From The Staff

Health Affairs Forum: Graduate Medical Education Governance And Financing


August 29th, 2014

Please join us on Wednesday, September 10, for a Health Affairs forum to discuss, Graduate Medical Education That Meets the Nation’s Health Needs, a recent report from the Institute of Medicine (IOM) Committee on the Governance and Financing of Graduate Medical Education (GME). Health Affairs Founding Editor John Iglehart will host the event.

For the past two years, the committee – co-chaired by former CMS and HCFA administrators Donald Berwick and Gail Wilensky – conducted an independent review of the governing and financing of the GME system, and the report is a roadmap for policymakers for repairing and improving its deficiencies. The Health Affairs forum is one of the first opportunities interested parties will have to gather in a public setting to discuss and debate the committee’s proposals.

WHEN
Wednesday, September 10, 2014
9:00 a.m. – 12:00 p.m.

WHERE
National Press Club
529 14th Street NW
Washington, DC, 13th Floor

REGISTER NOW

Follow Live Tweets from the briefing @Health_Affairs, and join in the conversation with #HA_GME. Read the rest of this entry »

Exhibit Of The Month: Income-Related Disparities Associated With Negative Health Outcomes


August 29th, 2014

Editor’s note: This post is part of an ongoing “Exhibit of the Month” series. Readers who’d like to highlight other noteworthy exhibits from the same issue are encouraged to make their pitch in the comments section below.

Much is known about income-related disparities when it comes to preventative care and chronic conditions, but less so about the associations between poverty and negative health outcomes.

In “Geographic Clustering Of Diabetic Lower-Extremity Amputations In Low-Income Regions Of California,” published in the August issue of Health Affairs, authors Carl Stevens et al. identify diabetic amputation “hot spots” in low-income urban and rural areas of California (Exhibit 2).

Based on California data from 2009, they isolated 7,973 lower-extremity amputations in 6,828 adults with diabetes. They compare this to a corresponding map of poverty rates in the same region based on households who reported incomes below 200 percent of the poverty level (Exhibit 3). Read the rest of this entry »

Health Policy Brief: The Relative Contribution Of Multiple Determinants To Health Outcomes


August 22nd, 2014

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) examines factors that can contribute to health status. In the United States, less than 9 percent of health expenditures go to disease prevention, and there is little support for social services, such as programs for older adults, housing, and employment programs.

This brief focuses on “multiple determinant” studies that seek to quantify the relative influence of some of these factors on health. It is part of a larger project, supported by the Robert Wood Johnson Foundation, which aims to create a structure for conducting analyses that demonstrate the value of investments in nonclinical primary prevention and their impact on health care costs.

Read the rest of this entry »

Health Affairs Briefing: Advancing Global Health Policy


August 22nd, 2014

Please join us on Monday, September 8, when Health Affairs Editor-in-Chief Alan Weil will host a briefing to discuss our September 2014 thematic issue, “Advancing Global Health Policy.”  In an expansion of last year’s theme, “The ‘Triple Aim’ Goes Global,” we explore how developing and industrialized countries around the world are confronting challenges and learning from each other on three aims: cost, quality, and population health.

A highlight of the event will be a discussion of international health policy—led by Weil—featuring former CMS and FDA administrator and current Brookings Institution Senior Fellow Mark McClellan and Lord Ara Darzi, surgeon, scholar, and former UK Health Minister. Additional panels will look at how countries are transforming chronic care, lowering costs, and redesigning delivery systems.

WHEN: 
Monday, September 8, 2014
9:00 a.m. – 12:30 p.m.

WHERE: 
National Press Club
529 14th Street NW
Washington, DC, 13th Floor

REGISTER NOW!

Follow Live Tweets from the briefing @HA_Events, and join in the conversation with #HA_GlobalHealth. Read the rest of this entry »

The Latest Health Wonk Review


August 15th, 2014

At Wright on Health, Brad Wright offers some health policy insight in his August recess edition of the Health Wonk Review. Brad highlights the Health Affairs Blog post by Jon Kingsdale and Julia Lerche on the “one-two punch” threatening the ACA’s second open enrollment period, as well as a variety of other great posts.  Read the rest of this entry »

Health Affairs Web First: Small Medical Practices Had Fewer Preventable Hospital Admissions


August 14th, 2014

The Affordable Care Act and other federal policy initiatives have created incentives for smaller practices to consolidate into larger medical groups or be acquired by hospitals. It is often assumed that larger practices provide better care. However, a new study, recently released as a Web First by Health Affairs, showed unexpected results: Practices with 1-2 physicians had 33 percent fewer preventable hospital admissions than practices with 10-19 physicians.

This study, which used data from the National Study of Small and Medium-Sized Physician Practices (NSSMPP) and surveyed 1,745 physician practices between July 2007 and March 2009, is believed to be the first of its kind in the United States. The study sample was limited to practices where at least 60 percent of the physicians were primary care providers, cardiologists, endocrinologists, and pulmonologists. Read the rest of this entry »

New Health Policy Brief: Interoperability


August 13th, 2014

A new Health Policy Brief from Health Affairs and the Robert Wood Johnson Foundation (RWJF) looks at the issue of health information exchange. The Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law at the very beginning of the Obama administration, bringing with it significant investments in health information technology (IT)—$26 billion to date.

While the adoption of electronic health records (EHRs) has increased considerably since 2009, there is very little electronic information sharing among clinicians, hospitals, and other providers. New models of care delivery, designed to improve quality and reduce costs, require both interoperable EHRs and electronic information sharing to be effective. This Health Policy Brief looks at the efforts the federal government has made to improve interoperability and increase the level of electronic information sharing, as well as the barriers to achieving these goals.

Topics covered in this brief include: Read the rest of this entry »

Health Affairs Web Firsts: Two Studies Find Mixed Results On EHR Adoption


August 11th, 2014

Since the Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted in 2009, Health Affairs has published many articles about the promise of health information technology and the challenges of promoting broad adoption and “meaningful use.”

Last week, on August 7, the journal released two new Web First studies, “More Than Half Of US Hospitals Have At Least A Basic EHR, But Stage 2 Criteria Remain Challenging For Most” and “Despite Substantial Progress In EHR Adoption, Health Information Exchange And Patient Engagement Remain Low In Office Settings.” These studies focus on the latest trends in health information technology adoption among U.S. physicians and hospitals. Both studies, which will also appear in the September issue of Health Affairs, show that while basic electronic health record (EHR) adoption plans have moved forward, more significant implementation remains a daunting challenge for many providers and institutions. Read the rest of this entry »

Narrative Matters: How Acute Care Training Is Failing Patients With Chronic Disease


August 8th, 2014

In the August Health Affairs Narrative Matters essay, a doctor questions how well acute care medical training serves those with chronic disease while watching the decline of two patients with kidney failure, one healthier and one frail. Dena Rifkin’s article is freely available to all readers, or you can listen to the podcast. Read the rest of this entry »

Posts On ACA Legal Challenges Lead Health Affairs Blog July Top Ten


August 7th, 2014

Two posts regarding legal challenges to the Affordable Care Act were the most-read Health Affairs Blog posts in July. In the top spot: Tim Jost’s discussion of Supreme Court actions that were arguably at odds with the Court’s Hobby Lobby decision. Next on the list: another post by Jost analyzing two federal appellate court decisions taking conflicting positions on whether consumers may receive premium tax credits under the ACA in states using the federally facilitated exchange.

Number three on the July top-ten list is Suzanne Delbanco’s post on bundled payment, part of her ongoing series on payment reform; Jennifer DeCubellis and Leon Evans’ post on investing in care coordination is next.

The full list is below: Read the rest of this entry »

Contributing Voices

Implementing Health Reform: Tax Form Instructions


August 29th, 2014

On August 28, 2014, the Internal Revenue Service re-released the draft forms that will be used by employer, insurers, and exchanges for reporting Affordable Care Act tax information to individuals and to the IRS for 2014 and 2015, as well as the instructions for completing those forms.  The IRS also released in the Federal Register requests for public comments on three of those forms – the 1094-Bthe 1094-C, and the 1095-C – under the Paperwork Reduction Act.  This post reports on these forms and instructions and on a guidance released by the Centers for Medicare and Medicaid Services.

The tax forms had been published earlier and are described in an earlier post.  The instructions for the forms, however, had not been available and had been eagerly awaited by employers, insurers, exchanges, and tax professionals. Forms 1094-C and 1095-C will be used by large employers with more than 50 full-time or full-time-equivalent employees to determine whether the employer is responsible for penalties under the employer shared responsibility requirements of the ACA.  They will also be used to determine whether employees have received an affordable and adequate offer of coverage, rendering them ineligible for premium tax credits.  Employers are required to provide each full-time employee with a form 1095-C and to file each of these together with a transmittal form 1095-B form with the IRS.

The instructions for the 1094-C and 1095-C are by far the most complex of the instructions released on August 28, filling 13 pages with dense, two column, print.  Most of the complexity derives from the options for complying with the employer mandate and the transition exceptions to that mandate that the administration has created.  These alternatives and exceptions were explored in my posts on the employer mandate final rule when it was issued in February, 2014.  These forms are also complicated by the fact that the IRS decided to allow self-insured large employers to file only the large employer 1094-C and 1095-C, rather than requiring them to also fill out the 1094-B and 1095-B forms, which are filed by other entities that provide minimum essential coverage.  Because the employer mandate has been delayed, large employers are not required to file these forms for 2014, although they may do so voluntarily. Read the rest of this entry »

Collaboration, Consistency, and Community Spirit: How Durham Advances Health


August 28th, 2014

Editor’s note: This post is part of an ongoing series written for Health Affairs Blog by local leaders from communities honored with the annual Robert Wood Johnson Foundation Culture of Health Prize. In 2014, six winning communities were selected by RWJF from more than 250 applicants and celebrated for placing a priority on health and creating powerful partnerships to drive change. Interested communities are encouraged to apply for the 2015 RWJF Culture of Health Prize. Applications are due September 17, 2014.

Durham, North Carolina is so richly endowed with health care resources that it is known as “the City of Medicine;” it is home to 95 percent of the companies that comprise the Research Triangle. Yet, while many of the county’s 288,133 residents are thriving, others are not nearly as healthy.

A 2004 community health assessment revealed that in Durham’s very diverse population — currently, 38.7 percent black, 42.1 percent white, and 13.5 percent Hispanic — there were high rates of cardiovascular disease and other chronic conditions, HIV and other sexually transmitted diseases, and infant mortality.

A 2007 evaluation also showed that 29 percent of the county’s adults were obese. The rate was 42 percent among African Americans. In the same report, 49 percent of adults said their health prevented them from participating in even moderate physical activities. Among children entering kindergarten in 2009, 18 percent were overweight or obese. Read the rest of this entry »

The Winding Path To Effective Bundled Payment


August 28th, 2014

Tom Williams and Jill Yegian’s excellent blog post makes a great companion to our recent paper on the evaluation of the Integrated Healthcare Association (IHA) Bundled Payment Demonstration. Williams and Yegian offer lessons from their experience implementing a demonstration project that failed to meet its original objectives. This type of analysis is essential.

It’s not unusual for a demonstration to fall short of its original objectives. Learning from such cases is part of the innovation process. This is especially worthwhile for bundled payment, which has many potential benefits for patients, providers, and payers.

None of the barriers encountered in IHA’s demonstration signal a “death sentence” for bundled payment. However, the demonstration clearly shows that bundled payment is difficult to implement. Read the rest of this entry »

State-Based Marketplaces: Leveraging Year-One Lessons To Boost Year-Two Enrollment


August 27th, 2014

In three months, consumers will log onto their state’s health insurance marketplace to investigate their options and enroll in a plan. Already, states are hard at work prepping for the second year of open enrollment, which begins November 15. State marketplaces are expected to increase the number of enrollees this year and adopting lessons from 2013-2014 can help.

A User-Friendly Marketplace

First and foremost, states need a user-friendly marketplace that functions properly and allows consumers, brokers, insurers and navigators to seek and provide information that is timely and credible. States know this, but recently, interviews with 100 staff from five successful state-based marketplaces (SBMs) unearthed several less obvious lessons.

To begin, states should move from last year’s ‘shotgun’ marketing that helped build awareness to a more targeted approach to outreach this year. In addition to some mass marketing to maintain awareness, states should target advertising dollars to high-priority segments and focus on less expensive tools, like direct mailing campaigns and walk-up enrollment centers, which proved to be most effective last year. Read the rest of this entry »

Rescue Me: The Challenge Of Compassionate Use In The Social Media Era


August 27th, 2014

The Development of Brincidofovir And Its Possible Use To Treat Josh Hardy

Last March 4, seven-year old Josh Hardy lay critically ill in the intensive care unit at St Jude Children’s Hospital in Memphis, Tennessee with a life-threatening adenovirus infection. His weakened immune system was unable to control the infection, a complication of a bone marrow stem cell transplant he needed as a result of treatments for several different cancers since he was 9 months old.

His physicians tried to treat the adenovirus with an anti-viral agent, Vistide (IV cidofovir), but had to stop due to dialysis-dependent renal failure. They were aware of another anti-viral in Phase 3 clinical development, brincidofovir, an oral compound chemically related to Vistide. In earlier clinical testing brincidofovir had shown the potential for enhanced antiviral potency and a more favorable safety profile.

Chimerix (where one of us, Moch, was CEO), a 55 person North Carolina-based biopharmaceutical company, had previously made brincidofovir available to more than 430 critically ill patients in an expanded access program for the treatment of serious or life-threatening DNA viral infections, including adenovirus as well as herpes viruses (such as cytomegalovirus) and polyomaviruses.  This program started in 2009 as a series of individual physician-sponsored emergency INDs — investigational new drug exemptions issued in physician-certified compassionate use situations.

The program evolved via word of mouth to the extent that brincidofovir was made available under emergency INDs for more than 215 patients. During 2011, Chimerix received funding from Health and Human Service’s Biomedical Advanced Research and Development Authority (BARDA) to provide brincidofovir to an additional 215 critically ill patients for the purpose of gaining insights into the potential use of brincidofovir as a medical countermeasure against smallpox. (Department of Health and Human Services Contract No. HHSO100201100013C.  For further information on brincidofovir Study CMX001-350, see ClinicalTrials.gov Identifier NCT01143181.)

When BARDA funding ended in 2012, Chimerix stopped accepting new requests for compassionate use under its expanded access program. Although requests continued from physicians around the world, the company decided that it was in the best interests of the greatest number of patients to devote its limited human and financial resources to the clinical development pathway necessary for FDA approval of brincidofovir.

This post examines the implications of the ultimately successful campaign waged by Josh Hardy’s family to obtain access to brincidofovir for their son. We discuss several issues raised by the Hardy case, including the overarching question of whether it is fair for social media or influence of any form to play a role in determining which patients get access to experimental treatments; whether rescuing individual patients in need can be reconciled with an evidence-based regulatory approval process for new therapies; and whether there is a duty to “rescue” terminally ill patients by paying for access to experimental therapies.

Finally, we propose a new framework for regulating access to experimental treatments. Read the rest of this entry »

The 125 Percent Solution: Fixing Variations In Health Care Prices


August 26th, 2014

Summer vacation’s finally here. You’re strolling along the beach, not a care in the world when – ouch – you step on a piece of broken glass and need a few stitches at the local hospital. Such routine procedures are painless enough, but depending on where you’re treated and by whom, the real pain could occur when you’re handed the ER bill.

In some of the latest evidence on the crazy-quilt patterns of U.S. health care prices, Castlight Health found prices in Dallas TX ranging from $15 to $343 for the same cholesterol test.  What makes these price variations particularly egregious is that the highest prices are typically reserved for those least able to pay, such as the uninsured.

What’s the solution?  In the long run, we need to establish a more transparent system where consumers can choose easily based on reliable quality and price measures.  But our current measures of quality are, to put it politely, inadequate, and people with insurance are often insulated or can generally afford those higher prices.  Reference pricing, in which insurance pays only enough to reimburse providers with adequate quality and relatively lower costs, would help to restrain high prices, but distracted patients or those with strong attachments to specific doctors or hospitals could still get stung with a big bill.

Capping Payments At 125 percent Of Medicare Rates

We suggest a short-term solution: The federal Medicare program has in place a complete system of prices for every procedure and treatment.  It’s not perfect, but it is uniform across regions, with a cost-of-living adjustment that pays more in expensive cities and less in rural areas.  If every patient and every insurance company always had the option of paying 125 percent of the Medicare price for any service, we would effectively cap the worst of the price spikes.  No longer would the tourist checked out at the ER for heat stroke be clobbered with a sky-high bill.  Nor would the uninsured single mother be charged 10 times the best price for her child’s asthma care.  This is not just another government regulation, but instead a protection plan that shields consumers from excessive market power. Read the rest of this entry »

Arkansas Payment Improvement Initiative: The First Year


August 25th, 2014

Editor’s note: This post is part of a periodic Health Affairs Blog series, which will run over the next year, looking at payment and delivery reforms in Arkansas and Oregon. The posts will be based on evaluations of these reforms performed with the support of the Robert Wood Johnson Foundation. The authors of this post are part of the team evaluating the Arkansas model.

Arkansas payers and providers actively participated in the design of both the episodic payment and patient-centered medical home (PCMH) models the state has recently implemented. We’ve written about each of these components of the multi-payer Arkansas Payment Improvement Initiative (APII) in our previous Health Affairs Blog posts.

The state’s fragmented and largely rural provider environment presents an important test for a novel episodic payment model that may, if successful, have broader applicability in other states sharing a similar health care landscape. Fourteen episodes have now been launched and provider participation is mandatory. While our first posting goes into greater detail on the nuances of Arkansas’ approach to episodes, we provide the following brief summary here to add context to this discussion. Read the rest of this entry »

Partnership And Progress On The Path To Achieving Millennium Development Goal 6


August 25th, 2014

Editor’s note: For more on global health, stay tuned for the upcoming September issue of Health Affairs.

In 2000, nearly 200 world leaders came together and agreed on a set of objectives intended to tackle some of the most pressing development challenges of our time, such as poverty, AIDS, and child mortality. With a target date of December 31, 2015, the Millennium Development Goals (MDGs) provided a clear path for progress and a platform for immediate action. Last week, on August 18, we reached a milestone on that path – as of that date, 500 days remained to achieve these eight goals. So where do we stand, and what more must be done?

Combatting HIV/AIDS, Malaria, and Other Diseases

For those of us focused acutely on MDG number 6—combatting HIV/AIDS, malaria, and other diseases—the recent Millennium Development Goals Report had encouraging news. An estimated 3.3 million deaths from malaria were averted between 2000 and 2012 due to the expansion of malaria interventions, and efforts to fight tuberculosis have saved an estimated 22 million lives since 1995. Read the rest of this entry »

Implementing Health Reform: New Accommodations For Employers On Contraceptive Coverage


August 22nd, 2014

On August 22, 2014, the Departments of Health and Human Services, Labor, and Treasury released an interim final  and a proposed  rule providing for the accommodation of religious objections on the part of an employer or institution of higher learning to providing their employees or students coverage for contraceptive services.  A fact sheet on the rules was also released,   as was a notice on the revision of the form used to collect information on religious objections to contraceptive coverage.

The proposed rule, which applies to for-profit entities, is being issued in response to the Supreme Court’s decision in Burwell v. Hobby Lobby, which ruled that closely-held for-profit corporations may refuse to cover contraceptives for religious reasons.  The interim final rule responds to the Court’s interim order in Wheaton College v. Burwell  (and to 31 lower court injunctions) that released religious non-profit organizations from accommodations earlier proposed by HHS. Read the rest of this entry »

The “Failure” Of Bundled Payment: The Importance Of Consumer Incentives


August 21st, 2014

Bundled payment for orthopedic and spine surgery and other major acute interventions has many attractive features, in principle. But implementation has been difficult in practice.  The recent Health Affairs paper by Susan Ridgley and colleagues, and the Health Affairs Blog commentary by Tom Williams and Jill Yegian, list quite a few practical implementation problems, and the points raised in both these pieces are well taken.

As leaders in the Integrated Health Association (IHA) bundled payment initiative, we shared the same hopes, devoted the same energies, and share the same frustrations with the modest results.  We feel it is important to emphasize what we consider to be the initiative’s most important design failure: the lack of engagement and alignment on the part of the consumer.  No one will ever reform the U.S. health care system without bringing the consumer along and, indeed, placing consumer choice and accountability at the very center of the reform initiative.

On an optimistic note, this design failure is being addressed by the larger health care marketplace in the wake of numerous failed attempts to reform health care by focusing exclusively on provider payment and incentives. Read the rest of this entry »

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