April 1st, 2015
Enactment of the Medicare Part D Prescription Drug Program in 2003 led to the creation of the first medication adherence quality improvement goals of truly national import. But one gaping problem remains: the failure of many patients to secure and take medications when they are first prescribed — the “first fill” that never happens.
Recent research confirms that rates of failure to secure a first dose of newly prescribed medications in major chronic disease categories are disturbingly high. Indeed, the failure rates in community-based settings (at community pharmacies, for example) range from 22 to 28 percent. Substantial rates of failure (15 to 26 percent) have even been found among highly integrated health care systems that often feature in-house pharmacies.
And so, just as payment reforms are pushing providers towards accountability for safe and appropriate treatment and good patient outcomes, particularly among the chronically ill, a significant proportion of patients are walking away from their provider’s office with sound, evidence-based orders for new medication therapy … but they never pick up the medicine. Read the rest of this entry »
March 31st, 2015
While all eyes in the health policy community have been fixed on the Supreme Court, awaiting its decision in King v. Burwell regarding the legality of premium tax credits granted through the federally facilitated marketplaces, a case of arguably equal importance has been quietly awaiting a decision. On March 31, 2015, a closely divided Supreme Court decided in Armstrong v. Exceptional Child Center, Inc. that health care providers cannot sue state Medicaid programs in federal court to enforce 42 U. S. C. §1396a(a)(30)(A) which requires states to “assure that payments are consistent with efficiency, economy, and quality of care” while “safeguard[ing] against unnecessary utilization of . . .care and services.”
Justice Scalia’s majority opinion, written for himself, Chief Justice Roberts, and justices Thomas and Alito, would have arguably swept away nearly a half century of Medicaid law and hold that lawsuits could not be brought by providers in federal court to enforce the requirements of the Medicaid program. A dissenting opinion, written by Justice Sotomayor for herself and Justices Kennedy, Kagan, and Ginsburg would have held that providers could have a cause of action under some circumstances to enforce the Medicaid law’s provider payment requirements against the states. Justice Breyer, the deciding vote for the majority, wrote a narrow opinion, joining Justice Scalia’s opinion only in part, leaving the law somewhat unsettled as to rights under the Medicaid program going forward. Read the rest of this entry »
March 31st, 2015
In January, an additional 89 provider organizations joined the Medicare Shared Savings Program (MSSP) as accountable care organizations (ACOs). While this year’s new entrants are a smaller cohort than those that joined in 2013 and 2014, they represent a continuation of the expansion of the accountable care movement.
The recent Department of Health and Human Services (HHS) announcement of its goal to move 50 percent of Medicare payments to alternative payment models (including ACO-based arrangements) indicates the government’s strong backing of the model and, coupled with continuing endorsement of the approach from state Medicaid programs and commercial insurers, there is strong support for this care delivery approach to continue.
In an ACO, health care providers accept responsibility for the cost and quality of care for a defined population. Each ACO’s laudable goal is to achieve what Don Berwick has called the “triple aim” — to improve quality, increase patient satisfaction, and lower costs. The key to reaching those goals is to change how providers are paid, based on reaching certain cost and quality benchmarks. In effect, the objective is to change incentives so that it is in providers’ best interest to maximize health, rather than focus on increasing the volume of services rendered. Read the rest of this entry »
March 30th, 2015
Editor’s note: This post is part of a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on a recent volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.
As our health system faces dramatically rising numbers of people living longer with complex chronic conditions, we have an unprecedented opportunity to mobilize a “quality-of-life” movement promoting patients’ choices and priorities about how they want to live at all stages of illness. Most of the current public policies and discourse about quality of life in health care focuses on the end of life. That tradition may actually impede delivery of person-centered and goal-directed quality care from the onset of illness. It also falls short in supporting shared decision-making, which requires early and continuing identification of what is most important to seriously ill patients and their families, and what they are hoping for as they progress along the continuum of care.
All people want to live healthy and disease-free lives for as long as possible. When serious illness does strike, patients and families want to achieve, cure, or keep disease progression in check. In addition, they place a high premium on maintaining good functioning and quality of life for as long as possible so they can continue to pursue life goals and enjoy what matters most to them. They want coordination and connection, including clear communication and quality time with their health care team to help them understand treatment options and the implications of those treatments in terms of survival, functioning, and quality of life. In addition, they want support to make informed decisions during and after treatment that align with their personal preferences and goals. Read the rest of this entry »
March 27th, 2015
This past January 20th, the Department of Health And Human Services established national Medicare pay-for-value goals. By 2016, the Department intends to tie 30 percent of Medicare payments, and by 2018 50 percent of payments, to quality or value through alternative payment models. Medicare Accountable Care Organizations (ACOs) are expected to make a significant contribution toward meeting these goals. With current ACOs accounting for 7.8 million beneficiaries and 15 percent of Medicare spending, it will be essential for the current 405 ACOs to stay in the Medicare Shared Savings Program (MSSP) through 2016, and for a substantial number of new ACOs to join the program.
However, common concerns about the MSSP became apparent a year ago when stakeholders submitted comment letters in response to the Centers for Medicare and Medicaid Services’ “Evolution of ACO Initiatives at CMS” RFI (Request for Information). These concerns were reinforced last July after CMS announced proposed changes to ACO quality measure set and quality performance benchmarking, and again in November when the National Association of ACOs reported survey data showing nearly two-thirds of member ACOs would leave the program unless substantial improvements were made.
Recognizing these concerns, this past December CMS published a proposed rule offering many possible improvements to the Shared Savings Program. Public comments were due February 6th. CMS now has the opportunity to use stakeholder input to redesign the program in a way that will allow ACO providers to drive payment and delivery reform and thereby enable DHHS to meet its newly established pay-for-value goals. Read the rest of this entry »
March 26th, 2015
For years now it has become apparent that the Sustainable Growth Rate (SGR) system is not sustainable. However, fixing the SGR will require increases in budgeted costs, and so one of the major barriers to replacing the SGR is figuring out how to pay for the fix. Towards this end, it is important to understand the appropriate cost-comparison.
Federal scorekeepers (appropriately) assess the cost of the SGR fix relative to current law, which assumes that fees will follow a trajectory defined by current policy. But as near as I can tell, few advocate for that path or believe it will occur; rather the current system will continue to require regular “patches.” Therefore, the appropriate measure of the cost of the doc fix is spending with the fix relative to spending without it. The latter includes the costs of future “patches” necessary to ensure continued operation (as well as any savings that can be achieved because of continued SGR related negotiations). Substituting this realistic alternative into the cost calculus likely substantially lowers the incremental cost of any SGR fix. Read the rest of this entry »
March 26th, 2015
Editor’s note: This post is part of a series stemming from the Third Annual Health Law Year in P/Review event held at Harvard Law School on Friday, January 30, 2015. The conference brought together leading experts to review major developments in health law over the previous year, and preview what is to come. A full agenda and links to video recordings of the panels are here.
The relationship between medicine and capital punishment has been a persistent feature of this past year in health law, both at the level of medical ethics and Supreme Court review.
Our story starts in Oklahoma, where the execution of Clayton Lockett was botched on April 28, 2014. National Institutes of Health (NIH) bioethicist Seema Shah described the events in question: Read the rest of this entry »
March 25th, 2015
Six years ago, President Obama signed into law the HITECH Act, which spelled out a path to a nationwide health information technology infrastructure. The goal was simple: every doctor, nurse, and hospital in America should use electronic health records — and do it in a way that leads to better care delivered more efficiently. The Act provided $30 billion in incentives for providers and hospitals who met the criteria for “Meaningful Use”, which the Obama administration was given the authority to define. The rules were set up to be rolled out in three stages, and while the first two stages have been out for a while, the criteria for the third and final stage of Meaningful Use (MU) were finally released on March 20.
David Blumenthal, the first national coordinator under HITECH, used the analogy of the Meaningful Use program as an escalator — with the first stage focused on just getting people on board and each stage requiring a higher level of use — which would focus on demonstrating better care through advanced EHR use. Put more simply, the goal of the three stages was to first get providers to just start using EHRs, and then over time to get them to use the systems more frequently, more robustly, and ultimately, in ways that lead to better, more efficient care.
The new stage 3 rule reflects both the successes and the failures of the first two stages. It moves toward making the EHR market more open and competitive, and providing more choices, in ways that I think are helpful — but possibly not helpful enough. Read the rest of this entry »
March 25th, 2015
The findings from a recent synthesis of the literature about the effectiveness of prevention initiatives focused on reducing the risk of Type 2 diabetes among high-risk populations (people already obese or inactive or diagnosed as having prediabetes) are largely encouraging.
The synthesis includes a comprehensive and systematic review of the medical, diabetes, and public health literature for evaluation studies of interventions published between 2002 and 2013. The search was undertaken using medical subject headings and keywords related to diabetes and its risk factors.
A number of interventions—such as the National Institutes for Health’s Diabetes Prevention Program and the Group Lifestyle Balance Program—focused on helping people eat better and become more physically active are effective in reducing the risk of diabetes onset. Robust studies show that these interventions work even better than medication to prevent diabetes. Read the rest of this entry »
March 24th, 2015
Anticipating the upcoming Supreme Court decision on King v. Burwell, which could halt health insurance subsidies available through the federal exchange, Republican Senators Richard Burr and Orrin Hatch joined with Representative Fred Upton to propose a comprehensive replacement for the Affordable Care Act (ACA). The Patient Choice, Affordability, Responsibility, and Empowerment Act, or Patient CARE Act, is modeled on a proposal of the same name offered last year by Senators Burr, Hatch, and Tom Coburn, who has retired from the Senate. The Burr-Hatch-Upton plan, like its predecessor, adopts consumer-based reforms of the insurance market, modernizes the Medicaid program, and makes other changes intended to lower cost and increase choices.
In an earlier post, we described in detail the provisions of the Burr-Coburn-Hatch bill. In this post, we discuss how the Burr-Hatch-Upton plan differs from the earlier proposal. We also discuss the impact of the new proposal on health insurance coverage, premiums, and the federal budget based on a new analysis from the Center for Health and Economy (H&E), a non-partisan think tank focused on producing informative analyses of trends in U.S. health care policy and reform ideas. We conclude by commenting on the direction Republicans are likely to take in reforming the health system in the aftermath of a Supreme Court decision in the King v. Burwell case. Read the rest of this entry »