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The foggy future of ACA implementation

Ken Bottles, M.D., a lecturer at the Thomas Jefferson University School of Population Health, in Philadelphia,  and chief medical officer of PYA Analytics, made these predictions to FierceHealthcare:

  • “Congress will not revisit the repeal and replacement of the Affordable Care Act before the end of the year. It is simply dealing with far too many other issues—passing a budget, raising the debt ceiling, approving disaster aid for Harvey and Irma, not to mention its desire for tax reform—that lawmakers must address.
  • “While the Senate HELP committee is attempting a bipartisan effort to shore up the ACA, the issues listed above will make it almost impossible for such a law to be passed during this session.
  • “The leadership of the Department of Health and Human Services ideologically opposes the very concept of the ACA and is also responsible for implementing the law. The tension between those two facts will lead to confusion and uncertainty for those of us in healthcare.
  • “The passage of the ACA changed the terms of debate around healthcare reform. Granting health insurance to more than 20 million Americans has now shifted public opinion so that a solid majority believes the federal government should ensure that its citizens have insurance.
  • “The ACA is not failing, but going forward it can be undermined without congressional action.”

To read more,  please hit this link.


Population-health programs vs. hospitals


Eric Hunter, CEO of safety-net health plan CareOregon, said that if its population-health efforts were as successful as he’d like, hospitals would significantly cut back on their services.

“I tell hospitals, and they hate when I tell them this, ‘In my perfect world, I would never need you,’” Mr. Hunter told panelists at a Politico event. “My goal is to put you out of business. If we can do the right thing, all you’ll have is an ER for when somebody gets in a car wreck.”

But many  providers won’t have  access to strong community health programs such as CareOregon’s.

Karen DeSalvo, M.D., former national coordinator for health information technology at the the Department of Health and Human Services, pressed for culture changes that include breaking down data silos that block providers from seeing the full picture of a patient’s, or a  community’s, health.

Dr. DeSalvo said: “It means that we really have to rethink how we look at health.”

To see the Politico event, please hit this link.


Selection of HHS chief signals massive effort to change federal role in healthcare



For Kaiser Health News

President-elect Donald Trump’s selection of  Georgia Congressman Tom Price, M.D., to head the Department of Health and Human Services signals that the new administration is all-in on both efforts to repeal the Affordable Care Act and restructure Medicare and Medicaid.

Price, a Georgia Republican who currently chairs the House Budget Committee and a retired orthopedic surgeon, was among the first to suggest that not just the ACA but also Medicare are on the near-term agenda for newly empowered Republicans.

Privatizing the Medicare program for seniors and disabled people and turning the Medicaid program for the poor back to the states are long-time goals for Republicans in Congress and the White House. They say that the moves could help put the brakes on health spending. Opponents argue, however, that both changes are aimed instead at shifting the financial burden of healthcare from the federal budget to states and individuals.

That question — should the federal government continue to provide open-ended health benefits? — could prove to be a key battle line.

Democrats and consumer advocates say the changes would break a promise to guarantee health services made when Medicare and Medicaid were enacted, in 1965.

“That is the explicit intent of these proposals, to cap liability and shift costs,” said Edwin Park of the left-leaning think tank the Center on Budget and Policy Priorities.

Len Nichols of George Mason University agreed: “It’s about fixing the growth rate so they can be certain of a lower federal commitment to healthcare.”

Republicans, however, say in the face of rising federal deficits, it would be irresponsible not to rein in the programs’ spending.

“We have a moral obligation to the country to do this,” House Speaker Paul Ryan told the New York Times in 2011, when he first proposed the plans as chairman of the House Budget Committee.

Medicare, which covers roughly 57 million elderly and disabled Americans, and Medicaid, which covers more than 77 million people with low incomes, are among the biggest items in the federal budget, together costing an estimated $1 trillion in 2016, according to the Congressional Budget Office.

And, more importantly, both programs are expected to keep growing, consuming ever more of the budget. According to the CBO, over the next 30 years, the percentage of federal spending claimed by the major federal health programs (primarily Medicare and Medicaid) is expected to rise from just over 6 percent to more than 10 percent.

“By reforming these programs in the future, we can preserve them for the present,” said Ryan in another 2011 interview.

Both GOP proposals for the major medical entitlement programs date back decades.

Proposals to replace the open-ended Medicaid program, in which the federal government matches whatever states spend, with a block grant that would limit the federal government’s financial responsibility first surfaced in the early 1980s, during the Reagan administration. When Republicans took over Congress in 1994, the idea reemerged, was passed and sent to President Bill Clinton, who vetoed it. President George W. Bush revived the idea again in 2003, but he could not get Congress to act on it.

The latest version of the proposal offered by House Republicans would give states the option of modifying the plan so that the federal payments to states would be based on a per capita funding formula.

A number of Republican governors have supported the idea, because the program would generally relieve states from rules governing who and what to cover in Medicaid in exchange for accepting limited funding.

But advocates for the poor say it would lead to fewer people getting fewer services. Because the federal contribution proposed by Ryan is specifically set to increase more slowly than predicted inflation in health care, “states could either contribute much more to their Medicaid programs, or, more likely, use that flexibility to make deep cuts to the program,” said Park.

A 2012 estimate from the Urban Institute said that year’s proposal could result in 17 million people losing coverage, and payments to healthcare providers could be cut by nearly a third.

Thomas Miller of the conservative American Enterprise Institute says more recent proposals have gotten less draconian. “It’s gotten a little better because as opposed to a big block grant, it’s gone to the per capita allotments” that would be based on the number of people enrolled in the program.

Park of the CBPP said that would be better than simply giving states a single pot of money. With a per-capita cap, the federal contribution would rise as more people are added to the program. But the cuts would still be deep, he said, because “you’re achieving similar savings by slashing spending per beneficiary.”

In Medicare, the concept of “premium support,” which would give enrollees a set amount of money to spend on the health plan of their choice, emerged in the mid-1990s. The original proposal was geared to using competition to slow the growth of Medicare spending.

But later iterations of the Medicare proposal would increase contributions intended to pay for insurance more slowly than the expected rate of health inflation. That means that instead of covering the government’s share of a set package of benefits, what is currently referred to as Medicare’s defined benefit, the program would instead pay a specific amount, often referred to as a defined contribution, that might not be able to pay for those benefits.

“Right now, the federal government says you pay [a set share] of those costs” through Medicare premiums, deductibles and co-pays and beneficiaries get government funding to cover guaranteed benefits in return, said Park. “Under premium support there would no longer be that guarantee and there would no longer be a defined set of benefits.”

Miller of AEI said any effort to push these GOP plans for Medicare and Medicaid will run into stiff headwinds — even in a Republican-controlled Congress — because it’s difficult to take something away from people.

Congress can’t simply cut the programs, he said. “You have to tell people why you’re doing this. You have to say this is actually going to improve the healthcare system.”

Deconstructing the healthcare part of Obama’s budget plan



Electron microscope view of the Zika virus.

In HealthAffairs, Timothy Jost looks at  the healthcare elements of President Obama’s proposed budget for 2017, which includes “new initiatives to increase access to mental-health care, expand opioid-abuse treatment, fight antibiotic resistance, address the Zika virus threat and fund a ‘cancer moonshot.”’

He writes: “To control Medicare spending, the budget proposal would reduce the target growth rate for Medicare enforced by the Independent Payment Advisory Board  {IPAB} to 0.5 percentage points above per-capita GDP growth. It also contains a host of Medicare payment and delivery reform proposals.”

Regarding private insurance, one proposal “would attempt to curb surprise balance bills by out-of-network providers by requiring hospitals to take steps to match patients with in-network providers and requiring physicians who regularly provide services in a hospital to accept an appropriate in-network rate as payment in full.

“Another proposal would allow HHS {Department of Health and Human Services} to develop uniform definitions and principles for standardizing medical billing and making it more transparent. Self-insured non-federal governmental plans would be prohibited from opting out of various federal consumer protection laws, such as the Mental Health Parity Law.”

Mr. Jost notes that “{T} budget request of a president in his final year of office ….is unlikely to lead to enacted legislation. Congress in unlikely to expand the authority of the IPAB or increase funding for the Medicaid expansions. But many of the expenditures identified in the budget—for the risk adjustment, reinsurance, premium tax credit, and (subject to the court decision in House v. Burwell) cost-sharing reduction payment programs—are mandated by law and are unlikely to be changed by Congress.”


States can’t keep up with telemedicine rush


Governing magazine looks at  how some states are dealing with the telemedicine revolution.

“Despite the momentum, there are still plenty of gaps and question marks when it comes to telehealth policy. The 21 states without a parity {on provider reimbursement} law aren’t uniformly liberal or conservative. Kansas, South Carolina and Utah don’t have one, but neither do Illinois or Pennsylvania. Massachusetts, a state known for progressive healthcare policies, doesn’t have a parity law. It currently only covers telemedicine under Medicaid with certain managed care plans, and not for fee-for-service payments.

“Even among states that do have parity laws, the patchwork of policies can vary widely from one state to the next. Texas, for example, requires insurers to cover telehealth, but it mandates that a patient’s first appointment with a new doctor must be an in-person visit. Within Medicaid programs, about half of the states require that a patient be in a medical facility for telehealth appointments, rather than at home. The differences among states can be frustrating for telemedicine providers. Kofi Jones, vice president of public relations and government affairs for the telehealth company American Well, says she has 30 binders in her office filled with state-by-state regulations and legislation. …”

“Traditional health-care providers can be slow to integrate new technology. After all, almost half of doctor’s offices polled in 2013 still used paper records, according to a survey from the U.S. Department of Health and Human Services. Other recent surveys have found that only 2 percent of patients nationwide have access to video visits with their primary care physician. Less than half — 45 percent — even receive a traditional phone appointment reminder.”


Details on $500 million to go to health centers


The U.S. Department of Health and Human Services  is distributing nearly $500 million in Affordable Care Act funding to support  community health centers nationwide in providing primary-care services to  low-income and other disadvantaged patients

The awards include about $350 million for 1,184 health centers to increase access to such services  as medical, oral, behavioral, pharmacy and vision care. Nearly $150 million will be awarded to 160 health centers for facility renovation, expansion, or construction to increase patient or service capacity.

More details, including a list of recipients, can be found at this link.

Happier days at FQHCs


The big increase in support for Federally Qualified Health Centers (FQHCs), which have received considerable bipartisan support over the years, has brought big smiles to FQHC leaders and patients who had feared that congressional gridlock would jeopardize the whole program.

The health centers have become the largest single primary-care system in the United States.

The Department of Health and Human Services will  distribute $169 million provided by the Affordable Care Act to open 266 new health centers in 46 states, the District of Columbia and Puerto Rico. That’s in addition to 700 new health centers opened  because of the Affordable Care Act.

The program seems safe at least through fiscal 2017 and probably indefinitely beyond.

What went wrong in Medicare savings project

By JAY HANCOCK, for Kaiser Health News

A $57 million experiment to deliver better, more efficient care at federally funded health centers struggled to meet its goals and is unlikely to save money, says a new government report.

The test to coordinate treatment for high-risk Medicare patients in hundreds of communities was one of many demonstrations run by the Department of Health and Human Services’ innovation center.

The Affordable Care Act created the lab and gave it $10 billion over a decade to test new ways to improve care and save money.

As the trial wound down last fall, 69 percent of the clinics that hadn’t dropped out had obtained full accreditation as “medical homes” — primary-care practices that coordinate care across the maze of specialists, hospitals and emergency rooms.

HHS had hoped for 90 percent.

Another goal was to cut unnecessary hospital visits. But admissions and emergency-room care rose in centers that were part of the experiment compared with results in those that weren’t. So did expenses.

“It appears that the demonstration will not achieve cost savings,” concluded the RAND Corp., an independent research group, in a study commissioned by HHS’ Centers for Medicare and Medicaid Services, or CMS. HHS recently posted the report on its website.

There had been talk of extending the three-year demonstration. But the health law requires HHS to stop experiments that don’t show signs of saving money or improving care. The program ended in October.

“They’re saying that they actually saw potential increases in utilization and costs, which is not what CMS was hoping to see,” said Dr. Eric Schneider, senior vice president for policy at the Commonwealth Fund. “But it’s not necessarily surprising.”

The project steered extra money to community health centers — nonprofit clinics that receive federal funds and care mainly for the poor. Medical homes typically appoint case managers to try to get people with diabetes, asthma and other chronic conditions to take medicine, eat well and stay out of the hospital.

HHS’s demonstration may have helped clinics identify patients with pent-up medical needs, causing the spike in treatment and costs, analysts said. Poor people served by federally funded centers often have trouble getting medical care.

The clinics “were developed to care for more-indigent people,” said Dr. Katherine Kahn, who led the RAND evaluation. “It’s not even entirely clear that one should expect lower costs initially.”

Medical homes have been widely promoted as one solution to America’s disconnected health system, which by some estimates wastes 30 percent of its spending on unnecessary treatment, fraud and administrative lard.

By making primary care doctors quarterbacks for treating the chronically ill, the thinking goes, patients can be kept healthy and away from expensive providers.

Health-reform specialists cautioned against counting the RAND report as a strike against medical homes.

“It would be a mistake to say we can conclude that the medical home model does not work,” said Dr. Marshall Chin, a professor at the University of Chicago medical school who reviewed drafts of the RAND study.

Indeed, the model was barely tested. Even among clinics that did qualify as medical homes, most weren’t certified until late in the program. Becoming a medical home, requiring patient-tracking software, referral protocols and lots of training, was more difficult and took longer than many expected.

HHS did not respond to requests for an interview. The agency has compared the innovation lab to a venture capital fund, in which some investments are expected to fail as the cost of finding high-payoff winners. Republicans have criticized it as a waste.

“No one study should define the value” of medical homes, said Amy Simmons Farber, spokeswoman for the National Association of Community Health Centers.

The report paints a picture of understaffed clinics struggling to file reports and participate in conference calls for the experiment while they did their normal jobs of caring for patients and trying to get paid by insurance plans.

“Sometimes we’re so caught up in all of these different requirements to be in our phone calls or webinars or whatever, and nobody has any time left to do the work that needs to be done,” said one unidentified nonprofit executive helping guide the clinics, who was quoted in the RAND study. “And I think that that’s kind of what the health centers are feeling, too.”

Others suggested that the extra money from HHS — a median of only $26,000 a year per clinic —wasn’t nearly enough to make a difference. Instead of trying to transform 500 outpatient centers, some said, HHS should have focused the same amount of money on fewer clinics.

“That’s going to go nowhere in supporting the kind of staff or information technology or the time it will take to reconfigure the clinic,” Chin said.

Other research shows mixed results on medical homes.

Many analysts believe the x-factor for successful medical homes and other payment innovation is giving doctors financial incentives to change referral patterns by letting them share savings from cutting unneeded care. The experiment with federally funded community clinics did not share savings with doctors.

“Transforming to a medical home — it’s not fixing one thing,” said Kahn. “It’s really changing everything about how the clinic works. On every single level.”

Feds close insurance loopholes


The U.S. Department of Health and Human Services has closed a series of insurance loopholes on coverage of preventive care.

The most important:

Henceforth insurers must cover at least one birth-control option under each of 18 methods approved by the Food and Drug Administration, and  without co-pays.

And insurers can’t charge patients for anesthesia  in connection with colonoscopies.

For insurers, the new government requirements take effect in 60 days but most consumers will not notice major changes until their coverage is renewed for 2016.

Jay Hancock: Meager results in anti-readmissions program

By JAY HANCOCK ( | @JayHancock1)

Kaiser Health News

Obama administration officials have warned that ambitious experiments run by the health law’s $10 billion innovation lab wouldn’t always be successful. Now there is evidence their caution was well placed.

Only a small minority of community groups getting federal reimbursement to reduce expensive hospital readmissions produced significant results compared with those from sites that weren’t part of the $300 million program, according to partial, early results. The closely watched program is one of many tests to control costs and improve care being run by the Center for Medicare and Medicaid Innovation, which was created by the Affordable Care Act.

Dozens of community agencies on aging, from Ventura County, Calif., to southern Maine were offered money to try to ensure that seniors leaving the hospital received care that reduced their chances of being readmitted within a month.

But an early evaluation found that only four groups out of 48 that were studied in the Community-based Care Transition Program significantly cut readmissions compared with those of a control group.

At the same time, 29 groups have either withdrawn from the program or been terminated by the Department of Health and Human Services for failing to achieve targets, agency officials said. The CCTP project, which has grown since the evaluation was done, now has 72 participating sites  that administration officials hope will still produce readmission reductions and lessons in post-hospital care in return for the investment.

The evaluation, produced under contract with HHS by consulting firm Econometrica, is one of the first independent analyses of an innovation-lab test to be made public. It is dated May 30, 2014, but was posted on HHS’s Web site Jan. 2.

The 111-page report notwithstanding, experts said it’s too soon to pronounce substantial judgment on CCTP.

“It’s really too early to tell,” said Ellen Lukens, who leads the practice on hospital and post-hospital care at Avalere Health, a consulting firm. “Can you really evaluate this when it’s been such a short period of time?”

A five-year experiment, the program signed its first round of deals with community agencies in late 2011 and its fifth and last round in March 2013. Econometrica’s report covered partial-2012 results from groups participating in the early rounds, including some for which only a few months of data were available. Congress required the lab to closely monitor all tests, which explains the early evaluation, experts said.

One positive note was that “a lot of the sites were able to implement the program very quickly,” Lukens said, adding that later data will give a better idea of CCTP’s effectiveness.

The readmissions result — less than one site in 10 significantly reducing them — “seems kind of wimpy,” said Eric Coleman, a professor at the University of Colorado whose previous work on care for discharged patients influenced the CCTP program. He said he remains optimistic about the tests, however, also noting that the results are early and praising HHS for cutting off nonperforming groups.

“This is really the first glance of the first two waves of the program,” said HHS spokesman Raymond Thorn. “It’s too early to determine whether this model is failing or not. We will have successes.”

CCTP is one of dozens of experiments being run by HHS’s innovation lab, which has a 10-year, $10 billion budget. Preventable readmissions are calculated to cost the Medicare program for seniors $17 billion a year.

Paying community agencies to work with hospitals was thought to be one potential way of reducing them. Rather than getting grants, agencies are paid according to the discharge cases they handle.

The program faces several challenges, experts said. In awarding funding, HHS favored groups working with hospitals with high readmission rates, perhaps making success more difficult.

Plus, numerous groups and hospitals are working to cut readmissions through other means. That increases competition for aging agencies trying to make their mark and raises the difficulty of measuring their results separately from those of other programs.

Readmissions have been dropping nationally since Medicare began penalizing hospitals in late 2012 if they have too many. Some CCTP groups reduced readmissions — but so did comparison hospitals. That means the system improved overall in those areas and money was saved, but statistically the aging agencies did not show up as the critical factor.

Coleman faulted HHS for requiring agencies to file detailed reports on care models and administration rather than letting them focus on the main job.

“If it doesn’t reduce readmissions it’s game over, so why do you want all these process measures?” he said. “If we want these sites to succeed we need to get out of their way.”

Originally more than 100 agencies agreed to participate. But 29, including New York Methodist Hospital and Pennsylvania’s Delaware County Office of Services for the Aging, have withdrawn or didn’t have contracts renewed because they missed readmission-reduction or enrollment targets, HHS said.

The health-law innovation program also includes Accountable Care Organizations to cut costs and improve care quality; tests giving more resources to primary-care doctors to coordinate care; and innovation awards for promising models to improve Medicare efficiency.

Administration officials like to compare the lab to a venture-capital fund, in which many investments are expected to fail but a few succeed spectacularly. Many Republicans think it’s a waste.


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