative work in any category. Great curators comment and share experience across content, authors and themes.
Great curators may see patterns others don’t, or may challenge or debate complex and apparently conflicting points of view.  Answers to specifically focused questions comes from the hard work of many in laboratory settings creatively establishing answers to definitive questions, each a part of the larger knowledge-base of reference. There are those rare “Einstein’s” who imagine a whole universe, unlike the three blindmen of the Sufi tale.  One held the tail, the other the trunk, the other the ear, and they all said this is an elephant!
In my reading, I learn that the optimal ratio of curation to creation may be as high as 90% curation to 10% creation. Creating content is expensive. Curation, by comparison, is much less expensive.  The same source says “Scoop.it is my content marketing testing “sandbox”. In sharing, he says that comments provide the framework for what and how content is shared.

Healthcare and Affordable Care Act

We enter year 2014 with the Affordable Care Act off to a slow start because of the implementation of the internet signup requiring a major repair, which is, unfortunately, as expected for such as complex job across the US, and with many states unwilling to participate.  But several states – California, Connecticut, and Kentucky – had very effective state designed signups, separate from the federal system.  There has been a very large rush and an extension to sign up. There are many features that we can take note of:

1. The healthcare system needed changes because we have the most costly system, are endowed with advanced technology, and we have inexcusable outcomes in several domains of care, including, infant mortality, and prenatal care – but not in cardiology.

2. These changes that are notable are:

  • The disparities in outcome are magnified by a large disparity in highest to lowest income bracket.
  • This is also reflected in educational status, and which plays out in childhood school lunches, and is also affected by larger class size and cutbacks in school programs.
  • This is not  helped by a large paralysis in the two party political system and the three legs of government unable to deal with work and distraction.
  • Unemployment is high, and the banking and home construction, home buying, and rental are in realignment, but interest rates are problematic.

3.  The  medical care system is affected by the issues above, but the complexity is not to be discounted.

  •  The medical schools are unable at this time to provide the influx of new physicians needed, so we depend on a major influx of physicians from other countries
  • The technology for laboratories, proteomic and genomic as well as applied medical research is rejuvenating the practice in cardiology more rapidly than any other field.
  • In fields that are imaging related the life cycle of instruments is shorter than the actual lifetime use of the instruments, which introduces a shortening of ROI.
  • Hospitals are consolidating into large consortia in order to maintain a more viable system for referral of specialty cases, and also is centralizing all terms of business related to billing.
  • There is reduction in independent physician practices that are being incorporated into the hospital enterprise with Part B billing under the Physician Organization – as in Partners in Greater Boston, with the exception of “concierge” medical practices.
  • There is consolidation of specialty laboratory services within state, with only the most specialized testing going out of state (Quest, LabCorp, etc.)
  • Medicaid is expanded substantially under the new ACA.
  • The federal government as provider of services is reducing the number of contractors for – medical devices, diabetes self-testing, etc.
  • The current rearrangements seeks to provide a balance between capital expenses and fixed labor costs that it can control, reduce variable costs (reagents, pharmaceutical), and to take in more patients with less delay and better performance – defined by outside agencies.

Cardiology, Genomics, and calcium ion signaling and ion-channels in cardiomyocyte function in health and disease – including heart failure, rhythm abnormalities, and the myoneural release of neurotransmitter at the vesicle junction.

This portion is outlined as follows:

2.1 Human Genome: Congenital Etiological Sources of Cardiovascular Disease

2.2 The Role of Calcium in Health and Disease

2.3 Vasculature and Myocardium: Diagnosing the Conditions of Disease

Genomics & Genetics of Cardiovascular Disease Diagnoses

actin cytoskeleton

wall stress, ventricular workload, contractile reserve

Genetic Base of Atherosclerosis and Loss of Arterial Elasticity with Aging

calcium and actin skeleton, signaling, cell motility

hypertension & vascular compliance

Genetics of Conduction Disease

Ca+ stimulated exostosis: calmodulin & PKC (neurotransmitter)

complications & MVR

disruption of Ca2+ homeostasis cardiac & vascular smooth muscle

synaptotagmin as Ca2+ sensor & vesicles

atherosclerosis & ion channels


It is increasingly clear that there are mutations that underlie many human diseases, and this is true of the cardiovascular system.  The mutations are mistakes in the insertion of a purine nucleotide, which may or may not have any consequence.  This is why the associations that are being discovered in research require careful validation, and even require demonstration in “models” before pursuing the design of pharmacological “target therapy”.  The genomics in cardiovascular disease involves very serious congenital disorders that are asserted early in life, but the effects of and development of atherosclerosis involving large and medium size arteries has a slow progression and is not dominated by genomic expression.  This is characterized by loss of arterial elasticity. In addition there is the development of heart failure, which involves the cardiomyocyte specifically.  The emergence of regenerative medical interventions, based on pleuripotent inducible stem cell therapy is developing rapidly as an intervention in this sector.

Finally, it is incumbent on me to call attention to the huge contribution that research on calcium (Ca2+) signaling has made toward the understanding of cardiac contraction and to the maintenance of the heart rhythm.  The heart is a syncytium, different than skeletal and smooth muscle, and the innervation is by the vagus nerve, which has terminal endings at vesicles which discharge at the myocyte junction.  The heart specifically has calmodulin kinase CaMK II, and it has been established that calmodulin is involved in the calcium spark that triggers contraction.  That is only part of the story.  Ion transport occurs into or out of the cell, the latter termed exostosis.  Exostosis involves CaMK II and pyruvate kinase (PKC), and they have independent roles.  This also involves K+-Na+-ATPase.  The cytoskeleton is also discussed, but the role of aquaporin in water transport appears elsewhere, as the transport of water between cells.  When we consider the Gibbs-Donnan equilibrium, which precedes the current work by a century, we recall that there is an essential balance between extracellular Na+ + Ca2+ and the intracellular K+ + Mg2+, and this has been superceded by an incompletely defined relationship between ions that are cytoplasmic and those that are mitochondrial.  The glass is half full!

 

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The Cost to Value Conundrum in Cardiovascular Healthcare Provision


The Cost to Value Conundrum in Cardiovascular Healthcare Provision

Author: Larry H. Bernstein, MD, FCAP

I write this introduction to Volume 2 of the e-series on Cardiovascular Diseases, which curates the basic structure and physiology of the heart, the vasculature, and related structures, e.g., the kidney, with respect to:

1. Pathogenesis
2. Diagnosis
3. Treatment

Curation is an introductory portion to Volume Two, which is necessary to introduce the methodological design used to create the following articles. More needs not to be discussed about the methodology, which will become clear, if only that the content curated is changing based on success or failure of both diagnostic and treatment technology availability, as well as the systems needed to support the ongoing advances.  Curation requires:

  • meaningful selection,
  • enrichment, and
  • sharing combining sources and
  • creation of new synnthesis

Curators have to create a new perspective or idea on top of the existing media which supports the content in the original. The curator has to select from the myriad upon myriad options available, to re-share and critically view the work. A search can be overwhelming in size of the output, but the curator has to successfully pluck the best material straight out of that noise.

Part 1 is a highly important treatment that is not technological, but about the system now outdated to support our healthcare system, the most technolog-ically advanced in the world, with major problems in the availability of care related to economic disparities.  It is not about technology, per se, but about how we allocate healthcare resources, about individuals’ roles in a not full list of lifestyle maintenance options for self-care, and about the important advances emerging out of the Affordable Care Act (ACA), impacting enormously on Medicaid, which depends on state-level acceptance, on community hospital, ambulatory, and home-care or hospice restructuring, which includes the reduction of management overhead by the formation of regional healthcare alliances, the incorporation of physicians into hospital-based practices (with the hospital collecting and distributing the Part B reimbursement to the physician, with “performance-based” targets for privileges and payment – essential to the success of an Accountable Care Organization (AC)).  One problem that ACA has definitively address is the elimination of the exclusion of patients based on preconditions.  One problem that has been left unresolved is the continuing existence of private policies that meet financial capabilities of the contract to provide, but which provide little value to the “purchaser” of care.  This is a holdout that persists in for-profit managed care as an option.  A physician response to the new system of care, largely fostered by a refusal to accept Medicaid, is the formation of direct physician-patient contracted care without an intermediary.

In this respect, the problem is not simple, but is resolvable.  A proposal for improved economic stability has been prepared by Edward Ingram. A concern for American families and businesses is substantially addressed in a macroeconomic design concept, so that financial services like housing, government, and business finance, savings and pensions, boosting confidence at every level giving everyone a better chance of success in planning their personal savings and lifetime and business finances.

http://macro-economic-design.blogspot.com/p/book.html

Part 2 is a collection of scientific articles on the current advances in cardiac care by the best trained physicians the world has known, with mastery of the most advanced vascular instrumentation for medical or surgical interventions, the latest diagnostic ultrasound and imaging tools that are becoming outdated before the useful lifetime of the capital investment has been completed.  If we tie together Part 1 and Part 2, there is ample room for considering  clinical outcomes based on individual and organizational factors for best performance. This can really only be realized with considerable improvement in information infrastructure, which has miles to go.  Why should this be?  Because for generations of IT support systems, they are historically focused on billing and have made insignificant inroads into the front-end needs of the clinical staff.

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Stanford Dropout is Already Drawing Comparisons with Steve Jobs

Larry H Bernstein, MD, Reporter

An interview by Eric Topol on Medscape of a 29 year-old Stanford University dropout is fascinating.

Editor’s Note:

If 29-year-old Elizabeth Holmes has her way, patients will no longer have to go to physicians’ offices, hospitals or laboratories to get high-complexity diagnostic blood tests. Nor will vial after vial of blood draws be necessary to do these tests.

Barely out of the gate after a decade of secrecy, the Stanford dropout is already drawing comparisons with Steve Jobs (she often wears the same black turtleneck). And her company, Theranos, Inc., which emerged from the shadows in September, just might be healthcare’s answer to Apple.[1] The so-called disruptive technology that Ms. Holmes, a former engineering major, and Theranos have created is said to have the potential to shake up and forever change the way laboratory medicine is conducted. Since forgoing college at 19, Ms. Holmes has secured millions of dollars in funding for her new venture, including $45 million in private equity funding in 2010.[2] The board of directors of her company is a Who’s Who of distinguished former and current technology, academic, and government officials.[2,3]

In an exclusive interview, Ms. Holmes talks to Medscape Editor-in-Chief Eric J. Topol, MD, about the decade she spent building her company; plans for the present and the future, including a recent deal with Walgreens drugstores; and whether she’s on the path to the creative destruction of laboratory medicine.

Leaving Stanford at Age 19

Dr. Topol: Hello. I’m Dr. Eric Topol, Editor-in-Chief of Medscape. Joining me today for Medscape One-on-One is Elizabeth Holmes, Founder, President, and CEO of Theranos.  We are here in Palo Alto, California, at the company’s headquarters. Elizabeth, welcome. This is going to be a fascinating discussion.

Ms. Holmes: Thank you. It’s wonderful to be here and have you here.

Dr. Topol: This is a story that has been brewing for a long time. You were at Stanford University, and at age 19 you decided to change your path. Is that right?

Ms. Holmes: Yes.

Dr. Topol: What made you think, “I’m on to something, and I don’t want to do college; I’ve got something else that’s  probably bigger than that”?

Ms. Holmes: I knew that I wanted to do something that could make a difference in the world.

To me, there was nothing greater that I could build than something that would change the reality in our healthcare system today, which is that when someone you love gets really, really sick, usually by the time you find that out, it’s too late to be able to do something about it. And in those moments it’s heartbreaking, because there is nothing you wouldn’t do.

 

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The Affordable Care Act: A Considered Evaluation.
Part III. Final Implementation of the Affordable Care Act and a Patient and Community Outcomes Focus

Author and Curator: Larry H Bernstein, MD, FCAP

 

UPDATED on 3/2/2018

Physicians’ Broader Vision For The Center For Medicare And Medicaid Innovation’s Future: Look Upstream

MARCH 2, 2018

https://www.healthaffairs.org/do/10.1377/hblog20180227.703418/full/

 

Introduction

This is the third discussion of a three part series on the Affordable Care Act, which is enacted and has passed review by the US Supreme Court with respect to Constitutional Legality. As a result, there is a requirement for States to implement the ACA by forming Accountable Care Organizations as a major mandate to provide an insurance safety net for the unemployed, the indigent children of unemployed or underemployed, and the highest risk population of our citizens.  The implementation of the law will take time, will need tweaking, and is already accompanied by significant reorganization of the insurance industry, which has been dominated by for-profit-organizations with a label ‘managed-care’, by the alignment of hospitals into large networks to gain leverage in negotiation of annual budget allocations, and reorganization of physicians either into very large ‘institutional providers’, or into groups of independent physicians into a ‘contract managed’ concierge group, or the persistent independent practice with assigned privileges in a department on the Medical Staff.  In any case, these arrangements are clearly matters of managing risk.  The current sequestration is an unneeded confounding factor is the matter of managing financial risk.

There are at least three issues that have surfaced:

[1] The formation of alliances of hospitals, not necessarily within one state, and the provision of care by maybe two hospitals in a community.  One interesting case is the existence of two hospitals in Erie, PA.  The Catholic Hospital has an assigned medical staff, and the other hospital is managed by University of Pittsburgh Healthcare Alliance, which is also a health insurance entity on its own.  The consequence of this arrangement is that there is no crossover of medical staff and patient choice of a physician is no longer an issue for choice.

[2] I have already mentioned where the physician is in this reorganization.  Young physicians coming into practice will choose an established group, or they might become an employee of the hospital with the ‘Part B’ payment coming through the organization’s finance (to the Medical Practice Organization), and the facilities and equipment costs taken care of by the organization.

[3] The hospital’s negotiate the insurance rates as a large network of organizations.  One risk for some members of the organization is the siphoning of cases to the strongest members of the group.  This would mean that smaller, non-metropolitan hospitals would have to refer any cases with moderate-high complexity.   That could present a problem of fairness in allocation of resources, and possibly a problem of access over large distances.

infographic The healthcare and life sciences industry is experiencing unparalleled disruption and consolidation while converging on new business models

mHealth: Managing Data on the Go

Follow the Connecting the Continuum series
By John Morrissey   Hospitals & Health News

The continuum of care requires continual communication and information sharing to tie it together, and that involves computerized equipment that clinicians and patients understand, are familiar with and will gladly use. The proliferation of cellphones, their morphing into miniature computers and the addition of wireless tablet computers have become a ready base for health-related information interchange.

The challenge for health care CEOs is to bring that potential into the particular realm of care delivery, surrounding it with reliable infrastructure and fostering policies on IT support and data security that keep a beneficial but strongly decentralizing force from getting out of corporate control, experts say.
http://www.hhnmag.com/hhnmag/images/pdf/ATTgate_july2013.pdf

A smartphone or tablet is engaging to clinicians “because it’s intuitive, it’s got the good battery life, it’s got the accessibility, fairly good speed; it brings everything to your fingertips,” says David Collins, who heads up mobile health activities with the Healthcare Information and Management Systems Society.

In contrast to interfaces for electronic record systems, which take some time to get to know and love, the intrinsic enthusiasm for mobile devices has required reining in physicians’ ambitions to use them beyond what may be practical or supportable.

An interdisciplinary committee for mobile-health policy — deciding not just device issues, but also the clinical issues of working them into health care operations — is the first step in developing a sensible rather than haphazard approach, says Collins.

Being HIPAA Compliant is a Journey

By Mike Semel

Here are a few simple things you can do to maintain a HIPAA compliant environment.

1.      HIPAA Compliant Human Resource Department

Make sure HIPAA stays on the radar of your HR staff. Be sure that HIPAA training is on the checklist for all employees. The next time a new employee is hired, ask to see the evidence that the person was trained prior to being given access to patient data. If it was done, document it as part of your internal auditing program to stay HIPAA compliant.

2.      HIPAA Compliant Employees

Audit your employees to make sure they are HIPAA compliant. Check work areas to ensure that passwords are not visible. Check the documentation for the tasks they perform. Observe them while they do their jobs. Let everyone know you are looking and conduct random HIPAA audits regularly.

3.      HIPAA Compliant Risk Analysis

Being HIPAA compliant means you will review it at least once a year. Immediately document any significant changes, like moving to a new location, relocating IT equipment to a new data center; or implementing a new EHR system. If nothing changes in a year, just make a note, and sign and date it.

4.      HIPAA Compliant Business Associates

A bigger challenge to being HIPAA compliant than your employees are your vendors. They can cause a data breach that could cost you millions of dollars. Demand evidence that they are HIPAA compliant, and their subcontractors are HIPAA compliant.

5.      Scheduling HIPAA Compliant Management

How can you remember everything needed to be HIPAA compliant?  Use your computer to schedule reminders to audit HR, your employees, and schedule reviews of the biggest threat to you staying HIPAA compliant— usually your IT company, cloud software vendor, data center, or online backup company.

ACP Concerns with Meaningful Use Program

Letter to: Sebelius, Ms. Tavenner, and Dr. Mostashari    Sep 12, 2013

On behalf of the American College of Physicians, I am writing to share our views on what has been released for Stage 2 and what we have been told to expect for Stage 3 of Meaningful Use.

ACP applauds ONC and CMS, as well as the Health IT Policy Committee and Standards Committee for their diligence and hard work in developing Stage 2 of the EHR Incentive Program. However, we are concerned that the very aggressive timeline combined with overly ambitious objectives may unnecessarily limit the success of the entire EHR Incentive program. Further, the reliance on evolving and draft standards, technologies for which integration is not yet completely tested, developing infrastructure, and upcoming regulatory requirements (i.e., ICD-10) add complexity and uncertainty to the situations faced by physicians and their teams.

As you work to transform the recommendations for Stage 3 into ambitious yet broadly achievable measures, we urge you to keep in mind the original guiding principles of the program – to position physicians and other healthcare providers to deliver excellent, patient-centered care focused on improving clinical outcomes.

While we support the goals represented by the Meaningful Use (MU) objectives, we are concerned about the appropriateness, focus and feasibility of some of the proposed measures, as well as the potential unintended consequences and additional costs to the practices of these well-intended efforts.

Return on Investment in EHRs

Meaningful Use Is Only the Beginning: Efficiency and More-Appropriate Coding Bring Savings and Increase Revenues

Today, the hope of receiving “Meaningful Use” rewards is motivating some physicians to begin using electronic health records sooner rather than later. But the government incentives will not cover all of their EHR-related costs, and there are many other reasons to get an EHR now.

Properly implemented, an EHR system with supe-rior features can:

•            Improve practice efficiency. By replacing paper records with EHRs, for example, practices can reduce record handling and access data more quickly for both clinical and billing purposes.

•            Help improve quality of care. Decision-support features can help avoid medical errors, while reporting and registry functions allow practices to track and reach out to patients who need preventive or chronic care.

•            Be a building block for a medical home. Many payers are now giving incentives to encourage physicians to create patient-centered medical homes, which require EHRs.

•            Prepare practices for accountable care: EHRs in interoperable networks are essential to accountable care organizations (ACOs).

•            Help recruit new physicians. Young doctors who trained on EHRs in residency want to work in computerized practices.

Sources Of Return On Investment (ROI)

According to experts, the incentives for Meaningful Use — up to $44,000 per provider through Medicare or nearly $64,000 through Medicaid — will cover only a portion of the long-term cost of an EHR system. Estimates of the five-year cost of EHR hardware and software range from $30,000 to $80,000 per physician, depend¬ing partly on practice size. And that doesn’t include the cost of training, interfaces, patient portals and conversions from other systems.

So a business plan for an EHR system acquisition must include sources of ROI that go beyond Meaningful Use rewards. A short list of these would include:

•            Tax write-offs (in 2011 and 2012)

•            Savings in labor and supplies

•            More accurate and complete coding, which usually results in higher revenue

•            Improved accounts receivable (A/R) manage-ment

•            Conversion of space currently used for chart storage

•            Rewards from Medicare’s Physician Quality Reporting Initiative (PQRI)

•            Pay for performance and medical home incen-tives

Except for depreciation, all of these ROI sources can be facilitated by the use of an integrated EHR and practice management (PM) system with a single database. The government’s regulations also allow physicians to show Meaningful Use by employing a combination of certified EHR modules — for example, electronic prescribing, document management, and charting systems. But if these systems are from unrelated vendors, it will be very difficult and expensive to con¬nect them with a single interface so they can work together. So, even though these modules may enable some practices to meet the Stage 1 Meaningful Use requirements, they will slow physicians down and make practices less, rather than more, efficient.

Government Incentives

To obtain financial incentives, physicians must demonstrate Meaningful Use of an EHR system certified by a government-approved certification body. In Stage 1 of Meaningful Use, a physician or other eligible professional (EP) may attest to Meaningful Use for a 90-day period in either 2011 or 2012. That attestation will entitle the EP to a payment of $18,000. Further payments fol¬low over the next four years if the EP meets the Stage 2 and 3 criteria for Meaningful Use.

EHR as a Powerful Tool in ICD-10 Conversion

The U.S. Department of Health and Human Services has mandated all health care providers begin use of ICD-10 on October 1, 2014. The conversion to the new coding set will demand incredible effort from the medical community and, if not proactively addressed, could cause major disruptions for health organizations. To complicate matters, the conversion comes at a time of other significant changes including the implementation of EHR (electronic health records). Although EHR and ICD-10 may seem like separate issues, adopting the right EHR system will help you prepare for the ICD-10 conversion. AdvancedMD EHR and integrated billing are powerful tools in the ICD-10 conversion. With over 60 years of experience, ADP is a trusted company with the knowledge and resources to give your practice the advantage in ICD-10 conversion and EHR implementation.

Getting ready for ICD-10

The conversion to ICD-10 has caused uneasiness in the health care community. The coding changes come at a time when healthcare providers are already grappling with other reforms, including the implementation of electronic health records (EHR). Recent regulations to implement ICD-10 and EHR are intended to streamline information sharing and create a more efficient national healthcare system. However, the changes can seem overwhelming for a busy private practice. Physicians are scrambling to purchase software and make upgrades before the quickly-approaching deadlines. You can’t afford to wait any longer to develop your EHR and ICD-10 implementation plans.

Although ICD-10 and EHRs may seem like separate issues, carefully designing a plan that address both your needs will save you time, money and energy. Selecting the right EHR system can aid in your conversion to ICD-10.

Today’s EHR systems are more powerful than ever. They have been designed to reflect regulatory changes to record-keeping, documentation, and coding. But not all systems are created equal— choosing an EHR system may be one of the biggest decisions you make for your practice’s financial health. EHR software should reduce the disruptions of ICD-10 conversion, not compound them.

Five things you should consider when selecting an EHR system

1. Invest in an EHR system that will be fully utilized by staff.

When you are selecting an EHR system, be sure that it will meet the specific needs of your practice. In order to reach Meaningful Use (MU) requirements and facilitate the ICD-10 conversion, your EHR system must be accessible to both clinical and administrative staff. An EHR system should meet the following standards:

•            Simple chart note creation
•            Minimal steps to access information
•            Easy-to-learn and easy-to-use interface
•            Intuitive workflow
•            Interoperability with internal and external systems

2. Choose an EHR designed to reduce ICD-10 transition challenges.

ICD-10 requires physicians and clinical staff to capture more specific patient data. With nearly nine times as many codes as ICD-9, the new coding set aims to record a higher level of medical data to use in patient care, billing, and reporting.

Additionally, EHR should aid in creating complete, detailed patient documentation. Physicians have always strove to create accurate patient charts, but the task may seem daunting with new ICD-10 codes and an expectation of increased specificity. EHR systems should provide point-and-click options to apply treatment codes and make chart notes.

3.           Ensure EHR software facilitates clinical information exchange.

When the federal government passed legislation to reform health care information technology, the reporting and exchange of patient information was a primary focus. An important consideration is how EHR technology will manage the data from other providers and health information exchanges (HIE).

Powerful EHR software makes this data an invaluable asset to patient care by intelligently organizing shared information. A private practice’s technology should present clinicians with applicable information in an easy-to-use format.

4.           Check for intelligent mapping and prompting.

An EHR system should enhance the patience experience, not complicate it. Systems that provide intelligent mapping and prompting will allow the provider to easily code and chart. Based on a patient’s history, current findings, and documentation, EHR software should suggest proposed ICD-10 codes.

Physicians can focus on engaging with the patients rather than worrying about coding proficiency or manually hunting through data screens. Intelligent mapping and prompting will reduce the time spent manually updating a patient’s chart or charge slip.

5.           Select an EHR system that will support future requirement updates.

An EHR system can be a powerful tool during the ICD-10 conversion; it can also be a hindrance. Selecting an EHR system that is capable of supporting the ICD-10 transition may be one of the most important decisions you make—but that is just a start. Be sure it will accommodate future regulatory changes.

EHR systems must be adaptable to new requirements through simple upgrades. A powerful EHR system can be updated without causing major disruption to your daily operations or to patient care. When evaluating a new system, be sure it can be modified to address future needs.

Expect more from your EHR. The EHR must provide tools that meet Meaningful Use requirements, maximize practice efficiency, and aid you in the ICD-10 conversion.

Closing Points:

•            Smoothly migrate to ICD-10 compliance with minimal disruption
•            Eliminate the costs and hassles of server-based software and hardware
•            Provide high-quality of care with access to shared health information
•            Increase proficiency and accuracy with an easy-to-learn, easy-to-use interface

Lower Health Insurance Premiums to Come at Cost of Fewer Choices

By         New York Times  Sep 22, 2013

From California to Illinois to New Hampshire, and in many states in between, insurers are driving down premiums by restricting the number of providers who will treat patients in their new health plans.WASHINGTON — Federal officials often say that health insurance will cost consumers less than expected under President Obama’s health care law. But they rarely mention one big reason: many insurers are significantly limiting the choices of doctors and hospitals available to consumers.

When insurance marketplaces open on Oct. 1, most of those shopping for coverage will be low- and moderate-income people for whom price is paramount. To hold down costs, insurers say, they have created smaller networks of doctors and hospitals than are typically found in commercial insurance. And those health care providers will, in many cases, be paid less than what they have been receiving from commercial insurers.

Some consumer advocates and health care providers are increasingly concerned. Decades of experience with Medicaid, the program for low-income people, show that having an insurance card does not guarantee access to specialists or other providers.

Consumers should be prepared for “much tighter, narrower networks” of doctors and hospitals, said Adam M. Linker, a health policy analyst at the North Carolina Justice Center, a statewide advocacy group.

“That can be positive for consumers if it holds down premiums and drives people to higher-quality providers,” Mr. Linker said. “But there is also a risk because, under some health plans, consumers can end up with astronomical costs if they go to providers outside the network
.

ED Use Could Surge Under ACA, Study Suggests

Sep 17, 2013  By Cole Petrochko,    MedPage Today

Action Points

[1] Note that this study of California registry data suggested an increase in ED visits among those insured by Medicaid from 2005-2010.

[2] Be aware that the authors speculate that the high use of the ED by Medicaid participants is due to poor access to primary care.

[3] Increases in California emergency department (ED) use were driven in large part by Medicaid patients, presaging increased burdens after the Affordable Care Act kicks in completely, researchers found.

From 2005 to 2010, the number of visits to California emergency departments rose by 13.2% from 5.4 million to 6.1 million annually, with a significant 35% increase in the number of patients insured through Medi-Cal (as Medicaid is known in California) driving this rise (P<0.001), according to Renee Hsia, MD, MSc, of the University of California San Francisco, and colleagues.

Medicaid patients also had the highest usage burden for ambulatory-care-sensitive conditions (54.76 per 1,000 patients on average) compared with those who had private insurance (10.93 per 1,000 patients) or none at all (16.6 per 1,000 patients), they wrote online in a research letter in the Journal of the American Medical Association.

According to previous research, many patients who will soon be insured under the ACA will be enrolled in Medicaid. While these people are generally healthier than current Medicaid enrollees, they may introduce a new and vast additional burden to treat undiagnosed and uncontrolled conditions.

The largest increase in visits occurred in 2009, most likely because of the “H1N1 pandemic and the influence of the economic downturn on coverage transitions and access to care,” the authors explained. Total visits per 1,000 adults living in California increased by 8.3% from 252 to 274 between 2005 and 2010.

Will healthcare reform drive up ED use?

By Alicia Caramenico
Medicaid patients use the emergency department more frequently than uninsured patients, as they still have trouble accessing primary care, according to a research letter in today’s issue of JAMA.

Researchers conducted a retrospective analysis of California ED visits by adults 19 to 64 years of age from 2005 to 2010, and found the number of visits to EDs increased by 13.2 percent to 6.1 million per year.

The largest increase in ED visit rates occurred among adult Medicaid beneficiaries, who had higher rates than both uninsured and privately insured patients.

Moreover, Medicaid patients’ high and growing ED use for ambulatory care sensitive conditions suggests the trend will continue with Medicaid expansion under healthcare reform, according to the research announcement.

Echoing those concerns, James McCarthy, M.D., of the University of Texas Health Science Center at Houston told MedPage Today the Affordable Care Act’s expansions to Medicaid “will certainly increase [ED visits] as Medicaid beneficiaries will have the most difficulty getting into primary care clinics.”

To prevent Medicaid patients from making frequent visits to the ED, hospitals could replicate efforts in Washington state that improve communication and care coordination between the ED and primary care providers, the article noted. The program in Washington educates Medicaid patients about appropriate care settings and involves case managers identifying and tracking frequent ED users, Michael Lee, M.D. of the Alpert Medical School at Brown University in Providence, R.I., told MedPage.

Hospitals should target Medicaid “super-utilizers,” using early intervention and primary care, to save money while improving the health outcomes of these complex patients, according to The Center for Medicaid and CHIP Services.

But despite concerns that high ED use by Medicaid patients stems from poor access to primary care, previous research has found most Medicaid patients go to the ED because they have to, seeking emergency or urgent care for serious medical problems, FierceHealthcare previously reported.

State Politics and the Fate of the Safety Net

K Neuhausen, M Spivey, and AL Kellermann
Sep 18, 2013       http://dx.doi.org/10.1056/NEJMp1310572             http://www.nejm.org/doi/full/10.1056/NEJMp1310572

Only 2% of acute care hospitals nationwide are safety-net facilities, but they provide 20% of uncompensated care to the uninsured. Because most are in low-income communities, they typically generate scant revenue from privately insured patients. The Medicaid Disproportionate Share Hospital (DSH) program was established to help defray their costs for uncompensated care.

Currently, Medicaid DSH disburses $11.5 billion annually to the states, which have considerable latitude in allocating these funds. Some states carefully target their DSH payments to hospitals providing large volumes of uncompensated care, but others, such as Ohio and Georgia, spread their payments broadly, transforming the program into a de facto subsidy of their hospital industry.

Because the Affordable Care Act (ACA) was expected to dramatically expand insurance coverage, safety-net hospitals were expected to need less DSH money. Therefore, to reduce the cost of expanding Medicaid, the ACA reduced Medicaid DSH funding by $18.1 billion between fiscal years 2014 and 2020. To allow time for coverage expansion to take effect, the cuts are back-loaded — starting at $500 million (4% of current national DSH spending) in 2014 but reaching $5.6 billion (49% of current spending) in 2019.

The DSH cuts are so deep in part because Congress assumed that all states would expand Medicaid, providing coverage for 17 million low-income people and sharply reducing uncompensated care. The anticipated increased revenue from Medicaid was considered sufficient to compensate hospitals for lost DSH funds. The fiscal math changed when the Supreme Court ruled that states could opt out of Medicaid expansion. Now, only 24 states and the District of Columbia plan to expand Medicaid in 2014; 22 states, including Texas and Florida, will not, and the rest are undecided. Thus, at least 6 million Americans who were expected to obtain coverage will remain uninsured. Because many states that won’t expand Medicaid currently receive large DSH payments, their safety-net hospitals will be hit hard when the DSH cuts kick in.

Even states that expand Medicaid will need some DSH support. After Massachusetts implemented its health care reform law, uncompensated-care costs at its hospitals dropped by 40% but soon climbed again. In 2011, Massachusetts hospitals required $440 million to offset their costs for uncompensated care.

Recently, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule allocating reductions in DSH payments across states for the first 2 years, on the basis of three equally weighted factors:

  1. the percentage of uninsured people in the state,
  2. how well the state targets its DSH payments to hospitals with high percentages of Medicaid inpatients,
  3. how well it targets DSH payments to hospitals with high levels of uncompensated care.

If the rule is adopted as written, states with lower percentages of uninsured citizens will receive steeper cuts, but the biggest reductions will hit states that don’t target DSH payments to hospitals providing large amounts of Medicaid and uncompensated care.

We believe the proposed rule moves DSH policy in the right direction by providing incentives to states to focus their remaining DSH funds on the hospitals that need it most. The proposed rule does not change states’ authority to use DSH funds for a broad hospital subsidy, but those that do will get less money.

States that refuse to expand Medicaid and to target DSH payments more carefully will not only forfeit billions of dollars for covering their poorest residents; they will also forgo hundreds of millions more when DSH cuts are ramped up in 2017. If politics continue to trump economic self-interest in these states, the consequences for their safety-net hospitals could be dire.

http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/0/nejm.ahead-of-print/nejmp1310572/20130918/images/small/nejmp1310572_t1.gif

If properly enforced, the proposed rule will help sustain the safety net. But if the state governments that refused to expand Medicaid also refuse to rethink their approach to allocating DSH funds, there will be little money left to sustain their safety-net hospitals when the cuts deepen in 2017. The cascade of service reductions and facility closures that this could trigger would have sweeping consequences.

Total Patient Engagement

AT Brooks, L Silverman and GR Wallen
Shared Decision Making: A Fundamental Tenet in a Conceptual Framework of Integrative Healthcare Delivery
Integrative Medicine Insights 2013:8 29–36   http://dx.doi.org/10.4137/IMI.S12783

With the increased usage of complementary and alternative medicine (CAM) in the US comes a need for evidence-based and integrated care systems which encourage open communication between patients and providers. This paper introduces a conceptual framework for integrative care delivery, with shared decision making being the “connecting force” between holistic treatment and improved health outcomes for patients.

The use of complementary and alternative medicine (CAM) is increasing. The National Center for Complementary and Alternative Medicine (NCCAM) defines CAM as “a group of diverse medical and health care … practices and products that are not generally considered part of conventional medicine” (referring to Western medicine). “Conventional” medicine is oft-referred to as allopathic, or biology-based medicine, which has emerged as the Western medical model. However, CAM is utilized by nearly half of all industrialized countries and similar or higher rates exist in many developing countries.2 These practices can be implemented together with conventional medicine, known as “complementary,” or in place of conventional medicine, known as “alternative”. Particularly in the United States, we are experiencing a shift toward combining the physiologic and technologic dimensions of curing with the spiritual dimensions of healing. The World Health Organization (WHO) recently launched a global strategy on traditional and alternative medicine, focusing on policy, safety, efficacy, and quality.4 Standardization across these dimensions has the potential to increase both access to and knowledge about CAM.

Potential barriers to CAM use and implications.

Despite developments in the field of CAM, certain barriers may inhibit its widespread adoption and integration. These potential barriers are engendered by lack of knowledge about CAM therapies, and difficulty incorporating CAM into daily routines. For treatments which require accessing a health care provider (as opposed to self-care), lack of accessibility may be an issue. Among younger individuals, the approval of family members and significant others can be important factors in individuals’ decision to use CAM.

Despite advances in technology and the power of emerging genetic and genomic discov¬eries, patients around the world are still seeking holistic, individualized care that is focused on health of both the mind and the body. Despite advances in technology and the power of emerging genetic and genomic discoveries, patients around the world are still seeking holistic, individualized care that is focused on health of both the mind and the body. Currently in the US, most patients who present to a primary care provider are scheduled into fifteen-minute visits, even though varying levels in acuity and complexity of conditions may require more intensive attention and longer visits. Expressing concern about patient needs and teaching patients how to control their symptoms are important and necessary in caring for patients in a holistic manner and require focused time and attention on the part of the health care provider. Ben-Arye and colleagues (2012) conducted a study in northern Israel and identified that patients expect that their primary care providers refer them to CAM treatments and participate in building a CAM treatment plan. Some studies suggest that making provider visits more patient-centered should be focused on “improving dialogue quality” and “efficient use of time” instead of lengthening the visits.

Patients have expressed concern about quality of care in general both in the US and internationally. Satisfaction with the care and performance delivered by our health care system is lower in the US than many other countries internationally, and health disparities within the US remain cause for concern because our current model of health care delivery is not adequate.  Experts in the field propose training more integrative health care providers to ensure that healthcare is both “high tech and high touch”.

Shared Decision-Making and CAM

The paradigm shift from “CAM” to integrative medicine reflects a need for open dialogue between patients and their providers, both conventional and CAM. Shared decision-making (SDM) between patients and providers is ethical, can preserve patient autonomy, considers patient values and preferences, and may lead to improved health outcomes. The conceptual framework introduced in this paper suggests that SDM is a vehicle that can help achieve implementation of integrative health care delivery. In a shared decision making model of care, the patient-provider relationship is interactional in nature, in that both the patient and provider are invested and actively involved in treatment decisions. Incorporating patient desires through shared decision-making (SDM) is considered to be ethical by promoting truthfulness and openness while encouraging patient autonomy. Most importantly, SDM has been associated with improved health outcomes across a range of illnesses.

The Challenge and Opportunity of ACOs: Insights from ACO Pioneers

By D Gentile, and T Samo

  1. What is an ACO?
  2. What is Clinical Integration?
  3. What is the role of Information Technology in an ACO?

How can healthcare organizations that were built on volume adapt to the arrival of a value-based reimbursement system? American providers, as well as payers, are struggling to find an answer to that critical question. When it comes to the Accountable Care Organization (ACO), the struggle generally takes two forms: either to jump in with both feet via a model such as the Medicare Pioneer ACO program, or to sit back and take a wait-and-see approach.

1.  What is an ACO?

Accountable Care Organizations are groups of physicians, hospitals and other healthcare providers in a specific geographic area who come together voluntarily to provide coordinated high quality care to their patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending healthcare dollars more wisely, its members share in the savings achieved for payers, whether Medicare or commercial insurers.

Medicare offers three ACO programs:

•            Medicare Shared Savings Program—a program that helps Medicare fee-for-service providers become an ACO

•            Advance Payment Initiative—a supplementary incentive program for selected participants in the Shared Savings Program

•            Pioneer ACO Model—a program designed for early adopters of coordinated care who already contract for defined populations on a risk basis

Many commercial payers have also entered into ACOs with providers, expanding on the long-standing concept of capitated reimbursement, a per-member, per-month advance payment model. In commercial ACO programs, capitated or value-based reimbursement is typically overlaid with targets for overall costs and incentive provisions for meeting cost goals and various quality metrics. Yet many commercial models are more tentative, providing arrangements such as traditional fee-for-service overlaid with shared savings and a care management fee.

2. What is Clinical Integration?

A concept that has been around for many years, clinical integration is the foundation of any ACO. Clinical integration is the means by which ACOs foster collaboration among independent physicians and hospitals to increase the quality and efficiency of patient care. Providers will need to achieve a significant level of clinical integration before they can contract with health plans, or participate in a shared savings incentives program, whether it is funded by Medicare or by commercial payers.

There are three key components of clinical integration: 1) an active, ongoing collaboration between hospitals and physicians; 2) a coordinated effort, informed by information technology, to improve the quality and efficiency of care through the use of evidence-based practices and data-driven performance improvement; and 3) an agreement with a payer that aligns the financial incentives of physicians and hospitals to accomplish these goals. In the Medicare ACO program, as well as a small but growing number of commercial programs, #3 is achieved using the shared savings approach.

3. What is the role of Information Technology in an ACO?

Successful ACOs will be those that best coordinate treatment of chronic diseases, which can, if left unchecked, balloon into expensive hospital stays. Accomplishing this requires all caregivers who treat these conditions to be in the same information loop. For most provider organizations, that means making a significant investment in information technology.

A robust IT infrastructure is required to plug the many gaps that impede the coordination of care across inpatient, outpatient and home care settings. Four basic IT components are needed: 1) a health information exchange to ensure providers across the community have access to the same patient information; 2) an interoperable Electronic Health Record (EHR) that can be accessed in multiple settings, both inpatient and outpatient, to coordinate care; 3) personal health records to help engage patients in their own health; and 4) data analytics tools to profile physicians and at-risk patients alike. Each of these technologies are now in use, but not often in a coordinated manner.

Besides these core technologies, important IT contributors to the success of an ACO include advanced utilization management functions, such as disease management, complex case management, preauthorization services, specialty referral management and other analytic tools, as well as the financial and actuarial modeling typically performed by health plans.

Four categories mirror the key constituents of an ACO: physicians, payers, hospitals and health systems and patients. A fifth category describes an ACO’s organizational imperative – helping these groups to work together by building a shared identity.

Physician:
•            Physician leadership is critical
•            Local governance advances shared goals
•            Equip physicians with infrastructure to succeed
•            Work to engage independent physicians
•            Use both local and global incentives
•            Educate and train on a schedule
•            Monitor physician performance

The ACO flips the traditional adversarial relationship between hospitals and physicians on its head. To be successful, an ACO requires shared, consensual leadership between hospitals and physicians, who come to the table as fully equal partners in the new organization.

Use of Clinical Analytics in the World of Meaningful Use

Feb 2011  Sponsored by Anvita Health

In June 2010, HIMSS Analytics released a white paper that addressed the use of clinical analytics in the marketplace. At that time, most of the respondents participating in this research indicated that they were actively engaged in collecting and/or leveraging both clinical and claims data to enhance patient care cost, safety, efficiency and reducing healthcare costs. It was noted that none of the applications in the EMR suite had reached market saturation. And, while utilization of each of these applications has increased in the past year, that is still the case.

It is this growth in EMR adoption which is one of the principal drivers of the increased use of clinical analytics, since it is the patient data captured by these applications that is the primary source of the information that healthcare organizations analyze using clinical analytics tools. Spurred by Title XIII of the American Recovery and Reinvestment Act (ARRA) adoption of these technologies is expected to continue to accelerate in the future. In July 2010, the Centers for Medicare and Medicaid Services (CMS) published the final rules on the Electronic Health Record Incentive Program. According to the Federal Register, “The HITECH Act statutorily requires the use of health information technology in improving the quality of care, reducing medical errors, reducing health disparities, increasing prevention and improving the continuity of care among health settings”. In order to meet the goals of this statement and receive incentive payments, CMS identified a core set of 14 meaningful use objectives on which eligible hospitals need to focus to qualify for incentive funds provided through the new CMS Medicare and Medicaid incentive program. Additionally, eligible hospitals must achieve five of 10 menu set objectives to qualify for incentive funds.

In addition to a focus on meaningful use measures, the industry’s shift to the use of ICD-10 (International Statistical Classification of Diseases and Related Health Problems-10th revision), mandated for the coding of all inpatient and outpatient claims beginning in October 20132, will also impact the use of clinical analytics.

1 HIMSS http://www.himss.org/content/files/MU Final Rule.pdf 
2 Centers for Medicare & Medicaid Services https://www.cms.gov/ICD10/

The increased granularity from ICD-10, combined with the increased electronic capture of clinical data will yield volumes of new data for which healthcare organizations will have the opportunity to translate into information that can be used to improve the delivery of healthcare in the United States. However, for this to be successful, healthcare organizations will need both the tools to review and analyze data and an environment, such as a data warehouse in which to store and stage the data for efficient analysis.

Drivers for Using Clinical Analytics

In the research conducted in 2010, two key drivers for using clinical analytics to translate data into information were identified. These were achieving a high quality of care and patient safety and increasing awareness about the costs associated with the provision of care. These two factors continue to be the principal drivers in the market, as respondents indicated that they are continuing to try to provide a high level of care to individuals in their service area, while carefully monitoring and managing costs.

One way in which organizations are framing the quality of care issues is within the context of meaningful use, which has become a powerful industry driver. Because of the financial carrot of incentives when meaningful use criteria are met, many healthcare organizations (HCOs) are evaluating how they are capturing and analyzing data. All of the respondents noted that they are carefully analyzing the data that is being generated during the care delivery process and mapping that data against the process measures, such as capturing flow sheet data and changes in vital signs that have been identified in the meaningful use criteria or entering orders using computerized practitioner order entry (CPOE). And, because organizations will be required to report on multiple measures to achieve the meaningful use incentives, they are driven to find ways to be able to capture and report successfully on all measures rather than focusing on only a handful of measures.

Cost control also continues to be a key driver for these organizations, and has become an area of heightened concern over the course of the past year. Healthcare organizations are under pressure to meet increased demands for services, while at the same time containing costs. Additionally, as HCOs shift to an environment in which Patient Centered Medical Homes (PCMH) and Accountable Care Organizations (ACOs) are being touted as key solutions for the future, HCOs are looking for ways to limit their financial risk and provide care in a smarter, more efficient and more cost-effective fashion. As such, both payer and provider respondents in this research suggested that they look at data that had the potential to allow them to improve the financial bottom line at their organizations.

Current Use of Clinical Analytics

Most of the respondents participating in the June 2010 research reported that they are collecting and/or leveraging clinical and/or claims data to enhance patient care cost, safety and efficiency. The respondents from the current research cited similar approaches. To ensure that they are able to understand trends emerging within their patient population, respondents from the HCOs represented in this study reported analyzing data from wide variety of departments within their organizations. Some of the data sources identified by the respondents from provider organizations included OR, other procedural suites and the emergency department (ED). They also noted that medication, laboratory, billing and claims data were also analyzed. A number of respondents are also looking at data captured in ambulatory environments. The payer respondents in this research are also analyzing data from a wide variety of sources, including laboratory data, pharmacy data and claims (i.e. UB92) data.

Data Sharing

In addition to patient data that is captured at the HCO that is providing care, respondents reported sharing data with other organizations such as Midas, United Hospital Consortium (UHC), Premier and Health Plan Employer Data and Information Set (HEDIS). In conjunction with their own data, these external data sources allow HCOs to create a series of benchmarking reports that help them identify and analyze variances on their performance compared to other organizations of similar size and composition on key metrics such as length of stay, case costs and outcomes measures. Respondents from payer organizations are also relying on external metrics such as HEDIS and CAHPS (Consumer Assessment of Healthplan Providers and Systems) to direct their analysis.

A 3-Year M.D. — Accelerating Careers, Diminishing Debt

SB Abramson, D Jacob, M Rosenfeld, et al.
It’s been more than 100 years since Abraham Flexner proposed the current model for medical education in North America: 2 years of basic science instruction followed by 2 years of clinical experience.1 Over the past several decades, major changes have caused the medical community to reconsider current educational models. These changes include increasing education costs, shifts in health care needs, the demographics of the applicant pool, and many scientific, pharmacologic, and technological advances resulting in increased specialization of physicians.

Oversight of U.S. medical education is compartmentalized, with standards independently set for undergraduate and graduate accreditation by the Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME), respectively. This system results in rigid, time-based, non–learner-centered training. Recognizing this limitation, the Carnegie Foundation recently recommended that education should “provide options for individualizing the learning process for students and residents, such as offering the possibility of fast tracking within and across levels.”

In the past 30 years, the required training period after medical school has increased substantially,2 but the time spent in medical school has not been shortened. The average age of physicians entering practice has therefore increased. Since 1975, the percentage of physicians who are younger than 35 years of age has decreased from 28% to 15% (see graph), as the prolongation of specialty training has delayed entry into the workforce, reducing the productive years of clinicians and physician scientists. Compounding the effect of the increased duration of training is the growing number of entering medical students who have taken “gap” years between college and medical school. National data indicate that the average age of first-year medical students is 24. At the New York University School of Medicine (NYUSOM), 55% of this year’s entering medical students have taken 1 or more gap years.

http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2013/nejm_2013.369.issue-12/nejmp1304681/20130918/images/small/nejmp1304681_f1.gif

Percentage of Physicians in the United States Who Are Younger Than 35 Years of Age, 1975–2011.

The Challenge and Opportunity of ACOs: Insights from ACO Pioneers

Djen Linji    http://bit.ly/acochallenges
How can healthcare organizations that were built on volume adapt to the arrival of a value-based reimbursement system? American providers, as well as payers, are struggling to find an answer to that critical question. When it comes to the Accountable Care Organization (ACO), the struggle generally takes two forms: either to jump in with both feet via a model such as the Medicare Pioneer ACO program, or to sit back and take a wait-and-see approach.

Related Articles in Pharmaceutical Intelligence.com

The Affordable Care Act: A Considered Evaluation.
Part I.  The legislative act (ACA) and the model for implementation (Insurance Gateways).

Larry H. Bernstein, and Aviva Lev-Ari

https://pharmaceuticalintelligence.com/2013/09/13/the-affordable-care-act-a-considered-evaluation-the-legislative-act-aca-and-the-model-for-implementation-insurance-gateways/

The Affordable Care Act: A Considered Evaluation.
Part II: The Implementation of the ACA, Impact on Physicians and Patients, and the Dis-Ease of the Accountable Care Organizations.

Larry H. Bernstein, and Aviva Lev-Ari

https://pharmaceuticalintelligence.com/2013/09/13/the-affordable-care-act-a-considered-evaluation-the-implementation-of-the-aca-impact-on-physicians-and-patients-and-the-dis-ease-of-the-accountable-care-organizations/

Innovators-Prescription-New-Wave-of-Disruptive-Models-in-Healthcare

hhs_medicare_docs participating in and billing Medicare

healthprices time price of HC over 50 years

NHEbyDCforHS1 NHE annual growth rate of 4%

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The Affordable Care Act: A Considered Evaluation.

Part I.  The legislative act (ACA) and the model for implementation (Insurance Gateways).

Writer and Curator: Larry H. Bernstein, MD, FCAP
and
Curator and Editor: Aviva Lev-Ari, PhD, RN 
This discussion is composed as two distinct chapters.  The first is a clarification of what is contained in the Affordable Care Act (ACA), the model of care it is crafted from, the insurance mandate, the inclusion of groups considered high risk and uninsured, the inclusion of groups low risk and uninsured, and the economics involved in going from a fractured for profit health care industry to a more stable coverage for patients.  The second is taken from selected articles on the care process and the cost and consequences for improving quality at lower cost.   There are inherent problems at looking at this from a systems point of view, mainly impacted by the relationship of providers to hospitals and clinics, and by the relationships of insurers to the patients and providers in an Accountable Care Organization (ACO) model.
This article has the following two parts:

Part I. The legislative act (ACA) and the model for implementation (Insurance Gateways).

Part II.  The Implementation of the ACA, Impact on Physicians and Patients, and the Dis-Ease of the Accountable Care Organizations.

Part I

The legislative act (ACA) and the model for implementation (Insurance Gateways)

A. Access and Coverage of Healthcare Reform Mandate

About 2.5 million young adults from age 19 to 25 attained health coverage as a result of the Affordable Care Act, which took effect in September 2010, according to the U.S. Department of Health and Human Services. Prior to the law’s approval, some 13.7 million young adults were uninsured, nearly one-third of the nation’s total uninsured population, according to the nonprofit Kaiser Family Foundation.
Employer-sponsored health insurance forms the backbone of our health insurance system. This leaves small businesses difficult to provide their workers with comprehensive coverage. In 2007, only 25 percent of employees in small businesses had coverage through their own employers, compared with 74 percent of workers in large firms. Moreover, there are few sources of affordable coverage outside the employer-based system, leaving millions of employees in small businesses uninsured or with inadequate health insurance. In 2007, half as many workers in small businesses were uninsured or underinsured compared to employees in large businesses. Congressional health reform bills to reform the health system include provisions specifically aimed at helping small businesses and their employees gain access to affordable, comprehensive coverage.  Then there is another issue since the “Great Recession” of 2008, that there is no stable coverage for an unemployed workforce and indigent families with competing needs for food and health.  (Kaiser Health News, 2009; 67).
The law created insurance exchanges to close the gap.  Employer interest in insurance exchanges is growing. The Kaiser Family Foundation found that 29% of employers with 5,000 or more employees are considering private exchanges as an option for buying healthcare coverage for their employees. A day later, consulting firm Towers Watson released its Health Care Changes Ahead survey, which found that 37% of employers think private exchanges are a reasonable alternative to traditional employer coverage in 2014.
See Figure.  M. M. Doty, S. R. Collins, S. D. Rustgi, and J. L. Nicholson, Out of Options: Why So Many Workers in Small Businesses Lack Affordable Health Insurance, and How Health Care Reform Can Help, The Commonwealth Fund, September 2009.

Changes in Health Insurance Coverage in the Great Recession, 2007-2010

This issue brief examines changes in health insurance coverage over the last decade, with a focus on how changes in the economy, particularly during the “Great Recession” of 2007 to 2009, have affected coverage and the number of uninsured. The paper finds that the number of uninsured grew substantially during the first recession of the decade, increasing by 5 million people from 2000 to 2004; increased more slowly during the brief recovery, growing by 2.1 million people from 2004 to 2007; and then again rose significantly during the Great Recession, rising by 5.7 million people since 2007.
The paper also finds that coverage, especially for children, through the Medicaid and Children’s Health Insurance Programs helped to prevent even more people from being uninsured. While the number of uninsured children declined in recent years, the number of uninsured adults rose. The only notable drop in uninsured adults was for young adults ages 19-25 in 2010, most likely due to the provision of the health reform law that permits young adults to stay on their parents’ insurance. The paper also considers trends in coverage by work status, race and ethnicity, citizenship status and geographical region.
http://kff.org/medicaid/issue-brief/changes-in-health-insurance-coverage-in-the/

Uninsured adults with chronic conditions or disabilities: gaps in public insurance programs.

Pizer SD, Frakt AB, Iezzoni LI. US Department of Veterans Affairs in Boston, MA. 

Health Aff (Millwood). 2009;28(6):w1141-50. http://dx.doi.org/10.1377/hlthaff.28.6.w1141
http://www.ncbi.nlm.nih.gov/pubmed/19843552
Among nonelderly U.S. adults (ages 25-61), uninsurance rates increased from 13.7 percent in 2000 to 16.0 percent in 2005. Despite the existence of public insurance programs, rates remained high for low-income people reporting serious health conditions (25 percent across years) or disabilities (15 percent). Previous research has established that low-income workers, those facing more stringent Medicaid eligibility requirements, and people employed by smaller firms are more likely than others to lack health insurance. Residents of southern states had even higher rates (32 percent with health conditions, 22 percent with disabilities). Those who did not belong to a federally mandated Medicaid eligibility category were about twice as likely as others to be uninsured overall, and uninsurance among this group increased more rapidly over time.
To address this growing problem, President Barack Obama and leaders in Congress passed health insurance reform legislation that is still taking shape. A common feature of the major proposals at this point is that coverage would be expanded by building on existing arrangements. This approach allows people to keep their current insurance if they wish to do so. The Medicaid program is particularly complicated because it is jointly financed and operated by the federal and state governments and because each state has implemented it differently.
See Table 1.

Ultimately, if Congress decides not to eliminate categorical eligibility restrictions, our results indicate that the preservation of eligibility expansions for people with disabilities or chronic conditions would target a population that is particularly vulnerable to uninsurance and its deleterious effects on health.

How Many Are Underinsured? Trends Among U.S. Adults, 2003 And 2007

Cathy Schoen, Sara R. Collins, Jennifer L. Kriss and Michelle M. Doty
Health Aff 2008; 27(4) w298-w309  http://dx.doi.org/10.1377/hlthaff.27.4.w298
With health insurance moving toward greater patient cost sharing, this study finds a sharp increase in the number of underinsured people. Based on indicators of cost exposure relative to income, as of 2007 an estimated twenty-five million insured people ages 19–64 were underinsured—a 60 percent increase since 2003. The rate of increase was steepest among those with incomes above 200 percent of poverty, where underinsurance rates nearly tripled. In total, 42 percent of U.S. adults were underinsured or uninsured. The underinsured report high levels of access problems and financial stress. The findings underscore the need for policy attention to benefit design, to assure care and affordability.
See Table 1 and Table 2
About seven in ten underinsured adults had annual incomes below $40,000 or below 300 percent of poverty—similar to the income distribution of the uninsured. In contrast, nearly two-thirds of those with more adequate insurance had incomes above $40,000. Underinsured adults were more likely than either of the other two groups to have health problems.
Based on a composite access indicator that included going without at least one of four needed medical care services, more than half of the underinsured and two-thirds of the uninsured reported cost-related access problems during the year. Among adults with at least one chronic health problem, half of uninsured adults and two in five underinsured adults said that they skipped doses of or did not fill a prescription for their condition because of cost—double to triple the rate reported by those insured all year, not underinsured.

Healthcare Costs: Another Top 1% Issue

By Chris Kaiser, Cardiology Editor, MedPage Today  Sep 11, 2013  http://www.medpagetoday.com/TheGuptaGuide/PublicHealth/41539

In the U.S., the top 1% of patients ranked by their healthcare expenses accounted for 21% of total healthcare expenditures in 2010, with an annual mean expenditure of $87,570, according to 2010 Medical Expenditure Panel Survey from the Agency for Healthcare Research and Quality in Rockville, Md.  In addition, the top 5% of the U.S. population ranked by healthcare expenses accounted for half of the total of healthcare expenditures, with an annual mean expenditure of $40,876, wrote Steven B. Cohen, PhD, and Namrata Uberoi, MPH, in the Statistical Brief No. 421.  Both of these figures are down from 1996, when the top 1% accounted for 28% of the total healthcare expenditures and the top 5% accounted for slightly more than half.  The total healthcare expenditures for 2010 were $1.26 trillion.

It is important that policy makers are aware of the the “concentration of healthcare expenditures … to help discern the factors most likely to drive healthcare spending and the characteristics of the individuals who incur them,” the authors noted.

Overall, there was a huge divide between the top and bottom 50% of the population in terms of total healthcare expenses. The top 50% accounted for 97% of total healthcare costs, while the lower 50% accounted for only 3% of the total healthcare expenditures.  In terms of income status,

  • the top 5% of those designated as poor accounted for 57% of the total healthcare expenditures, with an annual mean expenditure of $46,600, while
  • the top 5% of those in the highest income group accounted for 45% of the total healthcare expenditures, with an annual mean expenditure of $40,800.

The report also broke down healthcare spending by the number of chronic conditions, age, race/ethnicity, sex, and insurance. The survey found that chronic diseases take a big chunk of healthcare dollars.

The top 5% of those with four or more chronic conditions accounted for 30% of all healthcare expenditures, with an annual mean of $82,000 — a figure that is

  • seven times higher than those in the top 5% with no chronic diseases and nearly
  • three times higher than the top 5% with one chronic condition.

A report from 2012 found that Medicare could cut up to 10% of its spending if it focused on chronic disease prevention and coordinated care for those with chronic conditions.   Conditioned on insurance coverage status, the uninsured had the most concentrated levels of healthcare expenditures and the lowest annual mean expenses. Regarding public insurance, the top 5% accounted for 56% of the total healthcare expenditures.

Virtually every state experienced deteriorating access to care for adults over the past decade

GM Kenney, S Zuckerman, D Goin, S McMorrow, Urban Institute  May 2012

We use the Behavioral Risk Factor Surveillance System (BRFSS) to examine state-level changes in three key access indicators over the past decade. Specifically, we explore changes in the likelihood of having unmet medical needs due to cost, receiving a routine checkup, and receiving a dental visit for all nonelderly adults and for the subgroup of uninsured adults. We also consider differentials in access between uninsured and insured adults within each state in 2010, and how these differences are reflected in the relationship between access to care and state-level uninsurance rates.

We find that the deterioration in access to care observed in national trends during the past decade was evident in virtually every state in the country. Similarly, consistent with the national trends, the situation deteriorated more for the uninsured than for other adults in most states, which exacerbated the differentials in access and use between the insured and uninsured that had prevailed at the beginning of the previous decade. At the end of the decade, the uninsured in every state were at a dramatic disadvantage relative to the insured across the three access measures we examined. This analysis suggests that the potential benefits of the coverage expansion in the Affordable Care Act (ACA) are large and exist in every state.

We also found that states with higher uninsurance rates have worse access to care for all three measures, which implies that these states have the most to gain from the ACA. In particular, the ACA coverage expansion has the potential to reduce unmet needs due to costs and other cost-related barriers, problems that are more severe in states with high uninsurance rates.

DOCUMENTATION ON THE URBAN INSTITUTE’S AMERICAN COMMUNITY SURVEY-HEALTH INSURANCE POLICY SIMULATION MODEL (ACS-HIPSM)

Matthew Buettgens, Dean Resnick, Victoria Lynch, and Caitlin Carroll    May 21, 2013

We use the Urban Institute’s American Community Survey – Health Insurance Policy Simulation Model (ACS-HIPSM) to estimate the effects of the Affordable Care Act on the non-elderly at the state and local level. This model builds off of the Urban Institute’s base HIPSM, which uses the Current Population Survey (CPS) as its core data set, matched to several other data sets including the Medical Expenditure Panel Survey-Household Component (MEPS-HC), to simulate changes under ACA. To create HIPSM-ACS, we apply the core behavioral components of the base HIPSM to ACS records to exploit the much larger sample size for more precise estimates at the state and sub-state level. The modeling on the ACS-HIPSM produces projections of coverage changes related to state Medicaid expansions, new health insurance options, subsidies for the purchase of health insurance, and insurance market reforms (see Appendix 1 for more detail on HIPSM).

We simulate eligibility for Medicaid/CHIP and subsidies using the Urban Institute Health Policy Center’s ACS Medicaid/CHIP Eligibility Simulation Model, which builds on the model developed for the CPS ASEC by Dubay and Cook.  (Dubay, L. and A. Cook. 2009. “How Will the Uninsured be Affected by Health Reform?” Washington, DC: Kaiser Commission on Medicaid and the Uninsured.)

We simulate both pre-ACA eligibility and the MAGI-based eligibility introduced by the ACA. This allows us to simulate different scenarios for Medicaid maintenance-of-eligibility under the ACA. The distinction between pre-ACA eligible and newly eligible is also important in determining the share of a beneficiary’s costs paid by the federal government.

Using the three-year pooled sample, the model simulates eligibility for comprehensive Medicaid and CHIP coverage or subsidy using available information on the regulations for implementing the ACA, including the amount and extent of income disregards for eligibility pathways that do not change under the ACA and for maintenance-of-eligibility for each program and state in place as of approximately June 2010.

Under the ACA income eligibility is based on the IRS tax definition of modified adjusted gross income (MAGI), which includes the following types of income for everyone who is not a tax-dependent child: wages, business income, retirement income, investment income, Social Security, alimony, unemployment compensation, and financial and educational assistance (see Modeling Unemployment Compensation in the appendix). MAGI also includes the income of any dependent children9 required to file taxes, which for 2009 is wage income greater than $5,700 and investment income greater than $950. To compute family income as a ratio of the poverty level, we sum the person-level MAGI across the tax unit.

Current eligibility is determined based on state rules for 2010. State rules include income thresholds for the appropriate family7 size, asset tests, parent/family status, and the amount and extent of disregards8, for each program and state in place as of the middle of 2010 .

we estimate two separate probit models, each with the following covariates:

  1. Age Category: 0 – 5, 6 – 18, 19 – 44, 45 – 64.
  2. Health Status
  3. Worker Status (Household Level)
  4. Wage (Logarithmic Transformation)
  5. HIU Income to Poverty Threshold Ratio
  6. Number of Children
  7. Presence of a child in Public Coverage
  8. Citizenship Status
  9. Number of Adults in the Family

The dependent variable is an indicator of non-group non-exchange policy holder status. Again we compare each respondent’s predicted probability to a standard uniform random number and assign enrollment in the non-group non-exchange to those observations with probabilities that exceed the random number. Appendix Table 5 shows the overall new enrollment in the non-group non-exchange coming out of our model. It shows that the large majority of non-group enrollees outside the exchange are expected to come from single-person policyholders.

We develop a model, again based on HIPSM output, to predict which single ESI policy holders in the ACS are likely to switch to a family plan. We restrict our model to HIUs in which there is at least one single policy holder and at least one other member of the HIU that could potentially be covered by an ESI family plan. The eligible dependents include those with baseline non-group or uninsurance that had not already taken up coverage in a previous model. Note that we only model moving from an individual plan to a family plan; we did not model adding a dependent to a current family plan. Within the eligible group of single ESI policy holders, we use the following covariates to estimate the probability that they will switch to a family ESI policy:

  1. HIU Type: Individual, Unmarried with child, Married without Child, or married with children
  2. Age Category: 0 – 5, 6 – 18, 19 – 44, 45 – 64.
  3. Health Status
  4.  Worker Status (Individual Level)
  5. •Wage (Logarithmic Transformation)
  6. •HIU Income to Poverty Threshold Ratio
  7. •HIU Income to Poverty Threshold Categories (<138% FPL, 138% – 200% FPL, 200% – 300% FPL, 300% – 400% FPL, 400%+ FPL)
  8. •Number of Children
  9.  Presence of a child in Public Coverage
  10.  Citizenship Status
  11.  Firm Size
  12.  Education Status

These estimates assume that the ACA is fully implemented with the Medicaid expansion in all states and that the same basic implementation decisions are made across the states. At the time of writing, even states such as Massachusetts which have been on the forefront of ACA implementation had not finalized their plans, so any modeling of variation in state decisions would necessarily involve a lot of guesswork. Also, it will take several years for enrollment in new programs such as the exchanges and Medicaid expansion to ramp up so the full effects that are estimated under the simulation model would not be felt until 2016 or later. Enrollment in the initial years would also be affected by state and federal decisions. For example, in the proposed rules released by HHS in January 2012, the deadline for establishing unified eligibility and enrollment between Medicaid and the exchange was pushed back to 2015.

Health insurance status change and emergency department use among US adults.

Ginde AA, Lowe RA, Wiler JL.
Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.   http://www.ncbi.nlm.nih.gov/pubmed/22450213 
Arch Intern Med. 2012 Apr 23;172(8):642-7.   http://dx.doi.org/10.1001/archinternmed
Recent events have increased the instability of health insurance coverage. We compared emergency department (ED) use by newly insured vs continuously insured adults and by newly uninsured vs continuously uninsured adults. Overall, 20.7% of insured adults and 20.0% of uninsured adults had at least 1 ED visit. However, 29.5% of newly insured adults compared with 20.2% of continuously insured adults had at least 1 ED visit. Similarly, 25.7% of newly uninsured adults compared with 18.6% of continuously uninsured adults had at least 1 ED visit. After adjusting for demographics, socioeconomic status, and health status, recent health insurance status change was independently associated with greater ED use for newly insured adults (incidence rate ratio [IRR], 1.32; 95% CI, 1.22-1.42 vs continuously insured adults) and for newly uninsured adults (IRR, 1.39; 95% CI, 1.26-1.54 vs continuously uninsured adults). Among newly insured adults, this association was strongest for Medicaid beneficiaries (IRR, 1.45) but was attenuated for those with private insurance (IRR, 1.24) (P < .001 for interaction). Recent changes in health insurance status for newly insured adults and for newly uninsured adults were associated with greater ED use.

Health Insurance and Access to Health Care in the United States

Catherine Hoffman, Julia Paradise
Annals of the New York Academy of Sciences 2008; 1136.    http://dx.doi.org/10.1196/annals.1425.007 
Reducing the Impact of Poverty on Health and Human Development: Scientific Approaches pages 149–160, June 2008

In the United States, where per capita health care costs are the highest in the world and continue to escalate, health insurance has become nearly essential. Having reasonable access to health care rests on many factors: the availability of health services in a community and personal care-seeking behavior, for example. However, these and other factors are often trumped by whether a person can afford the costs of needed care. Health insurance enables access to care by protecting individuals and families against the high and often unexpected costs of medical care, as well as by connecting them to networks and systems of health care providers.
Health insurance, poverty, and health are all interconnected in the United States. This article synthesizes a large and compelling body of health services research, finding a strong association between health insurance coverage and access to primary and preventive care, the treatment of acute and traumatic conditions, and the medical management of chronic illness. Moreover, by improving access to care, health insurance coverage is also fundamentally important to better health care and health outcomes. Research connects being uninsured with adverse health outcomes, including declines in health and function, preventable health problems, severe disease at the time of diagnosis, and premature mortality.
Most working-age adults obtain health coverage for themselves and their dependents as a benefit of employment. However, this benefit has been gradually eroding as health premiums, in tandem with higher health care costs, grow at a rate far outpacing rates of general inflation and wages. In 2005, 61% of the nonelderly had insurance through an employer, down from 66% in 2000.1 Low-wage workers are far less likely than higher-wage workers to have access to job-based coverage. In 2005, more than half of workers in poor families and more than a third of those in near-poor families had no offer of job-based coverage in the family.2 When it is available, health insurance is often unaffordable for low-income people, whose household budgets are strained to meet food, housing, and other basic needs.

Figure 1. Health insurance coverage of the nonelderly population, 2006.

http://onlinelibrary.wiley.com/store/10.1196/annals.1425.007/asset/image_n/NYAS_1136007_f1.gif    Source: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of Current Population Survey, March 2007.
Those with Medicaid coverage are the most likely to be in fair or poor health because the program’s eligibility requirements include being severely disabled and/or low-income (fig. 2).

Figure 2. Percentage of U.S. nonelderly population reporting fair or poor health, by income and insurance status, 2006.

http://onlinelibrary.wiley.com/store/10.1196/annals.1425.007/asset/image_t/NYAS_1136007_f2_thumb.gif       Source: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of Current Population Survey, March 2007.
The model for healthcare reform was selected from that enacted in Massachusetts. Important statements from the Massachusetts Act are as follows:
to promote patient-centeredness by, including, but not limited to, establishing

  • 1137 mechanisms to conduct patient outreach and education on the necessity and benefits of care
  • 1138 coordination, including group visits and chronic disease self-management programs;
  • 1139 demonstrating an ability to effectively involve patients in care transitions to improve the
  • 1140 continuity and quality of care across settings,
  • 1146 establishing mechanisms to protect patient provider choice,

Individual Mandate

A provision called the individual mandate, requires all Americans to buy some form of health insurance. Whether it is constitutional was in question before the Supreme Court. While the mandate is separate from the provision allowing young adults up to the age of 26 to be covered under their parents’ policies, the court could have decided to scrap the entire law — instead of just the mandate — leaving millions of young adults in the lurch. The mandate was upheld.

For many young adults, affording health insurance on their own will be particularly difficult.  The unemployment rate for young adults age 16 to 24 was 16.4% in March, twice the national average for the population as a whole.  And many of those who do find jobs, often aren’t being offered health benefits.  Less than a quarter, or 24%, of workers between the ages of 19 and 25 were offered health insurance by their employers in 2010, down from 34% in 2000, according to the Employee Benefit Research Institute, an independent public policy organization. Meanwhile, nearly 57% of the rest of the working population between the ages of 26 and 64 were covered.

B. Economics of Universal Delivery of Care – Stakeholders’ Trade offs

There is no question that repealing the Affordable Care Act would cause health costs to skyrocket, particularly for seniors who rely on Medicare to help pay for their healthcare.
According to a new report released by the Kaiser Family Foundation, a healthcare analysis non-profit, repealing the Affordable Care Act would be disastrous for seniors, who would be forced to pay higher premiums, prescription drug costs, and copayments.
According to the report, if health care reform is repealed:
  • Medicare Part A deductibles and copayments would increase.
  • Part B premiums would go up.
  • Savings from closing the Part D donut hole would be eliminated, and the gap in prescription drug coverage would be reopened; under the Affordable Care Act, an estimated 3.6 million Medicare Part D beneficiaries saved an average of $600 each in 2011 once they hit the donut hole, and the donut hole will be closed by 2020.
  • Free preventive services would be eliminated; under the Affordable Care Act, seniors can now get many preventive services for free, including an annual wellness visit, mammograms and other cancer screenings, and other important health services.

U.S. Faces Crisis in Cancer Care

http://www.biosciencetechnology.com/videos/2013/09/us-faces-crisis-cancer-care?et_cid=3474892&et_rid=442219320

Wed, 09/11/2013

Delivery of cancer care in the U.S. is facing a crisis stemming from a combination of factors—a growing demand for such care, a shrinking oncology work force, rising costs of cancer care, and the complexity of the disease and its treatment, says a new report from the Institute of Medicine. The report recommends ways to respond to these challenges and improve cancer care delivery, including by strengthening clinicians’ core competencies in caring for patients with cancer, shifting to team-based models of care, and communicating more effectively with patients.

Adding to stresses on the system is the complexity of cancer and its treatment, which has grown in recent years with the development of new therapies targeting specific abnormalities often present only in subsets of patients. Incorporating this new information into clinical care is challenging, the report says. Given the disease’s complexity, clinicians, patients, and patients’ families can find it difficult to formulate care plans with the necessary speed, precision, and quality; as a result, decisions about cancer care are often not sufficiently evidence-based.

Another challenge is the cost of cancer care, which is rising faster than other sectors of medicine, having increased from $72 billion in 2004 to $125 billion in 2010, says the report.  The single largest insurer for those over 65, the Centers for Medicare and Medicaid Services (CMS), is struggling financially.

The report recommends strategies for improving the care of cancer patients, grounded in six components of high-quality cancer care. The components are ordered based on the priority level with which they should be addressed.

  1. Engaged patients. The cancer care system should support patients in making informed medical decisions that are consistent with their needs, values, and preferences. Cancer care teams should provide patients and their families with understandable information about the cancer prognosis and the benefits, harms, and costs of treatments. The National Cancer Institute, the Centers for Medicare and Medicaid Services, and other stakeholders should improve the develop­ment and dissemination of this critical informa­tion, using decision aids when possible.  Patients with advanced cancer face specific communication and decision-making needs, and cancer care teams need to discuss their options, such as revisiting and implementing advance care plans. However, these difficult conversations do not occur as often as they should; recent studies found that 65 percent to 80 percent of cancer patients with poor prognoses incorrectly believed their treatment could result in a cure.
  2. An adequately staffed, trained, and coordinated work force. New models of team-based care are an effective way to promote coordinated cancer care and to respond to existing work-force shortages and demographic changes. And to achieve high-quality cancer care, the work force must include enough clinicians with essential core competencies for treating patients with cancer. Professional organizations that represent those who care for patients with cancer should define these core competencies, and organizations that deliver cancer care should ensure their clinicians have those skills.
  3. Evidence-based cancer care. A high-quality cancer care delivery system uses results from scientific research to inform medical decisions, but currently many medical decisions are not supported by sufficient evidence, the report says. Clinical research should gather evidence of the benefits and harms of various treatment options so that patients and their cancer care teams can make more informed treatment decisions. Research should also capture the impacts of treatment regimens on quality of life, symptoms, and patients’ overall experience with the disease. Additional research is needed on cancer interventions for older adults and those with multiple chronic diseases. The current system is poorly prepared to address the complex care needs of these patients.
  4. A learning health care information technology system for cancer care. A system is needed that can “learn” by enabling real-time analysis of data from cancer patients in a variety of care settings to improve knowledge and inform medical decisions. Professional organizations and the U.S. Department of Health and Human Services should develop and implement the learning health care system, and payers should create incentives for clinicians to participate as it develops.
  5. Translation of evidence into practice, quality measurement, and performance improvement. Tools and initiatives should be delivered to help clinicians quickly incorporate new medical knowledge into routine care. And quality measures are needed to provide a standardized way to assess the quality of cancer care delivered. These measures have the potential to drive improvements in care, inform patients, and influence clinician behavior and reimbursement.
  6. Accessible and affordable cancer care. Currently there are major disparities in access to cancer care among individuals who are of lower socio-economic status, are racial or ethnic minorities, lack health insurance coverage, and are older. HHS should develop a national strategy that leverages existing commu­nity interventions to provide accessible and afford­able cancer care, the report says. To improve the affordability of care, professional societies should publicly disseminate evidence-based information about cancer care practices that are unnecessary or where the harm may outweigh the benefits. CMS and other payers should design and evaluate new payment models that incentivize cancer care teams to provide care based on the best available evidence and that aligns with their patients’ needs. The current fee-for-service reimbursement system encourages a high volume of care, but fails to reward the provision of high-quality care.

Institute of Medicine Calls for Immediate Reforms in Health Care (2012)

By Kimberly Scott, Managing Editor, G2 Intelligence
A new report from the Institute of Medicine released Sept. 6 calls for a broad range of reforms to make timely changes to the U.S. health care system that would provide high-quality care at lower cost. “Unmanageable” complexity in the science and administration of health care, coupled with costs that have increased at a greater rate than the economy as a whole for 31 of the past 40 years, make the status quo “untenable,” said Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.
“If unaddressed, the current shortfalls in the performance of the nation’s health care system will deepen on both quality and cost dimensions, challenging the well-being of Americans now and potentially far into the future,” the report said.
The report, which follows a series of IOM studies on various aspects of the U.S. health care system, was written by the IOM’s 18-member Committee on the Learning Healthcare System in America. It was sponsored by the Blue Shield of California Foundation, the Charina Endowment Fund, and the Robert Wood Johnson Foundation.
A theme of the report is that “health care now must be a team sport,” Smith said. Physicians in private practice interact with as many as 229 other physicians in 117 practices for their Medicare patients, he said. An elderly patient with multiple chronic diseases can be on up to 19 medications a day, he said. About 30 percent of health care spending in 2009, an estimated $750 billion, was wasted on
  • unnecessary services,
  • excessive administrative costs,
  • fraud, and other problems, the report said.
An estimated 75,000 deaths might have been avoided in 2005 if every state had delivered care at the quality of the best-performing state, it said.
The report is available at http://www.iom.edu

Graphical Excursion into National Healthcare Expenditures

Dan Munro, Forbes
According to the Deloitte Center for Health Solutions, this number has been historically underreported – by a significant amount. In their report (The Hidden Costs of U.S. Health Care), they cite two important components that have not been included in tradtional calculations. The first is out-of-pocket spending by consumers on professional services and the second is the “imputed value of supervisory care provided to a friend or family member.” Using a conservative annual growth rate of 4% (from Deloitte’s baseline year of 2010), here’s what Deloitte suggests is our real NHE.

 NHEbyDCforHS1  NHE annual growth rate of 4%

http://blogs-images.forbes.com/danmunro/files/2012/12/NHEbyDCforHS1.png

The Kaiser Family Foundation also provided a comparison of cumulative increases in health insurance premiums – relative to Workers’ Contributions, Inflation and Workers’ Earnings (from 2000 to 2012).

percentageincreasekff  % increase in HI premiums

http://blogs-images.forbes.com/danmunro/files/2012/12/percentageincreasekff.png

Another annual chart is Medscape’s Physician Compensation Report: 2012 Results (slide #2 – 2011 data).

salaries1  physician compensation  (Medscape)

For those that may be relying exclusively on the transformative effects of PPACA (Obamacare) – this chart highlights the nominal impact of PPACA reform on our National Healthcare Expenditure. It’s from a Commonwealth Fund Issue Brief (May, 2010) – The Impact of Health Reform on Health System Spending (Exhibit #3 – page 5).
NHE-BeforeAfter   nominal impact of PPACA reform on our National Healthcare Expenditure  (Commonwealth Fund)
This last one from Mary Meeker’s landmark report – USA, Inc. (slide #111) – is definitely not new but it is foundational. It compares per capita costs and life expectancy across all 34 OECD member countries using OECD data from 2009.
cost1  per capita costs and life expectancy across all 34 OECD member countries using OECD data from 2009.

C. Political Divisions – Destiny of Healthcare Reform

An Oncology Perspective on the Supreme Courts Pending Decision Regarding the Affordable Care Act

By SK Stranne, MG Halgren, P Shughart. Washington, DC.
Beginning on March 26, 2012, the Supreme Court of the United States heard oral arguments regarding challenges to the recent federal health care reform legislation. The Court scheduled this unusually lengthy series of arguments to last for three days—a reflection of both the high stakes and the complexity of the legal issues involved.  We provide a summary of the questions under consideration by the Supreme Court regarding the health care reform legislation, and we explore how the pending decision on this high-profile matter may impact the oncology community.
Congress enacted the reforms through two separate bills. The two laws, the Patient Protection and Affordable Care Act[1] and the Health Care and Education Reconciliation Act of 2010,[2] have become known collectively as the Affordable Care Act (ACA). The Court is not charged with deciding whether the ACA is good health care policy, only constitutionality.

Issues Before the Court

[1] whether Congress has exceeded its powers with respect to two specific provisions of the ACA
One of these provisions is the law’s requirement that individuals maintain a minimum level of health insurance, which is often referred to as the “minimum coverage requirement” or the “individual mandate.” The other contested provision is the law’s expansion of eligibility and financial support for the Medicaid program, through which the federal government provides grants to state governments to help fund health insurance for the poor.
[2] the Obama administration contended that two powers delegated to Congress each provide sufficient authority for the minimum coverage requirement
[a] Immediately preceding the minimum coverage requirement in the text of the ACA itself, Congress offered its own lengthy justification of why the Commerce Clause, which is a provision in the Constitution that delegates to Congress the power of regulating commerce among the states, authorizes this individual mandate.
[b] the problem is … as much as they say, ‘Well, we are not in the market,’ … [the uninsured] haven’t been able to meet the bill for cancer, and the rest of us end up paying because these people are getting cost-free health care.” Ruth Bader Ginsberg.
[c] the Constitution’s Taxing and Spending Clause also gives Congress authority to enact the minimum coverage requirement and collect a penalty for noncompliance via federal income tax returns.
The arguments in favor of the ACA’s Medicaid expansion relied on the Taxing and Spending Clause and also on the Appropriations Clause, both of which are generally regarded as giving Congress significant discretion in dictating how federal funds are spent. However, the Court has previously indicated that Congress may not use its spending power to unduly coerce the states. The ACA’s opponents argued that the Medicaid expansion is unconstitutionally coercive because it attaches new terms (ie, the requirement to cover more people) to substantial existing funds (ie, the grants the federal government already gives to the states for the original Medicaid program and its various pre-ACA expansions). Due to the size of the Medicaid program, the argument goes, the states have no real alternative but to continue participating in Medicaid under the ACA’s terms.
The severability discussion concerns whether the Court would strike only the provision in question, only the provision in question plus some closely related provisions, or the entire ACA. The arguments on this issue mainly addressed the minimum coverage requirement and focused on the degree to which certain provisions of the ACA are linked with that provision and what Congress would have intended to occur if the provision were found unconstitutional.

Convergence is Coming: A Brave New World

KPMG Report  by Liam Walsh
Healthcare payers, providers and life sciences companies should be thinking beyond transformation and focus more on convergence and the implications of operating in a collaborative and integrated healthcare delivery model.  This has come about because
  • the business of healthcare is changing to an ‘outcomes-based’ system
  • that compensates organizations based on the effectiveness of a product or service, not as a consumable.
The result is a driver of consolidation, and participants will fall substantially over the next decade. It is expected that the evolving system will bring about significant benefits with a more effective system when the dust settles.  However,patients will have less choice in the market, either due to services having been consolidated with one provider or because payer incentives drive patients to more cost-effective options. But the rapid development of a digitalized data handling with introduction of superior analytics, and moving more information onto ‘smart devices’ is already beginning to transform the way we source, deliver and pay for healthcare services.  The restructuring is transforming the healthcare business models.

Transforming Healthcare: From Volume to Value

KPMG Healthcare & Pharmaceuticals  Sept 2012
Over the next decade, all parts of the healthcare services and life sciences industry will need to change, from revenue based on volume to revenue based on value, to be sustainable and cost effective.  The emphasis on sustainability requires
  • contracting for healthcare value and
  • improving the productivity of the healthcare workforce.
Given the current high costs and variable outcomes, the U.S. healthcare system is undergoing an unprecedented transformation.

Bundle with Care — Rethinking Medicare Incentives for Post–Acute Care Services

Judith Feder, Ph.D.

n engl j med  2013; 369(5):400
Although health policy experts disagree on many issues, they largely agree on the shortcomings of fee-for-service payment. The inefficiency of a payment method that rewards increases in service volume, regardless
of health benefit, has become practically indefensible. But replacing discrete payments for each service with bundled payment for a set of services does not simply promote efficiency; it also potentially promotes
skimping on care or avoidance of costly patients.
The Medicare program already has considerable experience not only with capitation payments to health plans for the full range of Medicare services but also with bundled payments for sets of services: inpatient hospital services are bundled into “stays,” skilled-nursing-facility (SNF) services are bundled into “days,” and home-health-agency (HHA) services are bundled into “episodes.”
The tip-off to the risk involved in offering powerful incentives for these providers to keep costs low is the presence of extremely high and varied profits, in a service area devoid of standards for high-quality care. In 2010, SNFs and HHAs earned profits of 19%, on average, and the top quarter earned in excess of 27%.
In theory these high and widely varying profits might reflect variations in efficiency. But two factors other than relative efficiency probably explain these margins. First is that classification of patients into payment categories for rate-setting purposes
  • is not sufficiently precise to eliminate variation in expected costs among the patients within a category.
Second is the long history of patient selection in nursing homes and recent evidence that the HHAs with the highest profit margins
  • provide fewer visits, despite serving patients with greater measured care needs.
Given the weakness of patient classification and quality norms, policymakers would do well to heed previous advice that, in these circumstances, a hybrid approach better balances efficiency and appropriate care.
Rather than replace fee for service with a single-payment system, I believe we should rely ona hybrid approach in which both savings and risk are shared. Providers would receive a share, rather than the full amount, of any excess payments over the actual costs incurred. Similarly, Medicare would pay a share of any provider costs that exceeded the amount of prospective payments. To encourage efficiency, the system would ensure that providers could earn a sufficient share of profits but would also bear the larger share of losses.
Sharing savings and risk would essentially produce for Medicare, which sets payment rates administratively, profit levels similar to those a competitive market would provide. When some providers are earning  excessive profits in a market, others will offer services at lower prices (earning lower profits) to attract more business. Sharing savings and risk gives Medicare a means of keeping profits high enough to maintain access for beneficiaries, while narrowing the range of profit levels closer to those a competitive market would produce.

Study: Bigger hospitals drive cost increases

By MATT DOBIAS | 5/7/12
For everyone out there worried that President Barack Obama’s health reform law will spur monopolies and make it easier for hospitals to raise their prices, a new study says it’s already happening, and it’s not because of the health law.
A study in the May edition of Health Affairs finds that hospitals’ power to win steep payment increases — and insurers’ relative inability to resist — varies quite a bit from one market to another and from one kind of hospital or hospital network to another. Reputation, location and the type of medical services provided play a role.

State Laws Hinder Obamacare Effort To Enroll Uninsured

President Barack Obama has set aside $67 million to make it easier to enroll in his health-care overhaul. Laws pushed by Republicans in 12 states may keep that from happening. Under the Affordable Care Act, the U.S. government plans to pay a network of local groups known as navigators to explain the law’s new coverage options to the uninsured and guide them through its online insurance markets (Bloomberg News: Nussbaum and Wayne, 8/23/2013).

Modern Healthcare: Reform Update: Employers Take Closer Look At Private Insurance Exchanges

With public small-business insurance exchanges opening Oct. 1, two studies released this week show employer interest in private insurance exchanges is growing. …
  1. the Kaiser Family Foundation found that 29% of employers with 5,000 or more employees are considering private exchanges as an option for buying healthcare coverage for their employees.
  2. A day later, consulting firm Towers Watson released its Health Care Changes Ahead survey, which found that 37% of employers think private exchanges are a reasonable alternative to traditional employer coverage in 2014 (Block, 8/22).

D. Looking in on the ACOs

ObamaCare’s Health-Insurance Sticker Shock

By Merrill Matthews and Mark E Litow, Forbes
Thanks to mandates that take effect in 2014, premiums in individual markets will shoot up.
Central to ObamaCare are requirements that

  1. (1) health insurers accept everyone who applies (guaranteed issue),
  2. (2) cannot charge more based on serious medical conditions (modified community rating), and
  3. (3) include numerous coverage mandates that force insurance to pay for many often uncovered medical conditions.

Guaranteed issue incentivizes people to forgo buying a policy until they get sick and need coverage (and then drop the policy after they get well).  While ObamaCare imposes a financial penalty—

  • —to discourage people from gaming the system,
  • it is too low to be a real disincentive.

The result will be insurance pools that are smaller and sicker, and therefore more expensive.
How do we know these requirements will have such a negative impact on premiums? Eight states—New Jersey, New York, Maine, New Hampshire, Washington, Kentucky, Vermont and Massachusetts—enacted guaranteed issue and community rating in the mid-1990s and wrecked their individual (i.e., non-group) health-insurance markets.
States won’t experience equal increases in their premiums under ObamaCare.  Ironically, citizens in states that have acted responsibly over the years by adhering to standard actuarial principles and limiting the (often politically motivated) mandates will see the biggest increases, because their premiums have typically been the lowest.
While ObamaCare won’t take full effect until 2014, health-insurance premiums in the individual market are already rising, and not just because of routine increases in medical costs. Insurers are adjusting premiums now in anticipation of the guaranteed-issue and community-rating mandates starting next year. There are newly imposed mandates, such as the coverage for children up to age 26, and what qualifies as coverage is much more comprehensive and expensive. Consolidation in the hospital system has been accelerated by ObamaCare and its push for Accountable Care Organizations.
Unlike the federal government, health insurers can’t run perpetual deficits. Something will have to give, which will likely open the door to making health insurance a public utility completely regulated by the government.

Health Insurance Premiums Will Rise

Merrill Matthews, Resident Scholar at Institute for Policy Innovation, Forbes
Subsidies cover a portion of the cost of health insurance, up to a maximum out of pocket for the family. The amount of the subsidy is based both on the cost of coverage and income. There has been a lot of head scratching over how to deal with the fact

  • that a family’s income can vary significantly within a year, up or down, in ways no one predicted at the beginning of the year.

So how does the government determine the correct level of subsidy? The PPACA has so many unknowns in the mix that actuaries don’t know how much to charge. This is a problem for setting annual rates.

Traditionally in the individual market, where people buy their own (i.e., non-group) health coverage, applicants sign a contract and the insurance company guarantees that premium for a year. No more. Health insurers started sending out notices in January informing insurance brokers and agents that

  • the companies will no longer guarantee that premium rate.

After carefully evaluating its individual market and rates, Aetna decided to discontinue its offer of an initial 12-month rate guarantee. This change applies to policies with a January 15, 2013 or later effective date, in all states where plans are sold. Existing members who are currently in a rate guarantee period will not be affected. Aetna published a notice saying in part, “While the policies will not have a 12-month rate guarantee, we fully expect the rates to stay the same until December 31, 2013.” While that announcement may alleviate the concerns of some, Aetna is not the only company ending the rate guarantee.
While the individual market has been relatively small (about 19 million people, according to the Employee Benefit Research Institute) compared to those with employer-based coverage (about 156 million), most honest analysts expect millions of employers to drop coverage and dump their employees into the individual market.

ACOs Can Save Medicare $$$, Study Finds

By David Pittman, Washington Correspondent, MedPage Today. Aug 27, 2013
An accountable care organization (ACO) established by a private insurer reduced costs of care for Medicare enrollees, a study in Massachusetts found.  Providers participating in the Alternative Quality Contract (AQC) — an early commercial ACO backed by Blue Cross Blue Shield of Massachusetts — reduced spending on Medicare beneficiaries by 3.4% after 2 years compared with enrollee costs at nonparticipating providers, ( Journal of the American Medical Association).

Medicare enrollees served by 11 provider groups in the AQC from 2007-2010 were compared with Medicare patients served by non-AQC providers. The study looked at quarterly medical spending and five quality measures, such as avoidable hospitalizations and 30-day readmissions. The AQC started in 2009 with providers bearing a financial risk for spending in excess of a global budget, gaining from spending below the budget, and receiving rewards for meeting performance targets.
Per-enrollee spending was $150 higher for patients of AQC providers than for those of non-AQC providers before the ACO took effect in 2009. Year-1 savings weren’t significant (P=0.18), but

  • by year 2, the AQC lowered Medicare beneficiary spending by 3.4% and the difference in spending between the AQC and non-AQC providers had dropped to $51 (P=0.02)

Savings came from reductions in outpatient services, including

  • office visits,
  • emergency department visits,
  • minor procedures,
  • imaging, and lab tests.

Also, savings were greater in patients with five or more conditions (P=0.002). Previous research showed the AQC reduced quarterly spending on Blue Cross patients by $27 per enrollee in year two.
ACOs have received sour press of late as nine of 32 pioneer ACOs — Medicare’s first and most advanced ACO provider groups — told the agency last month they want to leave the program. Despite that outlook and ACOs’ struggles to achieve consistent cost savings, Medicare-led ACOs (253) now outnumber commercial ACOs (235), according to a recent report from the consulting group Leavitt Partners.

New Care Models Look at Social Factors in Health

By David Pittman, Washington Correspondent, MedPage Today. Aug 22, 2013
Models such as PCMHs, ambulatory intensive care units, and medical neighborhoods should thrive on connecting patients’ clinical care with broader social services that can help provide better housing and other benefits. (ReportingOnHealth.org)
“The medical neighborhood coordinates care for patients at a community level, working with organizations in the community that can help expand the impact of healthcare and, more specifically, focus on the social determinants,” Manchanda (founder and president of HealthBegins) said. “And this fits more into the model of community-centered health home.” (Medicaid Medical Home)

  • Lack of access to good housing, places to exercise, safe neighborhoods, and health food sources make people more vulnerable to heart disease, diabetes, obesity, and other diseases.

Evidence is growing linking people’s physical environments and social conditions to their health. Three in four doctors wished the healthcare system would pay for the cost associated with connecting patients with needed social services. That aspect of the situation is improving with advent of PCMHs and other delivery models which pay for the care coordination of the most at-risk patients. This will be addressed by electronic medical records (EMRs) will help collect social history if EMR vendors provide an avenue for it to be requested and stored. The facilitation of internet communications will allow clinicians to share data with social services about their patients, and connect with patients themselves.

What Do Employers Want From Hospitals? The Rules of the Road

Aegis Health Group. 2013; 5(7).
Corporate America has long viewed the healthcare system as one of the biggest drains on the economy—and on the profitability of businesses nationwide. With the advent of Accountable Care Organizations as the model of the future for managing overall population health, hospitals are ideally positioned to harness this opportunity

  • to build profitable partnerships with employers.

In this paper hospital executives will learn about new approaches to this challenge along with some simple, tried-and-true rules of the road for attaining mutually beneficial partnerships with employers.

Why does Corporate America think the current state of healthcare is a quagmire – and that they are in the middle of it?

COST OF POOR HEALTH IN BILLIONS

 Medical & Pharmaceutical     $227
Wage Replacement                  $117
Lost Productivity                        $232

They are ready to take control of the issues and turn them from business detractors to business advantages. Consider this:

  • »» According to the 17th annual Towers Watson Employer survey on “Purchasing Value in Healthcare,” employee healthcare costs have increased 42 percent since 2007.
  • »» Total costs average more than $11,600 per employee each year, with employers paying out 34 percent more compared to just five years ago.
  • »» Healthcare now costs employers $576 billion annually.
  • »» These dollars relate not only to insurance premiums and the actual cost of care provided, but absenteeism and lost productivity when workers either do not show up or perform marginally on the job due to illness.

On the flip side workers have felt the sting as well. With more employers scaling back benefits or selecting higher-deductible plans, employee out-of-pocket expenses and payroll deductions for premiums increased 82 percent, averaging $5,000 per year according to the same Towers Watson survey. The escalation of healthcare costs almost mirrors the increasingly poor health of U.S. adults. Only one in seven workers are of a normal weight and free from any chronic health conditions, such as diabetes, hypertension or heart disease.
A full 62 percent of employers want to increase employee wellness and preventive health programs. Hospitals are well positioned to provide

  • the medical talent, best practices and expertise required for a comprehensive workforce health initiative (WHI).

As the country moves toward an accountable care model of healthcare delivery, the timing has never been better for hospitals to take a leadership role in developing population health programs in the workplace and beyond.

Employee View: Who provides the greatest value in healthcare?

Primary Care                  60%
Prescription Drugs        50%
Hospitals                         47%
Specialty Care               46%
Wellness Programs      43%
Health Insurance
Plans                               39%
Retail Clinics                  31%
In a Deloitte Center for Health Solutions survey in 2012, employers ranked primary care and hospitals as providing the most value to the healthcare system. Yet it is not unusual for 30 percent of employees to report they have no primary care physician. These are consumers who may be at significant risk for hidden health problems that may become chronic conditions later on. Employers have a vested interest in linking these employees with a primary care doctor sooner rather than later.

What are the Six Sigma Elements of an Effective Workforce Health Initiative?

The most effective workforce health initiatives take a data-driven approach to enhancing the health of a defined population. The five key steps in the Six Sigma process actually reflect the major tactics of a WHI and population health strategy.

 48-Graph-4-30_2012  Age-Adjusted Prevalence of Cardiovascular Disease Risk Factors in Adults, U.S., 1961–2011

49-Graph-4-31_2012  hypertension, treated awareness

52-Graph-4-35_2012  Total Economic Costs of the Leading Diagnostic Groups, U.S., 2009

278px-Preventable_causes_of_death

8443-exhibit-2-7  nonelderly population uninsured

8443-exhibit-2-8  nonelderly uninsured under ACA with all states expanding Medicaid

8443-exhibit-2-3  increase in medicaid_CHIP all states expanding medicaid

Causes_of_death_by_age_group

correlates of in-hospital mortality

healthprices  time price of HC over 50 years

fs310_graph3  leading causes of death by income class worldwide

FUSA_INFOGRAPHIC_50-state-medicaid-expansion_rev_06-27-13_FACEBOOKCOVER

milliman1   2012 Milliman Medical Index

hhs_medicare_docs   participating in and billing Medicare

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The Affordable Care Act: A Considered Evaluation. The Implementation of the ACA, Impact on Physicians and Patients, and the Dis-Ease of the Accountable Care Organizations.


The Affordable Care Act: A Considered Evaluation. Part II: The Implementation of the ACA, Impact on Physicians and Patients, and the Dis-Ease of the Accountable Care Organizations.

Writer and Curator: Larry H. Bernstein, MD, FCAP

and

Curator and Editor: Aviva Lev-Ari, PhD, RN 

INTRODUCTION

This discussion is the second of two distinct chapters. The first is a clarification of what is contained in the Accountable Care Act (ACA), the model of care it is crafted from, the insurance mandate, the inclusion of groups considered high risk and uninsured, the inclusion of groups low risk and uninsured, and the economics involved in going from a fractured for profit health care industry to a more stable coverage for patients with problems in creating a new workable model from an actuarial standpoint, with the built in complexity of not just age, but education, achievement in the workforce, and a consolidating hospital and eldercare industry, the unpredictability of disease evolution, and add on the multicultural and social structures, as well as rapidly evolving communications and computational platforms needed to transform the U.S. Healthcare system.. The second is taken from selected articles on the care process in the New England Journal of Medicine about the cost and consequences for improving quality at lower cost. Dr. Justin Pearlman has chosen this topic to become as the Second Chapter in the Cardiovascular Disease Volume and Dr. Aviva Lev Ari has selected the sub-universe of sources been elaborated on in this Chapter

There are inherent problems at looking at this from a systems point of view, mainly impacted by the relationship of providers to hospitals and clinics, and by the relationships of insurers to the patients and providers in an Accountable Care Organization (ACO) model. These relationships have been evolving for many decades, first with the increased availability of highly skilled medical specialists trained in numerous university-based programs funded by Training Grants from the National Institutes of Health, then a high concentration of these skilled physicians in metropolitan locations, where there was an adequate patient-base for developing groups of refering physicians. Prior to WWII, there were many Asian physicians receiving their postgraduate training in the U.K. The number of foreign graduates coming to the U.S. Increased enormously with the opportunities that opened up in U.S. The first change in medical education that created a science-based professional came after the Flexner Report in 1910, sponsored by the Carnegie Endowment. Many aspects of the present-day American medical profession stem from the Flexner Report and its aftermath.The Report (also called Carnegie Foundation Bulletin Number Four) called on American medical schools to enact higher admission and graduation standards, and to adhere strictly to the protocols of mainstream science in their teaching and research. Joseph Goldberger discovered the cause of pellagra in 1916.  When the 1918 influenza pandemic struck Washington, physicians from the then PHS laboratory were pressed into service treating patients in the District of Columbia because so many local doctors fell ill.

goldberger  1916  Pellagra

http://www.nih.gov/about/lmedia/goldberger.jpg

In 1930, the Ransdell Act changed the name of the Hygienic Laboratory to National Institute (singular) of Health (NIH) and authorized the establishment of fellowships for research into basic biological and medical problems. The roots of this act extended to 1918, when chemists who had worked with the Chemical Warfare Service in World War I sought to establish an institute in the private sector to apply fundamental knowledge in chemistry to problems of medicine. In 1926, after no philanthropic patron could be found to endow such an institute, the proponents joined with Louisiana Senator Joseph E. Ransdell to seek federal sponsorship. The truncated form in which the bill was finally enacted in 1930 reflected the harsh economic realities imposed by the Great Depression. Nonetheless, this legislation marked a change in the attitude of the U.S. scientific community toward public funding of medical research.

bengston_lg nurse in bacteriology lab of NIH

http://history.nih.gov/exhibits/history/assets/images/bengston_lg.jpg

cholera_sm  cholera epidemic of 19th century  (Koch bacillus)

http://history.nih.gov/exhibits/history/assets/images/cholera_sm.jpg

Vaccines and therapies to deal with tropical diseases were also critically important to the WWII war effort by the PHS. At the NIH’s Rocky Mountain Laboratory in Hamilton, Montana, yellow fever and typhus vaccines were prepared for military forces. In Bethesda as well as through grants to investigators at universities a synthetic substitute for quinine was sought to treat malaria.  Research in the Division of Chemotherapy revealed that sodium deficiency was the critical element leading to death after burns or traumatic shock. This led to the widespread use of oral saline therapy as a first-aid measure on the battlefield. NIH and military physiologists collaborated on research into problems related to high altitude flying. As the war drew to a close, PHS officials guided through Congress the 1944 Public Health Service Act, which defined the shape of medical research in the post-war world. Two provisions in particular had an impact on the NIH. First, in 1946 the successful grants program of the NCI was expanded to the entire NIH. From just over $4 million in 1947, the program grew to more than $100 million in 1957 and to $1 billion in 1974. The entire NIH budget expanded from $8 million in 1947 to more than $1 billion in 1966. Between 1955 and 1968. In this period, there was expansion of the NIH extramural budget, as well, and the grants dispursed were in support of developing the medical faculty of the future. It has nothing to do with then organization of the practice of medicine, but it has contributed much to the widespread quality of american medical education.

flowchart_sm  NIH 1949

http://history.nih.gov/exhibits/history/assets/images/flowchart_sm.jpg

 As the cost of healthcare was increasing, mainly after the Korean and Vietnam War periods, there was a medically initiated concept of a National not-for-profit health maintenance organization (HMO), which would be modeled after the likes of Mayo Clinic, Cleveland Clinic, the Kaiser Permanente Plan, and Geisinger. But the insurance industry was already mature, and the hospitals were closely tied to Aetna, CIGNA, and Blue Cross Blue Shields, which had the actuarial pieces needed. Then an HMO industry emerged with a for-profit motive. As the U.S. Became enmesshed in two military engagements in Iraq and Afganistan for a full decade, there was a fierce competition between the need to support military requirements and the need to support the welfare of the community, with brilliant accelerated achievements that brought the Human Genome Project to a successful conclusion in 2003, and from that emerged advances in both clinical laboratory diagnostics and imaging, and which portends to continuing significant advances in treatments in cardiology, surgery, endocrinology, and cancer. In order to succeed, there has been a redesign or rearrangement of how these services are delivered, with a business model intended to – in time – bring down costs, and to also improve quality. Ironically, there is an insufficiency of primary care physicians, even considering internal medicine, pediatrics, obstetrics, and general surgery, as well as osteopathic physicians.

Part I. The Establishment, Structure, and Nature of the Accountable Care Act (ACA)

Part II. The Implementation of the ACA, Impact on Physicians and Patients, and the Dis-Ease of the Accountable Care
Organizations.

Failure to Launch? The Independent Payment Advisory Board’s Uncertain Prospects

Jonathan Oberlander, Ph.D., and Marisa Morrison, B.A.
N Engl J Med 2013; 369:105-107July 11, 2013 http://dx.doi.org/10.1056/NEJMp1306051

The Affordable Care Act (ACA) established the IPAB as a 15-member, nonelected board. Among other duties, the IPAB is empowered to recommend changes to Medicare if projected per-beneficiary spending growth exceeds specified targets. If Congress does not enact legislation containing those proposals or alternative policies that achieve the same savings, the IPAB’s recommendations are to be implemented by the secretary of health and human services. President Obama has proposed strengthening the board’s role by lowering the Medicare spending targets that would trigger IPAB action.

Because the board is prohibited by law from making recommendations that raise revenues, increase cost sharing of Medicare beneficiaries, or restrict benefits and eligibility, it is expected to focus on savings from medical providers. In January 2013, the GOP adopted a House rule declaring that the IPAB “shall not apply” in the current Congress, thereby rejecting the special procedures that the ACA had established for congressional consideration of IPAB recommendations.

On April 30, the chief actuary of the Centers for Medicare and Medicaid Services released a report projecting Medicare spending growth during 2011–2015. According to the report, per-person Medicare spending will grow at an average rate of 1.15% during that period, far below the target growth rate set by the ACA — the average of the Consumer Price Index (CPI) and the Medical CPI (see graph).

8443-exhibit-2-3  increase in medicaid_CHIP all states expanding medicaid50-Graph-4-33_2012  Hospitalization Rates for Heart Failure, Ages 45–64 and 65 and Older, U.S., 1971–2010

8443-exhibit-2-7  nonelderly population uninsured52-Graph-4-35_2012  Total Economic Costs of the Leading Diagnostic Groups, U.S., 2009

http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2013/nejm_2013.369.issue-2/nejmp1306051/20130708/images/small/nejmp1306051_f1.gif

Projected Growth in Medicare Per Capita Spending, the Consumer Price Index (CPI), and the Medical CPI, 2011–2015.

       healthprices  time price of HC over 50 yearsjournal.pmed.0020133.g001  Global Mortality and Burden of Disease Attributable to Cardiovascular Diseases and Their Major Risk Factors for People 30 y of Age and Older

NHEbyDCforHS1  NHE annual growth rate of 4%      percentageincreasekff  % increase in HI premiums

journal.pmed.0020133.t001   Risk and Socioeconomic Variables Used in the Analysis     T1.large  uninsured by health and disability by region 2000-2005

T3.large  uninsured by medicaid eligibility        T5  Characteristics Of Insurance, By Insurance Adequacy, Among Insured Adults Ages 19–64, 2007

The rate of increase in Medicare expenditures per enrollee has slowed since 2006, and because Medicare spending growth has moderated, the IPAB will be irrelevant to cost containment. 3 years after the ACA’s enactment, the IPAB still has no members. If no members are appointed, the power to recommend changes to Medicare when spending targets are exceeded does not disappear: it reverts to the secretary of health and human services.

The board’s appeal lies largely in its aspiration to remove politics from Medicare — to create a policymaking process that is informed by experts and insulated from pressures outside their professional overview. If Medicare spending growth accelerates, the IPAB’s role could expand. But that future is uncertain.

Causes_of_death_by_age_group

The Road Ahead for the Affordable Care Act

John E. McDonough, Dr.P.H.
N Engl J Med 2012; 367:199-201 http://dx.doi.org/10.1056/NEJMp1206845
http://www.nejm.org/doi/full/10.1056/NEJMp1206845

The Affordable Care Act (ACA), the U.S. health care reform law enacted in 2010, was upheld as constitutional by the U.S. Supreme Court on June 28, 2012. As a result of the Court’s ruling –

  • the individual responsibility requirement (the individual mandate to obtain insurance coverage),
  • insurance reforms such as the elimination of coverage exclusions for preexisting conditions,
  • the establishment of state health insurance exchanges, and
  • the provision of private health insurance subsidies

stand unaltered despite the Court-ordered switch in the basis for constitutional legitimacy from the Commerce Clause to Congress’s taxing authority.

One consequential outcome of the ruling is the continuing benefit, and harm averted, for millions of Americans from ACA provisions that have already been implemented. Those benefiting include more than 6 million young adults enrolled in their parents’ insurance plans, 5.2 million Medicare enrollees who have saved on prescription-drug costs because of the shrinking Part D “doughnut hole,” 600,000 new adult Medicaid enrollees in seven states that have already expanded Medicaid eligibility, 12.8 million consumers who will receive more than $1 billion in insurance-premium rebates, and many others.

Also undisturbed are the ACA’s numerous system reforms, such as accountable care organizations, patient-centered medical homes, the Prevention and Public Health Fund, and the Patient-Centered Outcomes Research Institute. Since the ACA’s passage, health system innovation has surged — a dynamic that would have been undermined by a negative Court ruling.

The biggest change involves Medicaid. The ACA required that Medicaid serve nearly all legal residents with incomes below 138% of the federal poverty level. As a result, there is a new inequity in the health system: by 2014, all Americans will have guaranteed access to affordable health insurance except adults with incomes below the poverty level who were previously ineligible for Medicaid (those with incomes between 100 and 138% of the poverty level will be allowed to obtain coverage through insurance exchanges). States have strong economic incentives to expand Medicaid, since the federal government will pay 100% of expansion costs between 2014 and 2016. By 2020, the federal share will drop to no less than 90% — much more generous than the 50 to 83% that the federal government contributes for traditional Medicaid and the Children’s Health Insurance Plan.

The current implementation queue includes writing definitions and rules for private health insurance markets, clarifying rules for determining required “essential health benefits,” explaining how employer-responsibility provisions will be devised, and much more. The ACA is the first U.S. law to attempt comprehensive reform touching nearly every aspect of our health system. The law addresses far more than coverage, including health system quality and efficiency, prevention and wellness, the health care workforce, fraud and abuse, long-term care, biopharmaceuticals, elder abuse and neglect, the Indian Health Service, and other matters.

Encouraging competition among health plans, even if one of them is “public,” will also fail to solve the cost problem. With the exception of highly integrated organizations, such as Kaiser Permanente, health plans have only two tools to control costs: financial disincentives for patients and fee reductions for providers. Acceptable out-of-pocket maximums, however, vitiate economic incentives to restrain use, particularly for expensive care such as inpatient care. Unable to alter provider behavior, health plans primarily try to avoid enrolling people who are likely to need costly care.

Budget Sequestration and the U.S. Health Sector

McDonough J.E.N Engl J Med 2013; 368:1269-1271 http://dx.doi.org/10.1056/NEJMp1303266

In August 2011, in an agreement to raise the nation’s debt ceiling, bipartisan majorities in the House and Senate approved the Budget Control Act of 2011 (BCA) to reduce the deficit by $1.2 trillion between 2013 and 2021. The BCA established a threat of across-the-board cuts, or “sequestration,” if the Joint Select Committee on Deficit Reduction failed to approve, and Congress to enact, alternative reductions. Sequestration became operational on March 1. Of the $1.2 trillion in cuts, $216 billion will be reductions in debt-service payments, and the remaining $984 billion will be split evenly over 9 years at $109 billion per year, and further adjusted and split evenly between cuts to national defense and nondefense functions at $42.667 billion each.

T2.large  Adults Ages 19–64 Who Were Uninsured And Underinsured, By Various Characteristics, 2003 And 2007   T3.large  uninsured by medicaid eligibility

The $42.667 billion per year in nondefense cuts will not fall equally on all health-related government programs. Nonexempt and nondefense discretionary funding faces reductions of 7.6 to 8.2% in this fiscal year; certain programs such as Medicare and community health centers will have 2% reductions; and certain programs such as Medicaid and the Veterans Health Administration are exempt.

nejmp1303266_t1  Impact of Budget Sequestration on Key Federal Health and Safety Programs,

Impact of Budget Sequestration on Key Federal Health and Safety Programs, Fiscal Year 2013.

http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2013/nejm_2013.368.issue-14/nejmp1303266/20130618/images/small/nejmp1303266_t1.gif

Medicare funding will be cut by 2% ($11.08 billion) through reductions in payments to hospitals, physicians, and other health care providers, as well as insurers participating in Medicare Advantage (Part C). The BCA prohibits cuts affecting premiums for Medicare Parts B and D, cost sharing, Part D subsidies, and Part A trust-fund revenues. The sequestration cuts arrive just as Medicare is beginning to fully implement the savings and cuts required by the Affordable Care Act (ACA), which the Congressional Budget Office estimates will slow Medicare’s rate of growth by $716 billion between 2013 and 2022. The National Institutes of Health (NIH) faces an 8.2% across-the-board reduction for the 7 months remaining in fiscal 2013, equaling cuts of $1.55 billion.

The Centers for Disease Control and Prevention (CDC), which is still recovering from major budget reductions in 2011, anticipates effective reductions of 8 to 10% for the remainder of the year. The American Public Health Association has projected that the reductions could result in 424,000 fewer HIV tests (the CDC funded 3.26 million in 2010) and 50,000 fewer immunizations for adults and children (from a baseline of about 300 million), elimination of tuberculosis programs in 11 states, and shutting down of the National Healthcare Safety Network.

Unaffected for all 9 years of the sequester are most expenses associated with the ACA. Medicaid is exempt, as is funding for its expansion, beginning next January, to all lower-income Americans in states that choose to participate. Also exempt are private insurance subsidies that will be available next January through new health insurance exchanges, because they were designed as refundable tax credits, another BCA-exempt category. Finally, the Children’s Health Insurance Plan, the Supplemental Nutrition Assistance Program, Temporary Assistance to Needy Families, and Supplemental Security Income are all exempt.

Threading the Needle ‹ Medicaid and the 113th Congress

fs310_graph3  leading causes of death by income class worldwideFUSA_INFOGRAPHIC_50-state-medicaid-expansion_rev_06-27-13_FACEBOOKCOVER

Rosenbaum S.N Engl J Med 2012; 367:2368-2369 http://dx.doi.org/10.1056/NEJMp1213901

Medicaid is a veteran of decades of warfare over its size and cost. Nevertheless, the program now plays a vital role in the U.S. health care system and a foundational role in health care reform. The central question, as we approach a major debate over U.S. spending and federal deficits, is how to preserve this role and shield Medicaid from crippling spending reductions. The Budget Control Act, which provides the initial framework for this debate, insulates Medicaid from sequestration. Budgetary protections for Medicaid date to the 1980s, but today’s politics are less tolerant of programs for poor and vulnerable populations. Medicaid is also at a deep political disadvantage. Medicaid is unequaled among federal grant programs: more than 60 million children and adults rely on the program, and it’s projected to grow to 80 million beneficiaries by 2020 if all states adopt the eligibility expansion in the Affordable Care Act (ACA). Medicaid’s cost is driven by high enrollment, not excessive per capita spending.2 As a result, there’s very little money to wring out of Medicaid without shaking its structure in ways that reduce basic coverage. Medicaid is part of the base on which health care reform rests; if it is not expanded per the ACA, the nation will lose its chance at near-universal health insurance coverage, which is essential to achieving systemwide savings and halting a $50 billion annual cost shift to insurers and patients. Deep federal spending reductions could lead states to abandon Medicaid expansion as a result of a confluence of factors —

  • the still-fragile nature of many state economies,
  • the continuing ideological opposition to Medicaid expansion, and
  • the Supreme Court decision to permit states to opt out of such expansion altogether.

Considerable evidence shows its effectiveness: most recently, a study by Sommers et al. documented its positive effects on health and health care. Experts in Medicaid spending also acknowledge the program’s operational efficiencies, achieved by states through the aggressive use of managed care and strict controls on spending for long-term care. Much of the health care that Medicaid beneficiaries receive is furnished through safety-net providers such as community health centers, which are highly efficient and accustomed to operating on tight budgets with only limited access to costly specialty care. Furthermore, Medicaid’s physician payments are substantially lower than those from commercial insurers and Medicare — a disparity that unfortunately limits provider participation even as it helps to keep per capita spending low. Indeed, the CBO has found that insuring the poor through Medicaid will cost 50% less per capita than doing so through tax-subsidized private insurance plans offered through state health insurance exchanges.

nejmp1306051_f1  Projected Growth in Medicare Per Capita Spending, the Consumer Price Index (CPI), and the Medical CPI, 2011–2015

The essential task is to thread the needle by accelerating efficiency reforms in health care payment and organization that, in turn, can generate savings over time while not damaging Medicaid’s role as a pillar of health care reform. Of particular importance is a heightened focus, begun under the ACA, on reforms that emphasize community care for millions of severely disabled children and adults, including patients who are dually enrolled in Medicare and Medicaid and who rely heavily on long-term institutional care.

The Shortfalls of ‘Obamacare’

Wilensky G.R. N Engl J Med 2012; 367:1479-1481 http://dx.doi.org/10.1056/NEJMp1210763

U.S. health care suffers from three major problems: millions of people go without insurance, health care costs are rising at unaffordable rates, and the quality of care is not what it should be. The Affordable Care Act (ACA) primarily addresses the first — and easiest — of these problems by expanding coverage to a substantial number of the uninsured. Solutions to the other two remain aspirations. The ACA’s primary accomplishment is that approximately 30 million previously uninsured people may end up with coverage — about half with subsidized private coverage purchased in the mostly yet-to-be-formed state insurance exchanges and the other half through Medicaid expansions. The law’s most controversial provision remains the individual mandate, which requires people either to have insurance coverage or to pay a penalty. The penalty for not having insurance is very small, particularly for younger people with modest incomes. It would have been smarter to mimic Medicare’s policies: seniors who don’t purchase the voluntary parts of Medicare covering physician services and outpatient prescription drugs during the first year in which they lack comparable coverage must pay a penalty for every month they have gone without coverage whenever they finally do purchase it.

Despite widespread recognition that fee-for-service reimbursement rewards providers for the quantity and complexity of services and encourages fragmentation in care delivery, the ACA retains all the predominantly fee-for-service reimbursement strategies currently used in Medicare. Much of the coverage expansion is financed through Medicare budget savings, which are produced by reducing the fees paid by Medicare to institutional providers such as hospitals, home care agencies, and nursing homes — but using the same perverse reimbursement system currently in place. Reducing payments to institutional providers should not be confused with lowering the cost of providing care.

The ACA also provides Medicare “productivity adjustments,” which assume that inflation adjustments can be reduced over time because institutions will become more productive, whether or not hospitals and other providers actually find ways to increase their productivity. Unless these institutions find ways to reduce costs, lower Medicare reimbursements will force providers to bargain for higher payments from private insurers. And eventually, seniors’ access to services will be threatened. The Medicare actuary expects that 15% of institutional providers will lose money on their Medicare business by 2019, and the proportion will increase to 25% by 2030 — a situation that he calls unsustainable

Most troubling, the ACA contains no reform of the way physicians are paid, which is the most dysfunctional part of the Medicare program. Through the Resource-Based Relative Value Scale, physicians are reimbursed on the basis of service codes, and payment for each physician service is reduced whenever aggregate spending on physician services exceeds a prespecified limit. This system disregards whether clinicians are providing low-cost, high-value care for patients. Given physicians’ key role in providing patient care, it’s impossible to imagine a reformed delivery system without one that rewards them for providing clinically appropriate care efficiently.

What is needed are reforms that create clear financial incentives that promote value over volume, with active engagement by both consumers and the health care sector. Market-friendly reforms require empowering individuals, armed with good information and nondistorting subsidies, to choose the type of Medicare delivery system they want. Being market-friendly means allowing seniors to buy more expensive plans if they wish, by paying the extra cost out of pocket, or to buy coverage in health plans with more tightly structured delivery systems at lower prices if that’s what suits them. 

Financing Graduate Medical Education — Mounting Pressure for Reform

John K. Iglehart N Engl J Med 2012; 366:1562-1563 http:dx.doi.org/10.1056/NEJMp1114236
http://www.nejm.org/doi/full/10.1056/NEJMp1114236

Disparate voices from the White House, a national fiscal commission, Congress, a Medicare advisory body, private foundations, and academic medical leaders are advocating changes to Medicare’s investment in graduate medical education (GME), which currently totals $9.5 billion annually. They offer various prescriptions, including reducing federal support, developing new achievement measures for which GME programs should be held accountable, and seeking independent assessment of the governance and financing of training programs.

The influential GME community has withstood most past efforts to change Medicare’s GME policies. But recognizing today’s more challenging political environment, the Association of American Medical Colleges (AAMC) has begun discussing alternative methods of financing GME that could better align training with the future health care delivery system and address U.S. workforce needs. The association is also examining the influence of student debt on the enrollment of a diverse student body.

When Congress enacted Medicare in 1965, it assigned to the program functions that reached well beyond its mission of financing health care for the elderly. One function was supporting GME, at least until the society at large undertook “to bear such education costs in some other way.” Almost 50 years later, Medicare remains the largest supporter of GME, providing both direct payments to hospitals that cover medical education expenses related to the care of Medicare patients (about $3 billion per year) and an indirect medical education (IME) adjustment to teaching hospitals for the added patient-care costs associated with training (about $6.5 billion).

In its 2013 budget, unveiled on February 13, 2012, the Obama administration proposed reducing Medicare’s IME adjustment by $9.7 billion over 10 years, beginning in 2014, citing a report from the Medicare Payment Advisory Commission (MedPAC) indicating that Medicare’s IME adjustments “significantly exceed the actual added patient care costs these hospitals incur.” The administration also proposed that the secretary of health and human services be granted the authority to assess GME programs’ performance in instilling in residents the necessary skills to promote high-quality health care. Similarly, MedPAC had recommended redirecting about half the IME adjustments ($3.5 billion) into “incentive payments” that GME programs could earn by meeting performance standards. The Obama budget would also eliminate coverage of the IME expenses of free-standing children’s hospitals with pediatric residency programs — which do not treat Medicare patients — reducing their federal support by 66% (to $88 million). Moreover, Congress has revealed its uncertainty over how to change federal workforce policy. In the Affordable Care Act (ACA), Congress emphasized the importance of expanding the primary care workforce. But legislators rejected the AAMC’s call to expand the number of Medicare-funded GME positions by 15% in response to reported physician shortages in some specialties.

On December 21, seven senators — Democrats Michael Bennet (CO), Jeff Bingaman (NM), Mark Udall (CO), and Tom Udall (NM) and Republicans Mike Crapo (ID), Chuck Grassley (IA), and Jon Kyl (AZ) — sent a letter to the Institute of Medicine (IOM) encouraging it to “conduct an independent review of the governance and financing of our system of [GME].” They urged the IOM to explore subjects including accreditation; reimbursement policy; the use of GME to better predict and ensure adequate workforce supply in terms of type of provider, specialty, and demographic mix; GME’s role in care of the underserved; and use of GME to ensure the creation of a workforce with the skills necessary for addressing future health care needs. The senators emphasized their interest “in IOM’s observations about the uneven distribution of GME funding across states based on need and capacity, and how to address this inequity.” In an interview, Bingaman said he initiated the letter for the same reasons he had championed creation of a National Health Care Workforce Commission as part of the ACA: to strengthen the government’s resolve to do “a more credible job of assessing workforce shortages” and because he believes Medicare’s GME policies are “outmoded.”

The priorities cited in the IOM letter parallel some of the recommendations of a group of academic medical leaders who gathered at two conferences underwritten by the Josiah Macy Jr. Foundation. At the first conference, in October 2010, the top recommendation was that “an independent external review of the goals, governance, and financing of the GME system should be undertaken by the Institute of Medicine, or a similar body.”3 George Thibault, president of the Macy Foundation, says the group concluded that “because GME is a public good and is significantly financed with public dollars, the GME system must be accountable to the needs of the public.” Acknowledging that some people in academic medicine “favor a behind-the-scenes discussion of GME reform alternatives,” Thibault noted, “I believe we should be upfront, providing examples of change that could influence the thinking of policymakers.” The foundation awarded the IOM $750,000 — about half the support it needs for the GME study.

Among subjects under discussion are the collection of more data highlighting the importance of the safety-net functions and unique services of academic medical centers and the creation of a long-term vision for GME financing that is more closely aligned with emerging care delivery models, such as accountable care organizations. The association is also revisiting a potential financial model under which all health care payers would explicitly cover GME expenses. Private insurers maintain that they accomplish this implicitly by paying teaching hospitals more for clinical services than they pay most other hospitals. GME leaders think one possibility would be to include the costs of residency training when calculating premium amounts for products sold through health insurance exchanges. Similarly, a recent Carnegie Foundation report asserted that “GME redesign demands . . . a more broad-based, less politicized flow of funds.”

Dr. Darrell Kirch noted, CEO of AAMC, “A significant step forward is the announcement by the ACGME [Accreditation Council for Graduate Medical Education] describing major changes in how the nation’s residency programs will be accredited in the future, putting in place an outcomes-based evaluation system by which new physicians will be measured for their competency in performing the essential tasks necessary for clinical practice in the 21st century.”

Achieving Health Care Reform — How Physicians Can Help

Elliott S. Fisher, M.D., M.P.H., Donald M. Berwick, M.D., M.P.P., and Karen Davis, Ph.D.
N Engl J Med 2009; 360:2495-2497 http://dx.doi.org/10.1056/NEJMp0903923
http://www.nejm.org/doi/full/10.1056/NEJMp0903923

The recent commitment by several major stakeholders — including the American Medical Association — to slowing the growth of health care spending is a promising development. But the controversy about whether the organizations actually agreed to a 1.5-percentage-point reduction in annual spending growth is just one indication that success is still far from assured.

Two threats in particular put reform at risk: conflicting doctrines (regarding the creation of a new public insurance option and government support for comparative-effectiveness studies) and opposition to change among some current stakeholders. In the face of this uncertainty, physicians have a choice: to wait and see what happens or to lead the change our country needs. We’d prefer the latter.

The first level is aims. For health care reform, we propose that physicians, through their advocacy, help lead the country to embrace the so-called triple aim: better experience of care (safe, effective, patient-centered, timely, efficient, and equitable), better health for the population, and lower total per capita costs.

The second level is the design of the care processes that affect the patient — clinical “microsystems.” Health care microsystems are famously unreliable, variable in costs, and often unsafe. Physicians, through their participation in quality-improvement initiatives in their practices and hospitals, can and should lead the needed changes in the systems of care in which they work, to make them safer, more reliable, more patient-centered, and more affordable.

However, neither physicians nor anyone else on the front lines can improve care much on their own. Their most important source of support for improvement is the third level described by the IOM — the health care organizations that house almost all clinical microsystems and can ensure coordination among them. We need organizations large enough to be accountable for the full continuum of patients’ care as well as for achieving the triple aim. We will create a high-performing health care system only if integrated delivery systems become the mainstay of organizational design. Organizations could be virtually integrated, such as networks of independent physicians sharing electronic health records and administrative and clinical support for care management and quality improvement, or structurally integrated, such as multispecialty group practices or staff-model health maintenance organizations. Fostering the development of such accountable care organizations need not be disruptive to patients or providers: almost all physicians already work within natural referral networks that provide the vast majority of care to patients seen by the primary care physicians within the network.

Innovators-Prescription-New-Wave-of-Disruptive-Models-in-Healthcare

The IOM’s fourth level is the environment, which includes the payment, regulatory, legal, and educational systems. On this front, too, we need physician advocacy. The United States cannot achieve the triple aim without health insurance for everyone. Integrated delivery systems that are accountable for populations won’t thrive unless payment systems encourage their development and unless we change the laws and regulations — including proscriptions of gainsharing and anti-kickback rules — that prevent cooperation among health care professionals and organizations.

If stakeholders can agree on such a vision of health care reform, perhaps we could shift our focus from the conflict over whether a new public plan should be created to a more constructive insistence that all health plans, whether public or private, focus on the development of professionally led, integrated systems.

If health care providers and suppliers could actually achieve this reduction in growth rates, the federal government would harvest about $1.1 trillion in savings over the 11-year period — enough, perhaps, to close the deal on affordable health insurance for all. Others would also see savings: $497 billion for employers, $529 billion for state and local governments, and $671 billion for households. One simple way for physicians to start contributing to this goal is by reassessing and scaling back, where appropriate, their use of clinical practices now listed as “overused” by the National Quality Forum’s National Priorities Partnership.

Editor-in-Chief Eric J. Topol, MD, interviews Secretary of Health and Human Services (HHS) Kathleen Sebelius

Medscape

Editor’s Note: On the eve of the first anniversary of the Supreme Court’s ruling to uphold most provisions of the Affordable Care Act (ACA), Medscape Editor-in-Chief Eric J. Topol, MD, questioned Secretary of Health and Human Services (HHS) Kathleen Sebelius about the act’s effect on medical technology, clinical trial participation, genetic testing, primary care, and patient safety.

Introduction

Dr. Topol: We are experiencing a digital revolution in which technological advances are putting healthcare where it should be: in the hands of patients. How is the ACA helping to foster medical innovation?
Secretary Sebelius: A recent New York Times column, “Obamacare’s Other Surprise,”[1] by Thomas L. Friedman, echoes what we’ve been hearing from healthcare providers and innovators: Data that support medical decision-making and collaboration, dovetailing with new tools in the Affordable Care Act, are spurring the innovation necessary to deliver improved healthcare for more people at affordable prices.
Today we are focused on driving a smarter healthcare system with an emphasis on the quality — not quantity — of care. The healthcare law includes many tools to increase transparency, avoid costly mistakes and hospital readmissions, keep patients healthy, and test new payment and care delivery models, like Accountable Care Organizations (ACOs). Health information technology is a critical underpinning to this larger strategy.
In May we reached an important milestone in the adoption of health information technology. More than half of all doctors and other eligible providers, and nearly 80% of hospitals, are using electronic health records (EHRs) to improve care, an increase of at least 200% since 2008. Also in May, we announced a $1 billion challenge to help jump-start innovative projects that test creative ways to deliver high-quality medical care and lower costs to people enrolled in Medicare and Medicaid, following 81 Health Care Innovation Awards that HHS awarded last year.
Dr. Topol: Physicians have long lamented the lack of participation by patients in clinical trials, but the ACA is opening the door for greater participation by allowing patients to keep their health insurance while participating in clinical research. Are patients even aware that this provision now exists? How do you see it affecting clinical trial participation in the future?
Secretary Sebelius: In 2014, thanks to the ACA, insurance companies will no longer be able to deny patients from participating in an approved clinical trial for treatment of cancer or another life-threatening disease or condition, nor can they deny or limit the coverage of routine patient costs for items or services in connection with trial participation. For many patients, access to cutting-edge medicine available through clinical trials can increase their likelihood of survival. This is an important protection for patients that not only could have a life-altering impact, but it’s also one that serves to facilitate participation in research that is critical to expanding our knowledge base and finding cures and treatments for those illnesses that threaten the lives of Americans each day.
Dr. Topol: One of the intentions of the ACA is to increase the primary care workforce. This is critical as we approach 2014, when more Americans than ever will have either private insurance or Medicaid. Have you seen any movement in the primary care workforce? Are there concerns that there aren’t enough clinicians available to meet the forthcoming patient load?
Secretary Sebelius: Primary care providers are critical to ensuring better coordinated care and better health outcomes for all Americans. To meet the health needs of Americans, the Obama Administration has made the recruitment, training, and retention of primary care professionals a top priority.
Together, the ACA, the American Recovery and Reinvestment Act of 2009, and ongoing federal investments in the healthcare workforce have led to significant progress in training new primary care providers — such as physicians, nurse practitioners, and physician assistants — and encouraging primary care providers to practice in underserved areas, including:
Nearly tripling the National Health Service Corps;
Increasing the number of medical residents, nurse practitioners, and physician assistants trained in primary care, including placing over 1500 new primary care providers in underserved areas;
Creating primary care payment incentives for providers; and Redistributing unused residency positions and directing those slots for the training of primary care physicians.
Additionally, the ACA is modernizing the primary care training infrastructure, creating new primary care clinical training opportunities, supporting primary care practice, and improving payment and financial incentives for coordinated care.
Improving Hospital Safety
Dr. Topol: George Orwell once said that the hospital is the antechamber to the tomb. That was written decades ago, and unfortunately there’s still truth to that today. One in 4 hospital patients in America have a problem with medical mistakes, contract hospital-acquired infections, and experience medication errors. The ACA last year began linking Medicare payments to quality of patient care, offering financial incentives to hospitals that improve patient care. How is this working? Have there been any meaningful care improvements over the past year?
Secretary Sebelius: The ACA includes steps to improve the quality of healthcare and, in so doing, lowers costs for taxpayers and patients. This means avoiding costly mistakes and readmissions, keeping patients healthy, rewarding quality instead of quantity, and creating the health information technology infrastructure that enables new payment and delivery models to work. These reforms and investments will build a healthcare system that will ensure quality care for generations to come.
Already we have made significant progress:
Healthcare Spending Is Slowing
Secretary Sebelius: Medicare spending per beneficiary grew just 0.4% per capita in fiscal year 2012, continuing the pattern of very low growth in 2010 and 2011. Medicaid spending per beneficiary also decreased 0.9% in 2011, compared with 0.6% growth in 2010. Average annual increases in family premiums for employer-sponsored insurance were 6.2% from 2004 to 2008, 5.6% from 2009 to 2012, and 4.5% in 2012 alone.
Health Outcomes Are Improving and Adverse Events Are Decreasing
Secretary Sebelius: Several programs tie Medicare reimbursement for hospitals to their readmission rates, when patients have to come back into the hospital within 30 days of being discharged. Additionally, as part of a new ACA initiative, clinicians at some hospitals have reduced their early elective deliveries to close to zero, meaning fewer at-risk newborns and fewer admissions to the NICU.
Providers Are Engaged
Secretary Sebelius: In 2012, we debuted the Medicare Shared Savings Program and the Pioneer Accountable Care Organization Model. These programs encourage providers to invest in redesigning care for higher-quality and more efficient service delivery, without restricting patients’ freedom to go to the Medicare provider of their choice.
Over 250 organizations are participating in Medicare ACOs, serving approximately 4 million, or 8%, of Medicare beneficiaries. As existing ACOs choose to add providers and as more organizations join the program, participation in ACOs is expected to grow. ACOs are estimated to save up to $940 million in the first 4 years.
Bundle with Care ‹ Rethinking Medicare Incentives for Post­Acute Care Services

Feder J. N Engl J Med 2013; 369:400-401

A Medicare payment approach in which savings and risk are shared may achieve a better balance of cost, quality, and access than a system of single bundled payments, at least until our capacity to measure patients’ care needs and outcomes is sufficiently robust.

Healthcare Reform 2014: Mandated Coverage, Insurance Exchanges, and Employer Requirements

3 of 5 in Series: The Essentials of Healthcare Reform
http://www.dummies.com/how-to/content/healthcare-reform-2014-mandated-coverage-insurance.html

The Affordable Care Act federal and state officials are working with leaders in the health and insurance industries to restructure our nation’s healthcare system. That restructuring means most Americans will be required to have health insurance and most businesses will be required to offer it to their employees. It also means the creation of another kind of insurance plan called a health insurance exchange.

The government will require most Americans to have health insurance by 2014. The government has enacted this provision as a way to get healthy people who don’t feel the need to pay for coverage to buy insurance. That way, the healthy people can help fund the cost of people who require more medical care.

Several states filed, and lost, a suit against the federal government saying that it is unconstitutional to make individual citizens to buy health insurance.

If you don’t have coverage and you’re not in one of the groups that is an exception to the rule, you’ll pay a penalty. You may not be required to purchase health insurance if you

  • Face financial hardships.
  • Have been uninsured for less than three months.
  • Have religious objections.
  • Are American Indian.
  • Are a prison inmate.
  • Are an undocumented immigrant.

If you’re penalized, the amount you’ll be fined will go up each year for the first three years. In 2014, you’ll pay $95 or 1 percent of your taxable income, whichever is greater. In 2015, the fine will be $325 or 2 percent of taxable income, and in 2016 the penalty will be $695 or 2.5 percent of income. Each year after 2016, the government will refigure the fine based on a cost-of-living adjustment.

To help you meet the cost of mandated insurance, the government will offer premium credits and cost sharing subsidies if you and your family meet certain income guidelines and if you enroll in one of the new state-run insurance exchanges.

If your income falls between 133 and 400 percent of the federal poverty level (FPL), you could receive premium credits that will lower the maximum amount of premium you have to pay for your coverage.

  • There will be a catastrophic plan for people under 30 and for those who are exempt from mandated coverage.

States don’t have to set up the exchanges. If a state chooses not to, the federal government can come in and create them. States that do opt for exchanges will decide whether they’ll be run by a government or not-for-profit entity.

Health Care Reform — Why So Much Talk and So Little Action?

Victor R. Fuchs, Ph.D
N Engl J Med 2009; 360:208-209 http://dx.doi.org/10.1056/NEJMp0809733
http://www.nejm.org/doi/full/10.1056/NEJMp0809733

First, many organizations and individuals prefer the status quo. This category includes health insurance companies; manufacturers of drugs, medical devices, and medical equipment; companies that employ mostly young, healthy workers and therefore have lower health care costs than they would if required to help subsidize care for the poor and the sick; high-income employees, whose health insurance is heavily subsidized through a tax exemption for the portion of their compensation spent on health insurance; business leaders and others who are ideologically opposed to a larger role of government; highly paid physicians in some surgical and medical specialties; and workers who mistakenly believe that their employment-based insurance is a gift from their employer rather than an offset to their potential take-home pay.

Second, as Niccoló Machiavelli presciently wrote in 1513, “There is nothing more difficult to manage, more dubious to accomplish, nor more doubtful of success . . . than to initiate a new order of things. The reformer has enemies in all those who profit from the old order and only lukewarm defenders in all those who would profit from the new order.”

Third, our country’s political system renders Machiavelli’s Law of Reform particularly relevant in the United States, where many potential “choke points” offer opportunities to stifle change. The problem starts in the primary elections in so-called safe congressional districts, where special-interest money can exert a great deal of influence because of low voter turnout. The fact that Congress has two houses increases the difficulty of passing complex legislation, especially when several committees may claim jurisdiction over portions of a bill. Also, a supermajority of 60% may be needed to force a vote in the filibuster-prone Senate.

Fourth, reformers have failed to unite behind a single approach. Disagreement among reformers has been a major obstacle to substantial reform since early in the last century. According to historian Daniel Hirshfield, “Some saw health insurance primarily as an educational and public health measure, while others argued that it was an economic device to precipitate a needed reorganization of medical practice. . . . Some saw it as a device to save money for all concerned, while others felt sure that it would increase expenditures significantly.” These differences in objectives persist to this day.

Health insurers are opening stores alongside department stores, other typical mall tenants.

Jayne O’Donnell , USA TODAY
 http://www.usatoday.com/story/news/nation/2013/09/12/health-insurance-sales-retail-stores-malls/2789897/

,The new health law known as the Affordable Care Act means most uninsured Americans are required to have insurance beginning March 31 or pay a penalty at tax time in 2015.

Insurers need to sign up as many healthy, younger people as they can to pay for all of the older, sick customers they will be taking on. The law prohibits insurers from denying people insurance because of pre-existing health problems and limits how much more they can charge older than younger people.

So, for the first time, insurers are fiercely competing to attract individual consumers and turning to traditional retail marketing techniques to do so, luring them into stores with special events and using splashy advertising. As any retailer knows, they have the greatest chance of converting shoppers to customers once they have them in their retail locations or on their sites.

The Medical Breakthrough Nobody’s Talking About

Toby CosgroveCEO and President at Cleveland Clinic

http://www.linkedin.com/today/post/article/20130912184535-205372152-the-medical-breakthrough-nobody-s-talking-about

The latest medical breakthrough hasn’t gotten much press, but it’s changing medicine even as we speak. It’s the dawning realization that healthcare is not about how many patients you can see, how many tests and procedures you can order, or how much you can charge for these things. The breakthrough is the understanding that healthcare is a value proposition, which means getting patients the right care, at the right time, in the right place. It’s a matter of focusing on outcomes and cost, so that more Americans will start getting what they pay for in healthcare dollars.

Value-based care focuses on two targets: outcomes and cost. Until recently, providers pursued these goals separately, with doctors concentrating on outcomes and the administrators trying to control costs. Value-based care does something different. It works to bring these targets into alignment. The caregivers in a value-based provider work with cost-experts as a team to simultaneously improve outcomes and lower expenses.

Doctors, hospitals and payers are partners in the move to value-based care. The Affordable Care Act includes incentives for providers to improve outcomes and lower costs. But this is one breakthrough that will take time for implementation nationwide. Providers who make the transition early will be rewarded with more satisfied patients, lower expenses and pride in a job well done.

Six-Month Enforcement Delay After Guidance

According to AAMC, the language in the final rule requires that the order to admit a patient be written by a practitioner “who has admitting privileges at the hospital,” something that few residents have as they are not considered members of the hospital’s medical staff.

AAMC said it brought the issue to CMS’s attention during an Open Door Forum call Aug. 15. The agency acknowledged it did not intend to prohibit residents from admitting patients, and said it would be issuing a Q&A. However, AAMC said until the issue can be resolved “to the satisfaction of the teaching hospital community,” CMS should make clear to all contractors that no inpatient admission should be denied because it was ordered by a resident while under the supervision of an attending physician.

AAMC said CMS should delay enforcing the new requirements for at least six months following the release of the guidance so hospitals will have sufficient time to understand the rules, educate physicians and others, and ensure that they have put in place the mechanisms that are needed to comply with the new requirements.

“As short inpatient stays have been a focus of audits by [Recovery Audit Contractors], hospitals feel especially at risk for failure to properly implement CMS requirements,” AAMC said.

The letter is available at http://op.bna.com/hl.nsf/r?Open=nwel-9auqls.

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