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Posts Tagged ‘ACO’


Wherefore Goes the Laboratory?

Larry H. Bernstein, MD, FCAP

Writer and Curatorthat both public and private payers develop clear and consistent evidence criteria for payment of

https://pharmaceuticalintelligence.com/2015/7/17/larryhbern/Wherefore_Goes_the_Laboratory?

 

Pharmaceuticals and Diagnostics are becoming more integrated in terms of payment initiatives

We have already seen the impetus for targeted-design of drugs. However, how this plays out in the complex world of personalized-medicine remains to be seen.  Certainly, the genomics of cancer and other diseases has been a matter of continuing investigation, and is not clear with respect to patient management.  The American Association for Clinical Chemistry (AACC) has issued a position statement on Personalized Medicine, emphasizing the role of laboratory medicine in the delivery of Personalized Medicine (PM).  The AACC stresses the need for Congressional funding for basic and clinical research in the field of PM tests. Important in this view is  the need to develop evidence based criteria for the reimbursement of companion diagnostics. In addition, the recommendation urges that laboratory professionals become more engaged in educating physicians about the availability of and limitations of PM tests, and to partner with other  healthcare professionals.

The Centers for Medicare and Medicaid (CMS) has issued new data on the cost savings of accountable care oganizations (ACOs).    The American Hospital Association Senior Vice President Linda Fishman calls attention to the need for the CMS to make the program more attractive to new and current participants. CMS announced in May that the Office of the Actuary found the Pioneer ACO model geberated more than $384 million in savings to Medicare over the first two years of the program while continuing to provide high-quality care.

An important issue, quite easily overlooked, is the importance of the restructuring of the electronic health record (EHR) to accomplish this task. There are unresolved issues that need serious attention:

1. The EHR needs to be functionally more than just a repository for data.

It has to be linked to multivariable algorithms that parse the data in real time, and thereby assist physicians in decision-making.  This would be essential for a population-based model for value-based payments by Medicare and all providers in the next several years, in accordance with the Affordable Care Act.

2. The EHR has to be accessible to all of the providers of care to the patient, and the information also protected from intrusion.  This means that if a patient has cancer, and is also diabetic, and has for example, rheumatoid arthritis, the data has to be available to all providers actively engaged in treatment. This might be the endocrinologist, a primary care physician, a rheumatologist, radiologist, and oncologist. This is not by any means a consideration in the current design of the EHR.

3. The access to laboratory and pharmacy data must be seamless, which has not been the case.

If these considerations were considered in a patient-focused design of the EHR, the benefits would almost certainly accrue.  I call attention to the fact that there are ongoing medical studies and pertinent findings that could also contribute to the quality of care, but these might take some time to be incorporated into an evidence-based program going forward.

Clin Lab News July 2015; 41(7). AACC
bmalone@aacc.org

 

 

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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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Reporter: Alan F. Kaul, Pharm.D., M.S., M.B.A., FCCP

 

Centers for Medicare and Medicaid (CMS) Targets Hospital Readmissions – Update on Practices and Policy

 

An earlier post on June 8, 2012 in Pharmaceutical Intelligence presented an overview of the Hospital Readmissions Reduction Program (HRRP) and its requirement to reduce payments under the Inpatient Prospective Payment System (IPPS) to hospitals reporting excess readmissions commencing with discharges on October 1, 2012.  As CMS moved forward with HRRP, hospitals readiness for population based accountable care seemed questionable based on a 34 percent survey response or 1,672 hospitals.

https://pharmaceuticalintelligence.com/2012/06/12/centers-for-medicare-and-medicaid-cms-targets-hospital-readmissions-a-disconnect-among-the-hospitals-or-poor-education/

 

According to Medicare Payment Advisory Commission (MedPAC) report, approximately two-thirds of hospitals will be penalized (capped at 1 percent) for above average readmissions commencing October 1, 2012. This penalty will escalate to 2% in 2014 and 3 percent in 2015.  Looking at the hospital readmission measures for Acute Myocardial Infarction (AMI), Heart Failure (HF), and Pneumonia (PN), this penalty will average $125,000 per hospital. Overall, the CMS payment to all hospitals will be reduced by 0.24 percent.  A preliminary analysis indicated little variation by hospital type (i.e., urban, rural, teaching, non-teaching, profit, non-profit).

 

MedPAC pointed out several long-term issues with the readmission reduction program including:

 

  • Computing the penalty multiple – Penalty increases as readmission rate decreases and the penalty multiplier differs for each condition. Solutions could include using a fixed multiplier, using all-condition readmissions, and eliminating the multiplier and setting a lower target readmission rate to maintain budget neutrality
  • Random variation and small number of observations – Solutions could include using all-condition readmissions, using more than the 3 years of data currently used, and allowing hospitals to aggregate performance within a system for penalty purposed while continuing to report individual hospital performance
  • Unrelated and planned readmissions – Solutions could include switching to a-condition measures that have exceptions for planned and unrelated readmissions such as the Yale all condition model or the 3M all-condition model.
  • Socio-economic status and risk-reduction- Possible situations may include allow current incentives to close the gap, comparing hospitals against similar hospitals to compute the penalty, and providing financial assistance to hospitals with a disproportionate share of low-income patients

 

Moving forward in refining the policy several objectives were noted: maintaining or increasing average hospitals’ incentive to reduce readmissions; increasing the share of hospitals with an incentive to reduce readmissions; making any penalty a consistent multiple of the cost of readmissions; being at least budget neutral to current policy, with a preference for lower readmission rates rather than higher penalties. Any policy refinements will require a change in law and must proceed carefully.

http://www.medpac.gov/transcripts/readmissions Sept 12 presentation.pdf

 

On October 3, 2012, CMS issues a notice indicating that errors were discovered in its initial calculation for readmissions penalties under the Inpatient Prospective Payment Systems (IPPS) that went into effect the beginning of October. The revisions were in part to implement capital and operating related costs to acute care hospitals arising from CMS’s continued experience with the systems. Also updated were payment policies and rate of increase limits for certain hospitals excluded from IPPS and paid under Medicare’s Prospective Payment System such as Long Term Acute Care Hospitals (LTACHs).

 

Based on a Kaiser analysis of the miscalculation, 1,422 hospitals will lose more and 55 hospitals will lose less than originally projected. The changes were tiny averaging 0.002 percent of a hospital’s regular Medicare reimbursement. A total of 2,217 hospitals are being punished in the first year of the program which began on October 1, 2012. Of those punished, 307 (14%) will be penalized the maximum 1% of their regular Medicare reimbursement.

 

http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2013-IPPS-Final-Rule-Home-Page-Items/CMS-1588-F-Text-Version.html

http://www.kaiserhealthnews.org/Stories/2012/October/03/medicare-revises-hospitals-readmissions-penalties.aspx

 

As reported in the Napa Valley Register on October 14, 2012, variations in local practices patterns are already being noticed. For example in Napa Valley, Queen of Valley Medical Center has a 18 percent readmission rate, St. Helena Hospital a 13 percent readmission rate, and Kaiser Permanente Vallejo Medical Center a 7 percent readmission rate. Local hospital officials are claiming that reduced readmissions incorrectly assumes better care and that not making exceptions for unavoidable readmissions are policy flaws.  While officials at Kaiser Permanente of Northern California indicated that they had no concerns about the policy change because “it promotes co-ordianation of care, individuals at Queen of Valley Medical Center and St Helena’s Hospital expressed a variety of concerns from the fragile natur of patients in certain of the included diagnoses and the 30-day time fram to evaluate readmissions.  Moving forward to lower readmission rates at Queen and St. Helena indicated that they will pay more attention as patients are discharged from the hospitals during transitions of care, Professionals will coach patients in self-management through home visits and phone-calls after they have been discharged from the hospital.

 

http://napavalleyregister.com/news/local/local-hospitals-challenged-to-cut-medicare-readmissions/article_1827ecfc-159c-11e2-8ad2-001a4bcf887a.html?comment_form=true

 

 

 

 

 

 

 

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The Relationship Between “Big Data” and Health Care – Value or Rubbish?

Author: Alan Fleischman, MBA      E-mail: a.fleischman@verizon.net

A blog (pathcareblog.com) entitled Why Big Data for Healthcare is Rubbish

http://pathcareblog.com/why-big-data-for-healthcare-is-rubbish/?goback=%2Eanb_1839273_*2_*1_*1_*1_*1_*1 takes direct aim at a recent report by the McKinsey Global Institute (Big Data: The Next Frontier for Innovation, Competition, and Productivity) http://www.mckinsey.com/insights/mgi/research/technology_and_innovation/big_data_the_next_frontier_for_innovation that projects substantial quantitative and qualitative benefits from implementing Big Data initiatives in health care.  Pathcare essentially states that McKinsey and Big Data ignore the two major stakeholders in healthcare – doctors and patients: “The study does not cite a single interview with a primary care physician or even a CEO of a healthcare organization that might support or validate their theories about big data value for healthcare. This is shoddy research, no matter how well packaged.” http://pathcareblog.com/why-big-data-for-healthcare-is-rubbish/?goback=%2Eanb_1839273_*2_*1_*1_*1_*1_*1

An article in Businessweek (The Health-Care Industry Turns to Big Data by Jordan Robertson, May 17, 2012) http://www.businessweek.com/articles/2012-05-17/the-health-care-industry-turns-to-big-data quotes benefits experienced by New York-Presbyterian Hospital from several data initiatives – including reducing “the rate of potentially fatal blood clots by about a third”, according to surgeon Nicholas Morrissey.  Morrisey is also working to develop a big data driven system to assess risk factors on new patients in the emergency room and the admission wards.  Along with hospitals, NSF and NIH have launched an initiative on Big Data to accelerate progress in biomedical research.

This article will not attempt to defend the research methodology utilized by McKinsey or the magnitude of the benefits projected, but it will defend the premise that medicine must improve its processes and procedures. Information systems are essential to this improvement and large amounts of data will need to be exchanged, integrated, and analyzed as a result. Evidence based medicine, effectiveness research, and performance assessments require the analysis of large amounts of data.  Like it or not, medicine is an industry with massive amounts of data, whether it is clinical, administrative, performance, or business.  Medicine can no longer function as a guild where senior craftsmen dispense tricks of the trade to apprentices and society grins and bears the results in terms of lives impacted and national treasure dispensed.  What is truly alarming to this author is the fact that healthcare has been so slow to adopt methods that have been proven effective in other industries – even low-tech methods.  This may explain the positive reception given to the use of simple checklists that have been advocated by the Institute for Healthcare Improvement and A. Gawandi in his book The Checklist Manifesto. http://gawande.com/the-checklist-manifesto  Checklists have been used in the airline industry since its inception.  Other industries have already demonstrated the benefits of Big Data over a substantial time frame – including finance, transportation, manufacturing, and retail. To be sure, I do not believe that Big Data is a cure-all for what ails medicine, nor do I believe that McKinsey advocated that viewpoint in its study.  However, it is one component on the road to improving a chaotic system.

The eye opening report by the Institute of Medicine on Medical Errors (To Err is Human: Building a Safer Health System, November 1999) http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf

estimated that as many as 98000 people die in hospitals each year as a result of preventable medical errors.  The costs in addition to loss of life are estimated to range from $17 billion to $29 billion each year.  One of the major conclusions from the Institute’s study was that faulty systems, processes, or conditions lead people to make mistakes or fail to prevent them.  The report clearly stated a need to address medicine from a systems perspective to decrease the alarming rate of medical errors.  A number of prominent physicians and healthcare organizations have advocated other approaches to improve the provision of healthcare – including changes to the basic organization of how primary care is dispensed (ACO, PCMH),  http://www.pcpcc.net/guide/better_to_best how hospitals fit into the provision of care, and how information systems can be utilized to improve both safety/quality and productivity /effectiveness.

Due to the impact of healthcare costs on our society and the slow rate of change in the industry, government policy makers have also been forced to take a more active role.  Thomas Lee and James Mongan of Partners HealthCare System in their book Chaos and Organization in Health Care http://mitpress.mit.edu/catalog/item/default.asp?ttype=2&tid=11875 strongly advocate for this role and the importance of improving the healthcare information infrastructure.    In 2009 Congress passed the HITECH Act http://www.pwwemslaw.com/content.aspx?id=540 providing nearly $30 billion to address barrier to health IT adoption, $14.6 billion of which went to encourage adoption of electronic medical records.  Other funds were focused on developing Health Information Exchanges (HIE)  http://searchhealthit.techtarget.com/definition/Health-information-exchange-HIE toward the goal of making patient information available across all care delivery settings.  Bitton, Flier, and Jha (Health Information Technology in the Era of Care Delivery, To What End? JAMA,June 27,2012 – Vol 307,No. 24, P2593)

http://jama.jamanetwork.com/article.aspx?articleid=1199162 argue that the debate over whether health information and technology will save money and improve care is anachronistic.  They state flatly that information technology will be used in health care.  “Health IT is inevitable.  The question now is how best to do it”.

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